wjpmr, 2017,3(9), 55-60 SJIF Impact Factor: 4.

103
Research Article
WORLD JOURNAL OF PHARMACEUTICAL
Tamer et al. AND MEDICALWorld Journal of Pharmaceutical and Medical Research
RESEARCH ISSN 2455-3301

www.wjpmr.com WJPMR

VENOUS THROMBOEMBOLISM PROPHYLAXIS: A SURVEY OF SURGEONS

CURRENT PRACTICE IN HIGH ALTITUDE AREA

Tamer M. Abdelrahman1,2*, Mohammed S. Al Saeed1, Rehab A. Karam3, Abdullah Fahad Altowairqi4,

Sara Mohammed Alosaimi4, Mutaz Hussain Althobaiti4, Khaled Fahad Altowairqi4
1
Department of Surgery, College of Medicine, Al Taif University, KSA.
2
General Organization for Teaching Hospitals and Institutes, Egypt.
3
Department of Biochemistry, College of Medicine, Al Taif University, KSA.
4
College of Medicine, Al Taif University, KSA.

*Corresponding Author: Dr. Tamer M. Abdelrahman

Department of Surgery, College of Medicine, Al Taif University, KSA, and General Organization for Teaching Hospitals and Institutes, Egypt.

Article Received on 08/07/2017 Article Revised on 28/08/2017 Article Accepted on 18/08/2017

ABSTRACT
Background: Awareness of venous thrombo-embolism (VTE) and its prophylaxis among surgeons will reduce the
incidence of hospital deaths and morbidity in patients undergoing surgery. Objective: In this study we aimed to
examine knowledge, attitude and practices of VTE prophylaxis among surgeons in high altitude area. Method: A
questionnaire was distributed to surgeons (consultant and Specialist) from different specialty in three hospitals in
Al Taif, Saudi Arabia. Results: 86% of our respondents routinely prescribe for thrombo-prophylaxis. 66% of
respondents routinely scored patients preoperatively using Wells score. A combination of physical and
pharmacological methods was used by 50% of surgeons and 64% of them were begun prophylaxis 2h
preoperatively. Conclusions: Surgeons included in our study are generally aware of the importance of
perioperative VTE prophylaxis, however, a number of inconsistencies and possible deficiencies exist. Continuous
medical education is advised on proper identification of at risk patients, importance of risk stratification, and
thrombo-prophylaxis methods and regimens.

KEY WORDS: Venous Thrombo-embolism; Deep Vein Thrombosis; Low Molecular Weight Heparin; VTE
prophylaxis, Anticoagulant Therapy.

INTRODUCTION Without anticoagulant prophylaxis incidence of DVT

varies from 10% in low risk to 40-80% in high risk
Venous thrombo-embolism (VTE) is a term
surgical patients and fatal PE occurs in 0.1-0.8% of
encompassing deep vein thrombosis (DVT) and
patients undergoing elective general surgery with 2-3%
pulmonary embolism (PE) or a combination of both,
undergoing elective hip replacement, and up to 4-7%
occurring in about 0.1% of people every year.[1] DVT is a
undergoing surgery for a fractured hip.[5]
silent killer, sometimes causes no symptoms and
therefore clinical data are unreliable for its diagnoses.[2]
National institute of health survey results of health care
providers in the year 2008 revealed that in many
The true incidence of VTE in the Kingdom of Saudi
hospitals, prophylaxis for DVT/PE is not yet standard
Arabia (KSA) is unknown. Assuming similar rate to
practice. Result shows that DVT occurs in 10-40% of
those present in other parts of the world, approximately
Medical or General Surgery patients and in 40–60% of
25,000 people are affected in the KSA annually.[3]
patients after major Cardiac, Orthopedic, Gastro and
Neurosurgery.[6]
About 25% of DVT occur in the calf veins which can
extend to involve the proximal veins (including the
Nevertheless despite the publication of international
popliteal, femoral and iliac veins). Proximal DVT if left
guidelines, many reports, mainly from developed
untreated can dislodge and embolism to the lungs in
countries, show suboptimal use of thrombo-prophylaxis.
about 50% of cases, leading to PE. The risk factors for
In fact, routine use of simple well-established and
development of VTE include obesity, increasing age,
effective methods of DVT prevention would save
major surgery, immobility, pregnancy, HIV infection and
thousands of hospitalized patients each year.[7]
sickle cell anemia. About 25% of cases with PE will
present with sudden death as the first symptom.[4]

www.wjpmr.com 55
Tamer et al. World Journal of Pharmaceutical and Medical Research

