The Problem with Postop Shots
The number one medication in the hospital that’s not delivered the way it’s ordered in the electronic medical record is DVT prophylaxis, according to Dr. Cramer. Whether patients miss it because they’re off the floor during a scheduled dose or they’re getting a lot of shots per day and start to refuse them, Dr. Cramer said the importance of these shots must be emphasized to patients and hospital staff for patients at high risk for VTE.
Explore This IssueJanuary 2020
For some surgical patients, there may even be a benefit to continuing Lovenox shots at home for two weeks after discharge. But while the recommendation is from primarily high-risk abdominal cancer surgery and there’s no data in otolaryngology to support it, Dr. Cramer said it’s potentially a question for very high-risk otolaryngology patients who have had flaps taken from the lower extremity if their ambulation profile is similar to some orthopedic patients.
“I want to get the right data set, and I want to study it,” he said. “We don’t routinely do it at my institution, but I’ve always been suspicious that our lower extremity free flaps are having a lot of pain and not walking and there could be a subpopulation that’s at a higher risk that could get a more intensive regimen and potentially benefit.”
When to Involve a Hematologist or Cardiologist
Dr. Kahue said she usually asks patients with a history of blood clotting disorders and prior VTE to discuss the appropriate time period to stop and restart antiplatelet and anticoagulation medications with the provider who prescribed them. She said she prefers patients to be off of aspirin or Plavix for five to seven days prior to surgery and resume these medications two to three days after surgery.
“Sometimes the cardiologist or hematologist will want to restart the blood thinners at postop day one and the surgeon prefers to delay restarting,” she said. “That’s another area that needs to be explored, because there’s no good answer. And that’s across all surgical subspecialties.”
In general, she said, an average of five days off anti-coagulation (AC) is what most ear, nose, and throat surgeons request. “Sometimes the cardiologist will give you two to three days and then you accommodate that,” she said.
Colleen Edwards, MD, board-certified hematologist at Mount Sinai Hospital in New York, said strict adherence to VTE prophylaxis is warranted for patients with a history of prior VTE who are having long, complicated surgeries requiring hospitalization for several days, particularly if those surgeries involve cancer. In this case, she said, that would mean Venodyne boots during surgery and prophylactic AC with Lovenox or fondaparinux beginning eight hours postoperatively and daily until the patient is fully ambulatory.