1. the proximal femoral fracture patients
Diagnostic usefulness of D-dimer for deep venous thrombosis and pulmonary embolism in the high risk elderly patients undergoing acute hip fracture surgery.
PA 11 (1579)
Shozo Tominaga, M.D1., Yoshiaki Terao, M.D., Ph.D. 1, Shigehiko Urabe, M.D. 1, Chikako Tsuji, M.D. 1, Makoto Oji , M.D. 1, Makoto Fukusaki M.D. , Ph.D. 1, and Tetsuya Hara M.D.,Ph.D2.

1 Department of Anesthesia, Nagasaki Rosai Hospital, Sasebo, Nagasaki, Japan. 2 Department of Anesthesiology, Nagasaki University School of Medicine, Nagasaki, Japan
BACKGROUND
MATERIALS and METHODS
DISCUSSION
RESULTS
Patients
・Total 744 ASA PS1-2 patients undergoing the proximal
femoral fracture surgery from January 2013 to December
2014 in Nagasaki Rosai Hospital.
・All patients were received comprehensive prophylaxis for
DVT during perioperative period.
D-dimer test for screening DVT
・The D-dimer level for the diagnosis by exclusion of DVT was
measured on admission and on demand before surgery.
・DVT was suspected when the D-dimer level of the patients
met following criteria(2).
D-dimer level was over 20μg/ml on admission1).
D-dimer level did not decline from admission to the later measurement time.
・ D-dimer value was assayed by the latex photometric
immunoassay method upon blood examination.
Diagnose DVT and PE
・Contrast-enhanced computed tomography scan (e-CT) was
　conducted if DVT was suspected according to our criteria.
>Group Thrombosis(+) was diagnosed for DVT or PE by e-CT.
>Group Thrombosis(-) was not diagnosed for DVT or PE by e-CT.
Statistical analysis
・We compared two groups in patients’ characteristics, D-dimer
level and other selected variables. Results were expressed
as median with interquartile range. The Intergroup
comparisons were made using Mann-Whitney U test.
Dichotomous variables were analyzed with either Fisher’s
exact probability test or the chi-square test.
A p value < 0.05 was considered statistically significant.
Outcome of patients
・By risk stratifying to low risk and a negative d-dimer , we can
safely rule out DVT without additional examination(3).
・However, proximal femoral fracture patients are moderate or
high risk of DVT. Moreover, almost all of our study subjects
showed positive D-dimer level, i.e. above the upper limit of
normal level(4).
・We need new criteria of D-dimer level ruled out DVT in
proximal femoral fracture patients.
・Pulmonary embolism (PE) is perioperative severe
complication and deep venous thrombosis (DVT) is the most
common cause of PE.
・Elderly patients with the proximal femoral fracture have been
identified as high risk for DVT/PE due to vessel trauma,
venous stasis of the limb, age and preoperative prolonged
immobility.
DVT risk for the typical femoral fracture patients
adapting Wells’ criteria(1)
・Typical femoral fracture patients almost met 2 or 3
items out of 9 criteria. These patients are categorised to
moderate or high risk group of DVT.
・The aim of this retrospective study is to investigate the
relationship between diagnosis of DVT and perioperative
D-dimer level in the patients undergoing the proximal femoral
fracture surgery.
the proximal femoral fracture patients
n=744
e-CT was conducted
n=32/744(4.3%)
Thrombosis(+)
n=20/32(63%)
e-CT was not conducted
n=712
Thrombosis(-)
n=12
DVT/PE(+)
n=4
only DVT
n=16
1: Paralysis, paresis, or recent plaster immobilization of the lower extremity
2: Bedridden recently >3 days or major surgery within four weeks
3: Localized tenderness along the deep venous system
4: Entire leg swollen
5: Pitting edema, confined to symptomatic leg
6: Collateral (nonvaricose) superficial veins present
7: Active cancer
8: Previously documented DVT
9: Calf swelling >3 cm compared to the other leg
Characteristics of patients
Variables
Thrombosis(+)
Thrombosis(-)
P value
Age ( years )
86 ( 80,87 )
89 ( 84,92 )
0.09
Women/Men ( n )
17/3
11/1
0.99
BMI
20.8 ( 17.9,22.1 )
20.3 ( 17.5,22.8 )
0.68
>complication
Chronic heart disease 2 5
0.07
Atrial Fibrilization
0.13
CONCLUSIONS
・Our study showed that the measurement of D-dimer level was useful for diagnosis of DVT/PE in the patients undergoing the proximal femoral fractures surgery. ・ It is important to follow up the D-dimer level before surgery. ・ There was the high possibility of DVT/PE in the patients without decline of D-dimer level preoperatively.
Perioperative differences between the groups
ADFT;Admission Days From Tauma
Variables
Thrombosis(+)
P value
ADFT
1 ( 0,2.5 )
1 ( 0,2 )
0.70
D-dimer on admission ( ug/ml )
18.8 ( 9.7,27.0 )
23.5 ( 11.9,43.9 )
0.39
D-dimer over 20ug/ml ( n ) 7 8
0.17
Not Decline D-dimer level ( n ) 19
0.02*
Max D-dimer ( ug/ml )
34.7 ( 25.2,56.8 )
36.8 ( 31.2,55.6 )
0.72
Operation time ( min )
43.5 ( 36.0,47.5 )
37.5 ( 31.5,58.0 )
PE positive ( n ) 6
0.06
REFERENCES
1.The New England Journal of Medicine ;349: Journal of Orthopaedic Science : BMJ 2014; JAMA Intern Med.2015;175: