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Low molecular weight heparin is recommended to reduce the risk of thromboembolic complications
- Michael L Jenkinson (2 July 2006)
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Questionable role of chemo thromboprophylaxis in hip fractures
- K C Kong (7 July 2006)
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Thromboembolic prophylaxis for hip fracture
- Martyn J Parker, Antony Johansen (11 July 2006)
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Role of Community Hospitals
- Yehu E Azaz, James Price, Consultant Geriatrician (14 July 2006)
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Randomised, controlled trial should have deserved mention.
- Hamzeh Hussein, Dr. Nial Quiney- Consultant Anaesthetist (29 July 2006)
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Michael L Jenkinson, Consultant Physician Queen Elizabeth, The Queen Mother Hospital, Margate, Kent CT9 4AN
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EDITOR- Hip fracture thromboembolic prophylaxis is a contentious issue as Parker and Johansen state in their review of hip fracture[1], but in a somewhat different way to what they imply. Well might eye brows be raised by their failure to recommend any form of low molecular weight heparin thrombo-prophylaxis contrary to the latest American and British guidelines [2] . The current debate, driven by epidemiological data and recent clinical trials, is not the benefit of low molecular weight heparin preparations at proven doses, but rather the likely inadequacy of typical 5 to 10 day courses, rather than longer and more inconvenient ones of 28 days or more[3] . The authors further appear to imply that with heparin it is best to give nothing because of the risk of bleeding complications. This might be their own opinion, but their referenced 2002 Cochrane review states there is a lack of power to identify outcomes of clinical importance apart from a reduction in deep vein thrombosis. Actually the evidence base has moved on from 2002. There are concerns about wound infection rates with those on low molecular weight heparin [4] but no reason to be concerned about bleeding complications in the total context of the entire evidence base and correctly timed thrombo-prophylaxis doses of heparin, taking into account spinal anaesthesia. Considering the well characterised evidence base from studies in many countries that consistently shows that clinicians tend to undertreat with anticoagulants patients such as the elderly at highest risk of thromboembolism, and overtreat patients at low risk such as the fit young coming in for elective operations[5], the article does a gross disservice to a very important issue. Failing to make recommendations consistent with international guidelines in a review article on the management of the fractured hip could unnecessarily help perpetuate the under-treatment of one of the highest risk groups of patients for thrombotic complications. Competing Interests: None declared. References 1. Parker M. Johansen A. Hip fracture. BMJ 2006;333:27-30 2. Baglin T, Barrowcliffe TW, Cohen A, Greaves M; British Committee for Standards in Haematology. Guidelines on the use and monitoring of heparin. Br J Haematol. 2006;133(1):19-34. 3. Arcelus JI, Kudrna JC, Caprini JA. Venous thromboembolism following major orthopedic surgery: what is the risk after discharge? Orthopedics. 2006;29(6):506-16. 4. Sanchez-Ballester J, Smith M, Hassan K, Kershaw S, Elsworth CS, Jacobs L. Wound infection in the management of hip fractures: a comparison between low-molecular weight heparin and mechanical prophylaxis. Acta Orthop Belg. 2005;71(1):55-9. 5. Deheinzelin D, Braga AL, Martins LC, Martins MA, Hernandez A, Yoshida WB, Maffei F, Monachini M, Calderaro D, Campos W Jr, Sguizzatto GT, Caramelli B; Trombo Risc Investigators. Incorrect use of thromboprophylaxis for venous thromboembolism in medical and surgical patients: results of a multicentric, observational and cross-sectional study in Brazil. J Thromb Haemost. 2006;4(6):1266-70. Competing interests: None declared |
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K C Kong, Consultant Orthopaedic Surgeon King George Hospital, IG3 8YB
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EDITOR- I read this paper with interest[1] in particular the authors' views on chemo-thromboprophylaxis. The point the authors have made provides a much needed balance on this contentious issue. While there is agreement that the routine use of chemo-thromboprophylaxis does reduce the incidence of deep vein thrombosis (DVT) in patients undergoing surgery for hip fractures and major joint arthroplasty there is still no evidence of a reduction in overall mortality rates in the increasing use of routine chemothromboprophylaxis in large patient study groups in the United Kingdom[1,2]. As this seems to be the case I question the basis and actual value for the increasing attempts at the introduction of these guidelines in clinical practice. One effect of such guidelines will be the instances when nursing staff continue to administer the low molecular weight heparin to their patients with serious un-noticed post-operative bleeding just because they are told to follow the guidelines. While the evidence would suggest that routine chemo-thromboprophylaxis does not cause an increase in post-operative bleeding this is not my observation in clinical practice. It would be logical to expect an increase in post-operative bleeding if chemo-thromboprophylaxis has such a marked effect in the reduction of incidence of DVT. The other concern often raised is the effect of post-operative DVT on future risks of venous ulceration. Again there is no evidence of such an effect [4]. References 1.Parker M. Johansen A. Hip fracture. BMJ 2006;333:27-30 2. Stephen E Roberts and Michael J Goldacre. Time trends and demography of mortality after fractured neck of femur in an English population, 1968-98: database study BMJ 2003; 327: 771-775 3. C. Howie, H. Hughes, A. C. Watts Venous thromboembolism associated with hip and knee replacement over a ten-year period: A POPULATION-BASED STUDY. Scottish Arthoplasty Project J Bone Joint Surg Br 2005 87-B: 1675- 1680. 