|Orient Journal of Medicine Vol 31 [1-2] Jan-June, 2019|
DEEP VENOUS THROMBOSIS: A PREVENTABLE SCOURGE IN SURGICAL PRACTICE
Deep venous thrombosis (DVT) poses a major and common preventable cause of death in surgical practice. However, only a few practicing surgeons in Nigeria have a good knowledge and practice of DVT prophylaxis.1
DVT can no longer be called a rare condition, as 90.5% of Nigerian surgeons have encountered cases of DVT in their surgical practice while 83.5% have encountered pulmonary embolism (PE), the dreaded acute complication of DVT.1 The prevalence of DVT among postoperative patients have been found to vary between 2.4% and 9.6%, with case fatality rate after surgery being 60%.2
History and clinical signs alone are insufficient in making a clinical diagnosis. Risk factors identified by surgeons include prolonged immobilization, advanced age and pelvic surgery.1 Orthopaedic procedures like hip surgeries generally have a higher risk than general surgical procedures. Well’s score, a standardized pretest probability assessment which combines risk factors and clinical features to stratify the disease into DVT unlikely (clinical score =1) and DVT likely (clinical score =2) is very useful in evaluation.3 Despite the clinical usefulness of the Well’s score, only 13.3% of Nigerian surgeons have used it in evaluating patients suspected to have DVT.1 If clinical score is =1, DVT is excluded if a D-dimer assay is negative but a positive D-dimer assay in the same scenario warrants investigation with venous ultrasonography while a positive D-dimer in the presence of a score =2 suggests DVT and is an indication to commence treatment.1
It is rather unfortunate that at least a quarter of patients who are at risk of venous thromboembolism in Africa are not receiving prophylaxis.2 To make matters worse, 15% of surgeons in Nigeria were reluctant to offer DVT prophylaxis citing bleeding complications, increased cost to patients and having predominantly paediatric patients as their reasons.1 Depending on the level of risk of DVT and the risk of major bleeding complication, prophylactic mechanical and pharmacological modalities can be used. Mechanical measures include early ambulation / limb physiotherapy as practiced by most of our surgeons and the use of intermittent pneumatic compression. Commonly used pharmacological agents include low molecular weight heparin (LMWH), dabigatran, abixaban and rivaroxaban.4 In addition to the traditional systemic anticoagulation commonly used, other treatment modalities include systemic thrombosis, catheter directed pharmacologic thrombolysis, and thrombectomy.5
The need for institutional guidelines has been expressed by our surgeons and this will go a long way in improving DVT knowledge and harmonizing preventive modalities in the sub region.
Mr. Emeka Kesieme MRCS
Department of Surgery, Irrua Specialist Teaching Hospital, Irrua
Edo State, Nigeria
1. Kesieme EB, Arekhandia BJ, Inuwa IM, Akpayak IC, Ekpe EE, Olawoye OA, et al. Knowledge and practice of prophylaxis of deep venous thrombosis: A survey among Nigerian surgeons. Niger J Clin Pract 2016;19:170-174
2. Danwang C, Temgoua MN, Agbor VN, Tankeu AT, Noubiap JJ. Epidemiology of venous thromboembolism in Africa: a systematic review. J Thromb Haemost. 2017;15(9):1770-1781
3. Kesieme E, Kesieme C, Jebbin N, Irekpita E, Dongo A. Deep vein thrombosis: a clinical re-view. J Blood Med 2011; 2: 59-69.
4. Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, et al. Prevention of VTE in orthopedic surgery patents: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S
5. Kesieme EB, Okokhere P, Eluehike S, Isabu P. Challenges in the management of iliofemoral deep vein thrombosis in a resource limited setting: a case series. Pan Afr Med J 2014;18:254