Page 210 - 2020_07-Haematologica-web

F. Paciullo et al.
Table 2. Differences between surgical procedures carried out with or without low molecular weight heparin thromboprophylaxis.
Age, median (IQR)
Females, N (%)
Platelet count before surgery x109/L,
median (IQR)
IPFD, N (%)
COPD, N (%)
Malignancy, N (%)
WHO bleeding score,
median (IQR)
Caprini score, median (IQR)
Caprini class, median (IQR)
Preoperative antihemorrhagic prophylaxis, N (%)
Any excessive post-surgical bleeding, N (%)
Treatment of post-surgical bleeding, N (%)
Post-surgical bleeding duration, hours, median (IQR)
Failure of post-surgical bleeding control, N (%)
Thrombosis, N (%)
LMWH use (N=22)
67 (79-55) 14 (63.6) 158 (120-287) 12 (54.5) 2 (9.1) 4 (18.4) 2 (0.75-3)
8 (5-12) 4 (3-4) 12 (54.5) 4 (18.2) 6 (28.6) 6 (4-8) 4 (19) 0
LMWH non use P (N=188)
42 0.01 (25-54)
120 (63.8) n.s. 120
(8-163) n.s. 98 (52.1) n.s. 2 (1.1) n.s.
7 (3.2)
2 (1-3) n.s.
4 (2-6) 0.02 3(2-4) 0.01 113 (60.1) n.s. 46 (25.8) n.s. 49 (27.2) n.s. 6 (1-6) n.s. 13 (7) n.s. 2 (1) n.s.
0.018
IQR: interquartile range; COPD: chronic obstructive pulmonary disease; IPFD: inherited platelet function disorders; IPND: inherited platelet number disorders; LMWH: low molec-
ular weight heparin; n.s.: not significant.
procedures). One was a pulmonary embolism (PE) in a bBSS patient who underwent mitral valve surgery, the other a femoral DVT in a GT patient occurring after the placement of a central venous femoral catheter for blood transfusions. Both patients were at high VTE-risk33 (Caprini score 12 and 8, respectively), had received pro- phylactic platelet transfusions before the invasive proce- dure, and had suffered excessive post-procedural bleeding prompting red blood cell transfusions. The patient suffer- ing from PE was a 56-year-old obese woman affected by chronic obstructive pulmonary disease. She was then treated with therapeutic dose enoxaparin, but died in hos- pital from septic shock, disseminated intravascular coagu- lation and acute respiratory distress syndrome. The patient suffering from DVT was a 60-year-old woman and she was then treated with therapeutic dose enoxaparin for three months, without bleeding complications and with complete resolution of the femoral thrombosis. Both patients had previously undergone major elective surgery without thromboprophylaxis and without thrombotic complications. When dividing the included surgeries according to procedure-related VTE risk, in two of 35 high-risk procedures (0.7%, both IPFD) a VTE event occurred, while in 114 intermediate-risk procedures and 61 low-risk procedures no VTE occurred.
Bleeding outcomes
The percentage of patients who suffered from excessive bleeding after surgery was not significantly different in LMWH users compared with non-users (4 of 22: 18.2% vs. 46 of 188: 25.8%; P=0.5) and no significant difference in bleeding duration after surgery was found between heparin users and non-users (Table 2). The rate of exces- sive bleeding was instead significantly higher in urgent (45.5%) than in elective (22.5%) procedures (P<0.05).
Also the need of post-surgical blood transfusions did not differ between heparin users and non users (18% vs. 19%; P=0.51) as well as the use of post-surgical anti-hemorrhag- ic interventions. In 57 cases emergency treatment of post- surgical bleeding was required (27.1%), with platelet transfusions administered in 38 procedures, anti-fibri- nolytic agents in nine, Desmopressin (DDAVP) in one, rFVII in one, other not specified treatment in six, and com- bination therapy with anti-fybrinolytic and DDAVP in two.
Thromboprophylaxis did not predict the need of post surgical anti-hemorrhagic intervention while the bleeding history did (Online Supplementary Table S4). Finally, heparin use was not significantly associated with the rate of success of emergency treatment of excessive post-surgi- cal bleeding, although percentages of cases with treatment failures were numerically higher in LMWH users than in non-users (19% vs. 7%; OR 2.05, 95% CI: 0.496-8.536; P=0.321) (Table 2 and Online Supplementary Table S5). Preoperatory prophylactic prohemostatic treatment was adopted in 125 procedures (59%), in 78 with platelet transfusions, in nine with anti-fibrinolytic agents, in six with DDAVP, in three with activated rFVII and in three with a not-specified agent, in 12 with anti-fibrinolytic agents and DDAVP, in six with platelet transfusions, anti- fibrinolytic and DDAVP in combination, in four with platelet transfusions and anti-fibrinolytics in combination, in two with platelet transfusions and DDAVP in combina- tion, in one with antifibrinolytic agents and a not-speci- fied agent combination, in one with platelet transfusions and not-specified agent combination. Thromboprophylaxis with LMWH was adopted in 10 procedures (11.8%) not managed with preoperatory pro- hemostatic prophylaxis and in 12 (9.6%) of those man- aged with preoperatory thromboprohylaxis (P=0.651).
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