Using a Bundle Prophylactic Approach in Post-Operative Total Knee and Hip Arthroplasty

Friday, 28 July 2017

Haofei Wang, DNP
Department of Nursing, NewYork-Presbyterian, New Yrok, NY, USA
Patrick G. Ryan, MS
Department of Nursing, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA

Background: Evidence is limited on which prophylactic intervention(s) to prevent post-operative VTE is/are optimal or suboptimal in TKA and THA population.

Objectives: To examine the different types of prophylactic interventions (pharmacological and mechanical), patient age and BMI, bleeding tendency and renal function, and type of surgeries (TKA and THA) in relation to VTE incidence.

Purpose: Deep vein thrombosis (DVT) is a blood clot that occurs in a deep vein of the body; pulmonary embolism (PE) occurs when a clot breaks free and enters the arteries of the lungs (CDC, 2015). Both DVT and PE comprise venous thromboembolism (VTE), which is a serious condition associated with prolonged duration of hospitalization and mortality. Each year in the United State, an estimated 350,000-900,000 people develop incident VTE, of whom approximately 100,000 die (CDC, 2014). Patients who undergo major orthopedic surgeries such as total hip arthroplasty or total knee arthroplasty are at the highest risk for postoperative VTE due to coagulation activation from tissue and bone injury, venous injury, reduced venous emptying intra-or post-surgery, and prolong immobilization (Florescu et al., 2013). The incidence of DVT varies from 42% to 57% after hip arthroplasty and from 41% to 85% after knee arthroplasty; the incidence of PE varies from 0.9% to 28% after hip arthroplasty and from 1.5% to 10% after arthroplasty (Januel et al., 2012). Methods of VTE prophylaxis include mechanical interventions such as compression stockings, compression device, or ambulation, and pharmacological intervention such as oral or subcutaneous anticoagulation agents. The purpose of this study is to look at the rates of VTE between those that received mechanical intervention only, pharmacological intervention only and those that received both mechanical and pharmacological interventions in the post-operative total hip and total knee arthroplasty patients.

Methods: A retrospective chart review study on a total of 135 adult patients underwent TKA (n = 66, 49%) and THA (n = 69, 51%) between October 2015 and December 2015 was conducted at a large tertiary Academic Medical Center. A convenient sample of the charts of all patients who underwent total hip or total knee arthroplasty and discharged from the hospital from October 2015 to December 2015 was pulled from the electronic medical record using the International Classification of Disease (ICD-10) code. Information was extracted including: age, gender, race, ethnicity, body mass index (BMI), surgery type, VTE risk factors, bleeding risks, mechanical measure used, pharmacological prophylaxis used, and duration of the mechanical measures used. The inclusion criteria included all adult patients greater than 18 years of age who underwent hip and/or knee arthroplasty procedures from October 1, 2015 to December 31, 2015. Exclusion criteria included patients with a documented VTE at the time of the surgery, past medical history of VTE and a past medical history of malignancy.

Results:  None of the patients developed post-operative VTE complications during the hospitalization. Compliance rate of using both pharmacological and mechanical prophylaxis was 99%. Majority of the patients were on either Rivaroxaban (n = 54, 40%) or aspirin (n =63, 46.7%) and mechanical intervention(s). Sixty-three percent of patients received early mobilization therapy within 24 hours of the surgery.

Conclusion: Use of a bundle prophylactic interventions, both pharmacological and mechanical, improved venous circulation and prevented the likelihood of VTE development in postoperative TKA and THA patients. Aspirin used along with mechanical intervention(s) might be as effective as an anti-coagulant agent. Strategies to improve practice compliance are crucial in efforts to prevent post-operative VTE. Future clinical trials of multiple VTE prophylactic interventions involving different types of pharmacological and mechanical approach for TKA and THA population and evaluation of the relative risks and benefits of these interventions are needed.