Implementation of already existing protocols has Section C: Structured attitude questionnaire, used for
suffered on account of lack of understanding of clear assessing the attitude of surgeons, and was based on
indications and contraindications for prophylaxis and statements on prevalence of DVT in high altitude area,
perceived risk of bleeding. To overcome this fear, common concerns expressed regarding VTE prophylaxis,
various ways have been used to improve the awareness the presence of institutional guidelines/protocol and
of VTE prophylaxis. Recently, a protocol involving a application of pretest probability assessment.
computer-based clinical decision support and program of
training seminar, electronic reminders and even didactic Section D: Structured clinical practice questionnaire
lectures have been used.[8] used for assessing the practice of the surgeons and was
based on statements on the diagnostic modality preferred
Studies have been conducted to figure out the reason for by the surgeons, preferences for the different modalities
this discrepancy between the actual rate of patients in of VTE prophylaxis, the commonest complications
need of DVT prophylaxis and the actual rate of DVT reported by surgeons, timing to start prophylaxis and
prophylaxis prescription in practice, showed that three Duration of thrombo-prophylaxis. Results were analyzed
main reasons have been associated with this problem, with SPSS® version 20.0 computer software (SPSS Inc,
including underestimation of VTE risk, lack of formal Chicago IL, USA).
prophylaxis programs and lack of interest.[9]
RESULT
The relationship between high altitude–related hypoxia
One hundred surgeons included in the survey; 42 were
and the development of VTE has been relatively well
consultant while 58 were specialist. The responders
studied in air travelers and mountaineers.[10] The lower
included 24 from department of general surgery, 16 from
ambient oxygen concentration at higher altitudes can
orthopedic department, 5 from Cardiothoracic
lead to hypoxia, which in turn causes increased platelet
department, 9 from plastic department, 7 from
aggregation and activation of blood coagulation factors,
Neurosurgery department, 13 from urology department,
resulting in a pro-thrombotic state.[11]
12 from vascular department and 14 from obstetrics -
gynecology department (Table 1).
The purpose of the current study was to assess surgeon's
knowledge, attitude towards VTE prophylaxis, by
Table 1: Participants by specialty.
considering their awareness and adherence to clinical
guidelines, treatment preferences and personal beliefs. Specialty No.
General surgery. 24
METHOD Orthopedic surgery 16
A semi-structured questionnaire to assess the knowledge, Cardiothoracic surgery. 5
attitude and clinical practice of surgeon on VTE Plastic surgery. 9
prophylaxis, which was adopted from other study,[7] with Neurosurgery. 7
some modifications was distributed to surgeons Urology. 13
(consultant and Specialist) from different specialty; Vascular surgery. 12
General, Orthopedics, Cardiothoracic, Plastic, Neuro, Obstetrics - gynecology 14
Urology, Vascular and Ob-gyne surgery, who were Total 100
working in three hospitals in AL-Taif, a city in Mecca
Province of Saudi Arabia at an elevation of 1,879 m on Knowledge: 84 % of the subjects had good knowledge
the slopes of Sarawat Mountains, in the period from on prevention of VTE and 16% had average knowledge
May-July 2017. on prevention of VTE.

The questionnaire was anonymous and the respondents Attitude: Most surgeons surveyed (86%) routinely
were told that their opinion will be analyzed and prescribe for thrombo-prophylaxis. Surgeons from
published. The research protocol was approved by Taif surgery department were the majority who gave
University ethical committee. prophylaxis.

