Perioperative Thromboprophylaxis in Elderly Patients
Thromboembolic disease (TED) is among the most common causes of death in hospitalized patients and also constitutes a significant portion of complications following surgical procedures. Without prophylaxis, thrombosis would develop in the perioperative period in almost 25% of patients. The risk of TED significantly increases with age, as does mortality. Over 21% of thrombotic complications occur in individuals over 65 years of age, and up to 16% of patients over 80 years old die shortly after being diagnosed with TED. It is crucial to focus on appropriate prevention and prophylaxis of TED in geriatric patients. However, studies have shown that thromboprophylaxis in hospitals in Europe and the USA is inadequate. Reasons may include concerns about increased bleeding during surgical procedures.
Age as a Significant Risk Factor
From a pathophysiological perspective, the development of TED is primarily influenced by a hypercoagulable state associated with the advanced age of the patient. Chronic inflammation and changes in microcirculation and cellular signaling also increase the risk of deep vein thrombosis development. For elderly patients, venostasis as a result of reduced mobility and the presence of other comorbidities (COPD, IHD, chronic heart failure, malignancies, fractures) is also characteristic. Tissue damage related to surgical intervention is then a sufficient trigger factor that leads to the development of TED.
Methods of TED Prophylaxis in Surgical and Geriatric Patients
Early mobilization of patients, as soon as possible after surgical procedures, plays a significant role in the prevention of TED. Elderly patients require intensive assistance and support from physiotherapists and rehabilitation workers, even in returning to regular daily activities. Mechanical prophylaxis methods include primarily elastic compression of the lower limbs. The benefits of compression undoubtedly include its effectiveness, ease of use, and low cost. However, it is essential to tailor it individually to the needs of each patient. Particularly in geriatric patients, skin changes, fissures, necroses, and ulcers may easily develop, and in rare cases, even compartment syndrome with compression of nerve and vascular structures can occur.
Pharmacological Prophylaxis
Low molecular weight heparins (LMWHs) are often used for pharmacological prophylaxis of TED, as they have been shown to reduce the risk of TED by up to 70%. Their efficacy is approximately comparable to unfractionated heparin (UFH), but they only need to be administered once daily, their pharmacokinetics are easier to predict, and their use is associated with a lower risk of heparin-induced thrombocytopenia. Therefore, LMWHs are among the first-line drugs in TED prophylaxis for surgical patients. Synthetic pentasaccharide fondaparinux or warfarin can also be used. However, the disadvantages of warfarin include a delayed onset of action, the need for INR monitoring, numerous drug and food interactions, and an increased risk of bleeding. The use of new oral anticoagulants (NOACs) may be beneficial, especially for patients requiring longer-term prophylaxis.
For geriatric patients, reduced renal function is typical, and changes in the pharmacokinetics of heparins can lead to an increased risk of bleeding. Therefore, dose adjustment is often necessary. For example, enoxaparin is commonly used at a dose of 2000 IU once daily for patients with moderate risk of TED and at a dose of 4000 IU once daily for patients at high risk. When glomerular filtration (GF) falls below 50 ml/min, careful clinical monitoring is recommended, but dose adjustment is not necessary. Adjustments are made when GF < 30 ml/min, where a dose of 2000 IU once daily is administered for prophylaxis. Enoxaparin is contraindicated in patients in the terminal stage of renal disease (GF < 15 ml/min).
Prophylactic administration of anticoagulants should last 7–10 days for patients with moderate risk of TED. In the case of high-risk surgical procedures in the abdomen and pelvis, it is advisable to extend thromboprophylaxis to up to 4 weeks. The first dose of enoxaparin is administered 12 hours before the procedure starts, and the next dose follows 12 hours after surgery.
Contraindications to Pharmacological Prophylaxis
Absolute contraindications for TED prophylaxis include bleeding disorders, active bleeding or high risk of bleeding (peptic ulcer, recent hemorrhagic stroke, liver failure), thrombocytopenia < 60 × 109/l, and hypersensitivity to heparin. In patients over 65 years old, the risk of bleeding complications doubles when oral anticoagulants are administered.
Conclusion
Pharmacological prophylaxis significantly and demonstrably reduces the risk of TED development. However, in geriatric patients, attention must be paid to changes occurring in the aging body. Reduced organ function, comorbidities, and polypharmacy can lead to difficult-to-manage bleeding complications. Proper individualization of therapy, i.e., its adaptation to the needs of each patient, will significantly help reduce mortality, not just during the perioperative period.
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Source: Delimpalta C., Ponchietti L. Thromboprophylaxis in elderly surgical patients: current state and future considerations. Chirurgia 2017; 112 (6): 664–672, doi: 10.21614/chirurgia.112.6.664.
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