1. Postoperative venous thromboembolic disease prevention in the neurosurgery population Ahmad Khaldi, M.D. 1 Michael Wall, PharmD 2 T.C. Origitano, M.D., Ph.D. 1 1 Department of Neurosurgery 2 Center for Clinical Effectiveness Confidential- For Quality Improvement Purposes Only

2. VTE in Neurosurgery Neurosurgical inpatients have increased immobility and are at an increased risk of VTE –DVT development can be as high as 29%-43% in following cranial/spinal surgery (no prophylaxis). * –The rate of “clinically evident DVT” in craniotomy patients is around 2-4%. –PE occurs between 0.8%-2% in patients undergoing craniotomy with mortality rate between 9-59%. * Farray, D., Carman, T., Fernandez, B. The treatment and prevention of deep vein thrombosis in the preoperative management of patients who have neurologic disease. Neurological Clin N Am (2004), 22: 423-439. Confidential- For Quality Improvement Purposes Only

3. Objective Reduce the rate of post-operative VTE in neurosurgical patients through increased use of pharmacologic prophylaxis Confidential- For Quality Improvement Purposes Only

4. Duplex Study Patients (n=555) All patients received mechanical DVT prophylaxis (both compression stocking and sequential compression device) Patients had a surveillance ultra-sound (duplex) of the lower extremities (twice a week, Monday and Thursday) –During their ICU stay or –If they are deemed to have a high risk of developing DVT while they were on the floor Patients who developed clinical sign or symptoms of DVT (calf swelling, tenderness along deep venous system, pitting edema) prompted an immediate ultra- sound Confidential- For Quality Improvement Purposes Only

5. VTE develop soon after neurosurgery * First Duplex (hospital day 1-4) * Second Duplex (hospital day 2-7) * Third Duplex (hospital day 7-11) Confidential- For Quality Improvement Purposes Only

6. Longer duration of surgery increases chance for DVT Surgery Length (hr) <1 123456789>10 Cases383435874492211349241261519 Positive DVT06158135101422 Percent0%2%3%2%6%4%11%2%15%13%11% Confidential- For Quality Improvement Purposes Only

7. Effect of Pharmacologic Prophylaxis of DVT The use of pharmacological subcutaneous heparin at 5000 units every 12 hours was inconsistent in neurosurgical patients prior to March 2007 As of March of 2007, the compliance for early (POD1) increased to 62% (55 to 85) after the implementation of standard pharmacological prophylaxis to the order set. Confidential- For Quality Improvement Purposes Only

8. 62% Compliance Compliance with heparin administration within 24 hours increased significantly Confidential- For Quality Improvement Purposes Only

9. VTE Prophylaxis Positive Duplex Negative DuplexTotal Percent positive Heparin within 24 hrs262562829% Heparin between 24 and 48 hrs768759% Mechanical prophylaxis only3116719816% Total6441055512% * * * <0.005 Confidential- For Quality Improvement Purposes Only

11. Conclusions Increased compliance of early subcutaneous heparin within 24 hours resulted a 43% risk reduction of developing DVT (from 16% to 9%). There is a direct relationship between heparin prophylaxis and reduction in DVT in neurosurgical inpatients There was a correlation between the duration of surgery and DVT development. Confidential- For Quality Improvement Purposes Only

12. Future work Include analyzing the data for complication (rate of hemorrhage) with and without pharmacological DVT prophylaxis (POD 0, POD1 and POD 2) Preoperative surveillance duplex to rule out pre- existing DVT (high risk patients) Assessing the usefulness of starting pharmacological DVT prophylaxis intra- operatively in reducing the rate of VTE Confidential- For Quality Improvement Purposes Only