The questionnaire consisted of four sections; When asking about their suspicion about the prevalence
Section A: Demographic data, Includes Position and of DVT is higher in high altitude area, 88% of our
Specialty of surgeons. responder's surgeons believed that the prevalence of
DVT is higher in high altitude area.
Section B: Structured knowledge questionnaire, includes
the minimum requisites information about VTE The most common concerns expressed regarding VTE
prophylaxis. Each correct answer carries one mark and prophylaxis were risk of postoperative complications
wrong answer carries zero, the maximum score is 7. The (50%), required strict monitoring (26%), and 17% had
scores are categorized as: Good knowledge: 5-7 Average the impression that it is not necessary (Table2).
knowledge: 3-4 Poor knowledge: 0-2.

www.wjpmr.com 56
Tamer et al. World Journal of Pharmaceutical and Medical Research

Table 2: Concern about VTE prophylaxis. There was a wide disparity in the commonly used
thrombo-prophylactic methods. 30% advised
If you occasionally, rarely or never used
pharmacological prophylaxis and 20% advised
DVT prophylaxis did so on account of Percent mechanical prophylaxis. Another 50% advised a
the fact that? combination of mechanical and pharmacological
Expensive increased cost to the patients. 4% prophylaxis.
In-effective 3%
Not needed 17% Table 5: Mechanical agent for thrombo-prophylaxis.
Risk of Complications 50%
Required Strict Monitoring 26% Mechanical agent of choice in thrombo-
Percent
Total 100% prophylaxis?
Early mobilization. 18%
42% of the responders thought that DVT developed in Limb physiotherapy. 3%
hospitalized patients is mostly symptomatic when they Compression stockings. 3%
were asked about their opinion and practice if most of Early mobilization and limb physiotherapy. 9%
hospitalized patients who develop DVT symptomatic. Early mobilization and compression
25%
stockings.
When we asked if they followed National Guidelines for Early mobilization, limb physiotherapy and
38%
Thrombo-prophylaxis and routinely scored patients compression stockings.
preoperatively using pretest probability assessment Pneumatic compression. 4%
(Wells score)? Only 66% of responders said that they Total 100%
routinely scored patients preoperatively using pretest
probability assessment (Wells score), while 34% of all When they asked about mechanical agent of choice in
surgeons not scoring patients. thrombo-prophylaxis for their patients; 18% of surgeons
advised early mobilization only, 38% said they advised
Some of the doctors prescribed anticoagulants because mechanical prophylaxis with early mobilization, limb
they felt the patients had a high risk of developing VTE physiotherapy and compression stockings together and
(68%), others prescribed it because it was routine in the 25% used early mobilization and compression stockings
unit to do so (20%), or did so because they had seen a together. Only 4% of surgeons advised Pneumatic
similar case develop VTE (12%) (Table 3). compression (Table 5).

80% of surgeons reported they knew that there was an Table 6: Pharmacological agent for thrombo-
institute-based protocol for VTE prophylaxis at their prophylaxis.
hospital while 20% of respondents did not knew if there
is a policy in their department or not. Pharmacological agent of choice
Percent
in thrombo-prophylaxis?
Table 3: Anticoagulant prescription. Unfractionated Heparin 17%
Low Molecular Weight Heparin 63%
Why the surgeons prescribed Warfarin 18%
Percent
anticoagulants? Asprin 2%
They felt the patients had a high risk of Dextran 0%
68%
developing VTE. Total 100%
Because it was routine in the unit to do so. 20%
Because they had seen a similar case 63 % of our surgeons said that they would advise low-
12%
develops VTE. molecular-weight heparin (LMWH) as the
Total 100% pharmacological agent of choice in thrombo-prophylaxis
(Table 6).
Practice: 71% of surgeons relied on Doppler venous
ultrasonography to diagnose VTE postoperatively while Table 7: Complication of pharmacological agents.
29% of them relied on clinical examination (Table 4).
Complication from pharmacological
Percent
Table 4: diagnosis of DVT. agents you experienced?
Minor hemorrhage 33%
What is the single tool you Major hemorrhage. 6%
Percent
preferred for diagnosis of DVT? Wound hematoma. 42%
Clinical examination 29% No complication. 19%
Doppler venous ultrasonography. 71% Total 100%
D‑dimer assay. 0%
Total 100% The commonest complications reported by surgeons after
use of pharmacological agents for prophylaxis were

www.wjpmr.com 57
Tamer et al. World Journal of Pharmaceutical and Medical Research

