chronic if a patient develops several DVTs during their procedure or when they become unresponsive to anticoagulation , and this latter effect can arise if an individual has an underlying problem with the anatomy of the veins .
Q Why do you think that the new guidelines were necessary ?
A Dr Parvizi explained how surgery induces a hypercoagulable state and which , in turn , increases the risk for the development of VTE . In the past after joint replacement , patients usually stayed in bed for a prolonged period of time . As a result , he added ‘ during the 1970s and 80s , the rates of DVT and PE were very high .’ In recent years , with a shift towards outpatient surgery and implementation of rapid recovery protocols , the overall incidence of VTE has declined drastically . Nevertheless , one practice from the past that has continued is the post-operative use of aggressive anticoagulation and Dr Parvizi discussed how in recent years , given the change in surgical practice and advice to avoid prolonged bed rest , the value of such aggressive anticoagulation has been called into question . A further consideration which might reduce the need for anticoagulation is greater use of intermittent compression devices . According to Dr Parvizi , due to a major shift in the delivery of care , there is now less requirement for aggressive anticoagulation . However , an important driver for change is the attendant risk associated with the use of anticoagulants , which lead to bleeding , increasing the risk for a haematoma , gross bleeding into the surgical wound or even in other organs such as the brain . Additionally , anticoagulants are both expensive and can be inconvenient to the patient , given the need for healthcare professionals to administer and / or monitor the anticoagulation drugs . Furthermore , anticoagulants are not benign drugs , and their use is associated with several other problems that include the need for re-hospitalisation , re-operation , infection and joint stiffness . In fact , Dr Parvizi noted how ‘ there have been studies showing that aggressive anticoagulation can kill patients , just like fatal PE .’
Dr Parvizi acknowledged that while there are current guidelines available to help surgeons , these are subject to several limitations . For instance , most relate to hip and knee replacement and do not specifically cover other orthopedic procedures such as spine , foot and ankle , and sports surgery . In addition , Dr Parvizi mentioned how ‘ the current guidelines are totally disparate and conflicting in nature , with some recommending either for or against aggressive anticoagulation .’ A further limitation was that the current guidelines do not take into account the genetic or geographic predisposition for formation of VTE . As Dr Parvizi explained , “ For example , Asian patients are at a much
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Reference 1 Recommendations from the ICM-VTE : General . The ICM-VTE General Delegates . J Bone Joint Surg 2022 ; 104 ( suppl 1 ): 4 – 162 . https :// journals . lww . com / jbjsjournal / Fulltext / 2022 / 03161 / Recommendations _ from _ the _ ICM _ VTE __ General . 2 . aspx ( accessed June 2022 ) lower risk of developing VTE than Caucasians ’. A final constraint of the currently available guidelines is that these were outdated , relating to surgical protocols that are not in effect any more , or limited themselves to reviewing literature that was mostly conducted by industry , which of course introduces some degree of bias .
Given all of the limitations , the International Consensus Meeting ( ICM ) gathered over 500 experts and specialists from across the world to produce updated and global guidelines using a strict and well defined process . The guideline committee reviewed the current literature , formulated relevant questions for current practice and sought consensus on these questions . Ultimately , the finished product was designed to be a global guideline for the prevention of VTE after all orthopaedic procedures . A further advantage of the new guideline was the inclusion of physicians from other medical disciplines , such as cardiology , haematology , anaesthesia , vascular medicine and others , which enhanced the value of the guidelines and made them more applicable .
Q What would you say are the overarching principles and key recommendations of the guideline ?
A Dr Parvizi felt that the overarching principle of the guideline was the prevention and management of VTE for all orthopaedic procedures . He explained how the guideline was divided up into ten parts , one of which was a general section , with each of the subsequent sections being related to the different sub-specialities , e . g ., foot and ankle , spine , etc .
The general recommendations were designed to answer questions relevant to all patients who underwent an orthopaedic surgical procedure . A total of 200 questions / issues were covered that included questions such as , ‘ are there genetic predispositions that cause VTE ?’ or ‘ does prolonged bed rest increase the incidence of VTE ?’ with the answer being yes to both questions .
Dr Parvizi felt that the most important recommendations were the following .