4. S. D. Muller, F. M. Khaw, R. Morris, A. E. Crozier, and P. J. Gregg. Ulceration of the lower leg after total knee replacement. J Bone Joint Surg Br, Nov 2001; 83-B: 1116 - 1118. Competing interests: None declared |
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Martyn J Parker, Hospital doctor Peterborough & Stamford NHS Foundation Trust, Antony Johansen
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Dear Sir, The issue of thromboembolic prophylaxis for hip fracture is not as clear cut as suggested by Dr Jenkinson1 and one needs to take a more critical view of the literature. Regrettably the evidence base remains weak and until randomised trials of sufficient size are undertaken, we are left with conflicting opinions regarding the relative merits of different preventative measures. The very frail elderly people who typically suffer hip fracture have a high prevalence of medical and psychiatric comorbidity, are in receipt of substantial numbers of other medications and will have suffered local bleeding at the fracture site even before surgery. Poor outcome is common and complex in nature, with symptomatic venous thromboembolism playing a relatively smaller part in this than in other clinical situations. These patients cannot be assumed to require, or to benefit from, the same approaches recommended for other patient groups. There are many observational studies which support the use of thromboembolic prophylaxis, but likewise one can quote studies which question the need. Many of the studies on this topic were small, used limited outcome measures or limited follow-up, and were sponsored by the pharmacological industry – all factors that may exaggerate the benefit and minimise the adverse complications of heparin use. 2 The British guidelines mentioned by Dr Jenkinson3 were focused on the results of the Cochrane review of heparins after hip fracture,4 but this focus does not justify the recommendation included in the guideline. The Cochrane review demonstrated a reduction in the incidence of ‘venographic thrombosis’ with the use of heparins, but no difference was demonstrated between placebo and heparin groups for the crucial clinical outcomes of pulmonary embolism and mortality. If thromboembolic complications are responsible for many of the deaths after hip fracture, then one would expect at least a trend for a reduction in mortality with prophylaxis. In fact the trend is the opposite direction; towards increased mortality with heparins. Clinical practice has changed since many of these studies were undertaken, and patients now wait for shorter periods before operation and are mobilised earlier. This may have altered the incidence of thromboembolic complications, and the balance between benefit and harm from prophylaxis may have changed. This deficiency in the evidence base is reflected in the clinical guidelines, which do not all support the use of heparin. The SIGN guidelines favour aspirin,5 whilst the New Zealand guidelines suggest either aspirin or heparin.6 Unlike heparin, aspirin has been shown to reduce the incidence of pulmonary embolism after hip fracture. Whilst no reduction in mortality after hip fracture has been shown with aspirin, at least the trend in mortality is in favour of aspirin.7 There is no clear justification for the use of extended heparin prophylaxis after hip fracture. Such a policy would have large administrative and cost implications and should not be considered until a solid evidence base exists for this approach. In summary, there is a need to stop arguing what may or may not be of benefit and concentrate on establishing an evidence base with properly conducted independently run studies on this topic. Competing Interests: None declared. References 1. Michael L Jenkinson. Low molecular weight heparin is recommended to reduce the risk of thromboembolic complications. BMJ rapid response 2 July 2006. 2. Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical industry sponsorship and research outcome and quality: systematic review. BMJ 2003;326:1167-70. 3. Baglin T, Barrowcliffe TW, Cohen A, Greaves M; British Committee for Standards in Haematology. Guidelines on the use and monitoring of heparin. Br J Haematol 2006;133:19-34. 4. Handoll HHG, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Milne AA, Gillespie WJ. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. (Cochrane Review). In: The Cochrane Library, 2002; Issue 4, Chichester, UK: John Wiley & Sons Ltd. 5. Scottish Intercollegiate Guidelines Network (SIGN). Prevention and Management of Hip Fractures in Older People. A National Guideline. Edinburgh 2002; SIGN. No.56. (www.sign.ac.uk). 6. Acute management and immediate rehabilitation after hip fracture amongst people aged 65 years and over. New Zealand Guidelines Group. 2003. www.nzgg.org.nz 7. Pulmonary embolism prevention (PEP) trial collaborative group. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000;355:1295- 302. Yours Sincerely Martyn Parker Antony Johanson Competing interests: None declared |