wound hematoma (42%) and excessive wound oozing symptomatic. With the fact that DVT is asymptomatic in
(33%) (Table7). approximately 5% of cases,[4] patients with VTE may go
undiagnosed if about half of the responders were not
With regard to timing to start prophylaxis, all surgeons aware of it.
started prophylaxis before surgery, 28% of them was
begun 12h preoperatively, 64% begun 2h preoperatively In our study 66% of responders routinely scored patients
and 8% started prophylaxis with the premedication. preoperatively using pretest probability assessment
When asking the surgeons when would they stop (Wells score), this finding is higher than the study by
prophylaxis after the surgery? All surgeons continued Prasannan et al., who found that only 21.8% of
prophylaxis after surgery; 71% until the patient was consultants were following national guide lines.[16]
mobile, and 18% until the patient was discharged, 7%
continued prophylaxis for seven days after discharge, More than two third of our respondents prescribed
and 4% would continue prophylaxis in high risk cases for anticoagulants because they felt the patients had a high
14 days after discharge. risk of developing VTE.

DISCUSSION 80% of surgeons reported they knew that there was an

institute-based protocol for VTE prophylaxis at their
VTE is a major cause of hospital deaths and morbidity;
department while 20% of respondents did not knew if
this can be easily prevented by simple measures.
there is a policy in their department or not. While in
Guidelines for thrombo-prophylaxis are available for
national survey in UK 34.4% of surgeons said that they
past many years but the compliance remains
had departmental policy for thrombo-prophylaxis.[17]
disappointing throughout the world.[12]
All our surgeons relied on Doppler venous
The purpose of the current study was to assess surgeon's
ultrasonography and clinical examination to diagnose
knowledge, attitude towards VTE prophylaxis, by
DVT post-operatively, no one in our study said they used
considering their awareness and adherence to clinical
D-dimer assay. While in a study by Bates et al, found
guidelines, treatment preferences and personal beliefs.
that 38% of their surgeons used D-dimer assay for
diagnosis.[18]
Eighty four percent of the respondents had good
knowledge on prevention of VTE. This high percentage
The ACCP recommends that the diagnostic test is
may originate from the high knowledge of the
dependent on the pretest probability of VTE. In low-to-
predisposing risk factors and clinical presentation, thus a
moderate VTE risk, D-dimer is advocated as the
potential patient with a risk for VTE will be correctly
diagnostic test of choice. In high VTE risk whole-leg
identified.
ultrasound is preferred.[18]
In our study 86% of the responders routinely prescribed
According to the commonly used thrombo-prophylactic
VTE prophylaxis. Our finding was higher than the
methods, 30% of our surgeons advised pharmacological
finding in the study of Bhatti et al.[13] where only 63.3%
prophylaxis and 20% advised mechanical prophylaxis,
of responders prescribed VTE. Surgeons from surgery
while 50% advised a combination of mechanical and
department were the group that most frequently
pharmacological prophylaxis.
prescribed anticoagulants as a prophylaxis which is
similar to our study.
A traditional non-pharmacological prophylaxis strategy
for DVT is a mainstay for conditions with absolute
It is well recognized that a hyper-coagulable state exists
contraindications to antithrombotic or anticoagulant
when a person is exposed to high altitude environment.
therapy like neurosurgery, ocular surgery. Such
This may manifest as early thromboembolic episodes,
strategies include early mobilization and the use of
which result in acute pulmonary embolism. A few
sequential compression devices to prevent blood clotting.
reports of DVT and cerebral, retinal and portal and
In addition, non-pharmacologic prophylaxis is
splenic vessel thrombosis have also been reported.[14]
recommended for low-risk patients throughout the
Most of our surgeons believed that the incidence of DVT
preoperative period until they are ambulatory. [7]
is higher in high altitude area and they should be
cautious about thromboembolic prophylaxis.
Sixty three percent of our surgeons said that they would
advise low-molecular-weight heparin (LMWH) as the
In our study, half of the respondents had the concern
pharmacological agent of choice when prescribing
while using VTE prophylaxis as they were afraid of
thrombo-prophylaxis agents. There seems little doubt
postoperative bleeding. Similarly a hospital based study
that the LMWHs are the most convenient of the
by Ansari et al, found that only 47% of patients received
pharmacological methods to administer: they are given
pharmacological prophylaxis for fear of bleeding. [15]
once daily and require no laboratory monitoring. There
should be a wider adoption of LMWH for prophylaxis,
Of the responders, 42% of surgeons believed that the
most of hospitalized patients who develop DVT were

