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Maximizing Chemoprophylaxis Against Venous Thromboembolism in Abdominoplasty Patients with Use of Preoperative Heparin Administration
William J. Campbell, MD, Justine Molas Pierson, MS, Bruce A. Mast, MD.
University of Florida, Gainesville, FL, USA.
Abdominoplasty is one the highest risk plastic surgery procedures for venous thromboembolism complications (VTE). Current recommendations for VTE prophylaxis are SCDs in the OR and optional use of subcutaneous heparin after surgery. Although preoperative subcutaneous heparin has been shown to be safe in other surgical groups, the large raw surface areas and dissection involved in abdominoplasty has been a relative contraindication for preoperative chemoprophylaxis. However, the period while the patient is under general anesthesia and immediately following the procedure is likely the highest risk time period for VTEs. Based on the high morbidity and mortality associated with this complication, the senior author began use of preoperative subcutaneous heparin for VTE prophylaxis. The purpose of this study is to determine if this regimen is safe.
All patients undergoing abdominoplasty by the senior author from 1/1/2005 to 1/1/2012 were retrospectively reviewed. All patients whose operation took place between 1/1/2005 and 1/18/2008 were given SCDs prior to induction of anesthesia and heparin (unfractionated) 5000 units SQ on call to the OR. All patients whose operation took place between 1/19/2008 and 1/1/2012 received enoxaparin (low molecular weight heparin) 40mg SQ on-call to the OR and then daily for 2 days post operatively, as well as SCDs. These groups were evaluated in regards to overall complication rate, incidence of VTE, and bleeding complications.
A total of 151 patients underwent abdominoplasty under general anesthesia during the study period. 101 patients received the SCD/heparin protocol and 50 had the enoxaparin protocol. The groups were similar in regard to pre-morbid conditions and risk factors for VTE (HTN, DM, tobacco use, cancer status, bleeding disorders, clotting disorders, previous diagnosis of cancer, use of OCPs or other hormone therapy.) There were no VTEs diagnosed in either group. The overall incidence of any complication was similar between the 2 groups (19% vs. 14%, p=0.503) and similar to other published series. The overall complication rate for the entire patient cohort was 17.3%. The most common complications were seroma, cellulitis, and minor wound dehiscence. The incidence of bleeding complications was similar between the two groups (1% vs. 0%, p=1.0). The only bleeding complication observed was a single minor hematoma which was treated with observation. There were no incidents of hemorrhage requiring return to the OR or bleeding requiring blood transfusion in this case series.
The use of either unfractionated or low molecular weight heparin as preoperative chemoprophylaxis in patients undergoing abdominoplasty can be done without an increase in bleeding complications or overall complication rate. Furthermore enoxaparin can also be used preoperatively and continued for two more days during the period of time of maximum immobility with easy administration for outpatients via use of a prescription home use kit. This provides maximum prophylaxis against a potentially devastating complication.
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