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Yehu E Azaz, Trust SHO in Clinical Geriatrics Department of Clinical Geratology, Radcliffe Infirmary, Oxford, OX2 6HE, James Price, Consultant Geriatrician
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Effective delivery of orthogeriatric care is likely to be a key determinant of outcome after hip fracture, but systems to deliver it are very diverse. The description given by Parker and Johansen(1) of five broad categories of rehabilitation is based on studies from Sweden and Australia, and studies mainly from the 1980s in the UK(2). Those conclusions may not be generalisable in the current UK context, and evidence regarding the effect of inpatient care delivered in community hospitals to this patient group is almost entirely absent. In the UK, community hospitals (CH) play a major part in post-acute care, facilitating early transfer from acute hospitals(3). Community hospitals are well supported by local communities, but viewed as expensive by cash-poor PCTs, and ambivalently by Government(4). One recent study(5) showed that care in CH was associated with greater independence for older people than care in wards in a district hospital. Other studies have reported no benefits(6-8). Care is usually led by local General Practitioners (GP), and less commonly by geriatric medicine specialists, sometimes supported by non- consultant career grade doctors or doctors in training. Nurse-led or therapist-led units are rare, unless one includes the recent and poorly evaluated profusion of inpatient intermediate care projects. There is little evidence to show which of GP, geriatrician, or nurse-led care is most clinically effective or cost effective in this setting. This is a subject which undoubtedly requires further research, in the interests of the health economy and patients. 1. Martyn Parker and Antony Johansen. Hip fractures. BMJ 2006; 333: 27-30 2. Cameron I, Crotty M, Currie C, Finnegan T, Gillespie L, Gillespie W, et al. Geriatric rehabilitation following fractures in older people: a systematic review. Health Technology Assessment 2000; 4(2). 3. Martin Hensher, Naomi Fulop, Joanna Coast, and Emma Jefferys. The hospital of the future: Better out than in? Alternatives to acute hospital care. BMJ, Oct 1999; 319: 1127 – 1130. 4. Adrian O’Dowd. Keep community hospitals open, primary care trusts told. BMJ April 2006; 332:873. 5. John Green, John Young, Anne Forster, Karen Mallinder, Sue Bogle, Karin Lowson, and Neil Small. Effects of locality based community hospital care on independence in older people needing rehabilitation: randomised controlled trial. BMJ, Aug 2005; 331: 317 – 322. 6. C Hine, VA Wood, S Taylor, and M Charny Do community hospitals reduce the use of district general hospital inpatient beds? J. R. Soc. Med. 1996 89: 681-687. 7. JE Baker, M Goldacre, and JA Gray. Community hospitals in Oxfordshire: their effect on the use of specialist inpatient services. J. Epidemiol. Community Health, Jun 1986;40: 117 – 120. 8. Peter J.Cook and Leonard Porter. Community hospitals and district general hospital medical bed use by elderly people: a study of 342 general practitioner beds in Oxfordshire. Age Ageing, May 1998; 27: 357 - 361. Competing interests: None declared |
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Hamzeh Hussein, Senior House Officer- Anaesthetics Anaesthetic Department,Royal Surrey County Hospital, Guildford GU2 7XX, Dr. Nial Quiney- Consultant Anaesthetist
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Dear Editor We read with interest the clinical review article (1) addressing the management of patients with fractured neck of femur. We totally agree that the prevention and management of hip fractures involves a wide range of disciplines. The complexity of care needed for hip fractures makes the condition a real test and a useful marker of the integration and effectiveness of modern health care. However we were disappointed that little mention was made of the anaesthetic management of such patients and in particular the study of Sinclair et al (2). This was prospective, randomised controlled trial comparing conventional intra-operative fluid management with repeated colloid fluid challenges guided variables derived from Oesophageal Doppler Measurements. The study showed that postoperative recovery was significantly faster in the protocol patients, with shorter times to being declared medically fit for discharge ( median 10 days vs 15 days, P <0.05) and a 39% reduction in hospital stay( 12 days vs 20 days). They concluded that intra-operative intravascular volume loading to optimal stroke volume resulted in a more rapid postoperative recovery and a significantly reduced hospital stay. The paper was not however able to demonstrate a significant change in peri-operative mortality. These findings, if reproduced across the NHS would have significant cost impact. We feel that, as this paper is likely to become a major source of reference for any doctors caring for such patients (including anaesthetists), the paper by Sinclair et al (2) should have deserved mention. References 1-M. Parker, A. Johansen. Clinical Review –Hip fracture: BMJ. 2006; 333: 27-30. (1 July) 2-S. Sinclair, S. James, M. Singer. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial: BMJ.1997;315:909-912. (October) Dr. Hamzeh Hussein--Senior House Officer/ Anaesthetics
Competing interests: None declared |
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