www.wjpmr.com 58
Tamer et al. World Journal of Pharmaceutical and Medical Research

which is justified on the basis of greater safety, patient stratification, improving the adherence to clinical
acceptability, and saving of nursing time.[19] guidelines and onset of prophylaxis and its duration
needs more attention.
In our study the commonest complications reported by
surgeons after prophylaxis were wound hematoma (42%) CONFLICTS OF INTEREST
and excessive wound oozing (33%), while major
There are no conflicts of interest.
hemorrhagic complications, have not been noted by any
of them. Postoperative bleeding as a complication of
REFERENCES
VTE prophylaxis was frequent in the study of Hull et al,
occurring in 55% of cases. Major bleeding was reported 1. Antony AM, Moly KT, Dharan DR. Assessment of
by 9%. They explained this by aspects of anticoagulant Knowledge and Self-Reported Clinical Practice on
administration such as the dose of drug used and its Prevention of Deep Vein Thrombosis (DVT) Among
proximity to surgery may account for some of the excess Staff Nurses. IOSR- Journal of Nursing and Health
bleeding.[20] The recent guidelines from seventh (ACCP) Science, 2016; 5(1): 18-24.
consensus conference in 2004 recommend that every 2. Nutescu EA. Assessing, preventing, and treating
hospital develop formal strategy to prevent complication venous thromboembolism: evidence-based
of Thrombo-embolism.[21] approaches. Am J Health Syst Pharm, 2007; 64(11
Suppl7): S5-13.
In our study most of surgeons started prophylaxis 2h 3. Al-Hameed F, Al-Dorzi HM, Shamy A, The Saudi
preoperatively (64%). As expected all surgeons start clinical practice guideline for the diagnosis of the
prophylaxis before surgery, with the majority starting it first deep venous thrombosis of the lower extremity.
more than two hours before operation. There appears to Annals of Thoracic Medicine, 2015; 10(1): 3-15.
be no adverse consequence of giving the first dose two 4. Korubo KI, Ekeke ON, Omunakwe HE. Awareness
hours before operation and there may be an additional of venous thromboembolism among doctors in a
benefit of preventing DVT developing during operation Nigerian tertiary center. East African medical
or in the immediate postoperative period. However high journal, 2015; 92(11): 366-370.
risk patients (where higher doses are required) would 5. Mismetti P, Laporte S, Darmon JY, Buchmuller A,
probably benefit more if prophylaxis started earlier Decousus H. Meta-analysis of low molecular weight
(12hours before an operation), in order to avoid heparin in the prevention of venous
excessive intraoperative bleeding.[22] thromboembolism in general surgery. Br J Surg,
2001; 88: 913-930.
In our study the restoration of mobility is seen as the 6. Goldhaber SZ. Deep-vein thrombosis: Advancing
commonest indication for stopping prophylaxis (71%). awareness to protect patient lives. 2003.: Available
There is evidence that the thrombotic risk persists for from: URL:
many weeks after surgery, despite this prophylaxis being www.apha.org/NR/rdonlyres/A209F84A-7C0E-
stopped by the majority within days of operation.[23] 4761-9ECF-
61D22E1E11F7/0/DVT_White_Paper.pdf. Accessed
The seventh ACCP conference recommended that February 1, 2008.
LMWH or other prophylaxis should be continued for a 7. Zobeiri M, Najafi F. Prophylaxis for deep venous
minimum of 10 days. In patients undergoing total hip thrombosis: Knowledge and practice of surgeons.
replacement or hip fracture surgery as well as in other Pak J Med Sci, 2011; 27(1): 16-20.
high-risk patients, prophylaxis should last 28-35 days or 8. Kesieme EB, Arekhandia BJ, Inuwa IM, Akpayak
longer postoperatively.[24] IC, Ekpe EE, Olawoye OA, et al. Knowledge and
practice of prophylaxis of deep venous thrombosis:
CONCLUSIONS A survey among Nigerian surgeons. Niger J Clin
Pract, 2016; 19: 170-4.
Our results indicate that our surgeons have a good
9. Ebrahimpur M, Moghadam KG, Sani MP, and
knowledge on the prevention of VTE and 88% of them
Naderpour Z. Knowledge, Attitudes and Practices of
believed that the prevalence of DVT is higher in high
Internal Medicine Residents towards Deep Vein
altitude area. All the respondents routinely use
Thrombosis Prophylaxis in a University Hospital in
prophylactic measures with 50% using a combination of
Tehran. Shiraz E-Med J., 2016; 17(12): 1-5.
pharmacological and physical methods. 80% of
10. Kuipers S, Cannegieter SC, Middeldorp S, Robyn L,
surgeons knew that there are protocols that are available
Büller HR, Rosendaal FR. The absolute risk of
in their units. However , practices among the surgeons
venous thrombosis after air travel: a cohort study of
appears doubtful given the fact only 66% of these
8755 employees of international organizations.
surgeons carry out VTE risk assessment/stratification of
PLoS Med, 2007; 4: e290.
hospitalized patients as well as comply with the clinical
11. Bradford A. The role of hypoxia and platelets in air
guidelines on thrombo-prophylaxis use.
travel–related venous thrombo-embolism. Curr
Pharm Des, 2007; 13: 2668-72.
Continuous medical education is advised on proper
identification of at risk patients, importance of risk

www.wjpmr.com 59
Tamer et al. World Journal of Pharmaceutical and Medical Research

12. Cohen AT, Tapson VF, Bergmann JF, Goldhaber

SZ, Kakkar AK, Deslandes B, et al. Venous
Thromboembolism risk and prophylaxis in acute
hospital care setting (ENDORSE study): a
multinational cross sectional study. Lancet, 2008;
371: 387–94.
13. Bhatti MA, Ahsin S, Salim B, Mansoor J.
Knowledge, attitude and practices of healthcare
providers towards deep vein thrombosis prophylaxis
in five teaching hospitals of Rawalpindi. J. Ayub
Med Coll Abbottabad, 2012; 24: 136-139.
14. Kumar S. High altitude induced deep venous
thrombosis: A study of 28 cases. Indian J Surg,
2006; 68: 84-8.
15. Ansari K, Dalal K, and Patel M. “Risk stratification
and utilisation of thrombo-embolism prophylaxis in
a medical surgical ICU: a hospital-based study,”
Journal of the Indian Medical Association, 2007;
9(105): 536–543.
16. Prasannan S, Chin L, Gu Y. Venous
thromboembolic disease prophylaxis among general
surgeons in Malaysia. Asian J Surg, 2009; 28:
125-30.
17. Alikhan R, Wilmott R, Khan A, Cohen AT.
Thromboprophylaxis in medical patients: national
survey of consultant physicians in the United
Kingdom. J Th romb Haemost, 2003; 1: 1405.
18. Bates SM, Jaeschke R, Stevens SM et al.,
“Diagnosis of DVT: antithrombotic therapy and
prevention of thrombosis, 9th ed: American College
of Chest Physicians evidence-based clinical practice
guidelines,” Chest, 2012; 2(141): e351–e418.
19. Kakkar VV, Cohen AT, Edmonson RA, et al. Low
molecular weight versus standard heparin for
prevention of venous thromboembolism after major
abdominal surgery. Lancet, 1993; 341: 259–65.
20. Hull RD, Pineo GF, Stein PD et al. Timing of initial
administration of low-molecular-weight heparin
prophylaxis against deep vein thrombosis in patients
following elective hip arthroplasty. Arch Int Med,
2001; 161: 1952–1960.
21. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen
MR, Colwell CW, et al. Prevention of venous
thromboembolism: the Seventh ACCP Conference
on Antithrombotic and Thrombolytic Therapy.
Chest, 2004; 126(3 Suppl): 338S-400S.
22. Bjerkeset P, Larsen S, Reiertsen O. Evaluation of
enoxaparin given before and after operation to
prevent venous thromboembolism during digestive
surgery: play-the-winner designed study. World J
Surg, 1997; 21: 584–9.
23. Scurr JH, Coleridge-Smith PD, Hasty JH. Deep
venous thrombosis: a continuing problem. BMJ,
1988; 297: 28–9.
24. Qaseem A, Snow V, Barry P, Hornbake ER,
Rondick JE, Tobolic T, et al. Current diagnosis of
venous thromboembolism in primary care: a clinical
practice guideline from the American Academy of
Family Physicians and the American College of
Physicians. Ann Fam Med, 2007; 5: 57-62.

www.wjpmr.com 60