Low molecular weight heparin combined with aspirin to prevent perioperative venous thromboembolism in patients with splenic rupture and lower extremity fracture_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

TANG Yilun ¹ , XU Yan ² , ZHANG Xiao ³ , SONG Jinhui ¹ , WANG Kunzheng ¹ ,  YANG Pei ¹

1. Department of Orthopedic and Joint Surgery, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an Shaanxi, 710004, P. R. China;
2. Department of Hematology, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an Shaanxi, 710004, P. R. China;
3. Department of Surgery and Anesthesiology, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an Shaanxi, 710004, P. R. China;

Corresponding?author：

YANG Pei, Email: yangpei@vip.163.com

Keywords：

Venous thromboembolism; splenectomy; lower extremity fracture; prophylactic anticoagulation

DOI：

10.7507/1002-1892.202207096

Video：

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Objective To investigate the effectiveness and safety of low molecular weight heparin combined with aspirin for perioperative prophylactic anticoagulation in patients with lower extremity fracture after splenectomy. Methods The clinical data of 50 patients with splenic rupture combined with lower extremity fracture between January 2009 and June 2022 were retrospectively analyzed. All patients were given enoxaparin sodium at 48 hours after splenectomy, and stopped at 24 hours before fracture surgery. After fracture surgery, the patients were divided into aspirin group (group A, 15 cases), low molecular weight heparin group (group B, 16 cases), and low molecular weight heparin combined with aspirin group (group C, 19 cases) according to different anticoagulation regimens. The treatment course was 28 days. There was no significant difference in gender, age, body mass index, cause of injury, fracture site, time from injury to operation, complications, and other general data between groups (P>0.05). The occurrence of venous thromboembolism (VTE) was observed; hemoglobin (Hb), platelet (PLT), D-D dimer, and fibrinogen degradation product (FDP) were recorded before operation and at 1, 3, and 7 days after operation, and the effect of anticoagulation regimen on coagulation function was observed. The incidences of wound complications and bleeding related complications were recorded, and the total perioperative blood loss, hidden blood loss, and overt blood loss were calculated. Results The incidences of VTE in groups A, B, and C were 13.33% (2/15), 12.50% (2/16), and 5.26% (1/19), respectively, and there was no significant difference between groups (χ²=0.770, P=0.680). There was no portal vein thrombosis and no VTE-related death in the 3 groups. There was no significant difference in the levels of Hb, PLT, D-D dimer, and FDP between groups before and after operation (P>0.05); and there was no significant difference in total perioperative blood loss, hidden blood loss, and overt blood loss between groups (P>0.05). No local skin necrosis was found in all patients. In group A, 1 case occurred redness and swelling of incision; in group B, 1 case had incision discharge, redness, and swelling, and 1 case had fat liquefaction; in group C, 1 case had repeated incision exudation accompanied by local tissue redness and swelling, and 1 case had local hematoma. The incidences of adverse incision in groups A, B, and C were 6.66% (1/15), 12.50% (2/16), and 11.76% (2/19), respectively, with no significant difference (χ²=0.302, P=0.860). There were 4 cases of bleeding related complications, including 1 case of incision ecchymosis in groups A and B respectively, with the incidence of 6.66% and 6.25%, respectively; there was 1 case of incision hematoma and 1 case of bleeding in group C, with the incidence of 11.76%; showing no significant difference in the incidence of bleeding related complications between groups (χ²=0.268, P=0.875). Conclusion Perioperative combined use of low molecular weight heparin and aspirin for prevention of anticoagulation in patients with splenic rupture and lower extremity fracture can effectively prevent the occurrence of VTE without increasing the incidence of complications, which is an effective and safe treatment method. However, whether the incidence of VTE can be reduced needs to be further studied by expanding the sample size.

Citation： TANG Yilun, XU Yan, ZHANG Xiao, SONG Jinhui, WANG Kunzheng, YANG Pei. Low molecular weight heparin combined with aspirin to prevent perioperative venous thromboembolism in patients with splenic rupture and lower extremity fracture. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(11): 1381-1387. doi: 10.7507/1002-1892.202207096 Copy

1.	李科研, 許家祥. 四肢骨折合并脾破裂行脾切除術后骨折內固定手術時機探討. 中國實用醫藥, 2016, 11(18): 83-84.
2.	黎介壽, 吳孟超, 黃志強. 普通外科手術學. 2版. 北京:人民軍醫出版社, 2005: 975.
3.	高志成. 脾切除術后血小板驟增35例分析. 西南軍醫, 2008, 10(2): 29-30.
4.	李鐵漢, 唐波, 田大廣, 等. 脾切除術后門靜脈系統血栓形成的臨床分析. 腹部外科, 2010, 23(6): 341-343.
5.	Caprini JA. Risk assessment as a guide to thrombosis prophylaxis. Curr Opin Pulm Med, 2010, 16(5): 448-452.
6.	Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: 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.
7.	Tan TL, Foltz C, Huang R, et al. Potent anticoagulation does not reduce venous thromboembolism in haigh-risk patients. J Bone Joint Surg (Am), 2019, 101(7): 589-599.
8.	Nadi S, Vreugdenburg TD, Atukorale Y, et al. Safety and effectiveness of aspirin and enoxaparin for venous thromboembolism prophylaxis after total hip and knee arthroplasty: a systematic review. ANZ J Surg, 2019, 89(10): 1204-1210.
9.	潘維亮, 張淑華, 徐朝陽, 等. 阿司匹林和低分子肝素對下肢骨折患者圍術期血凝狀態的不同影響. 濟寧醫學院學報, 2008, 31(1): 51-52.
10.	李曉東, 安可英, 孫國鋒, 等. 低分子肝素預防老年髖關節周圍骨折圍術期下肢深靜脈血栓的研究. 重慶醫學, 2013, 42(25): 2964-2965, 2968.
11.	李興杰, 王鵬, 楊明. 外傷性多發性肋骨骨折合并脾破裂的急診診斷及臨床治療. 世界復合醫學, 2022, 8(2): 120-123, 127.
12.	中華醫學會外科學分會脾功能與脾臟外科學組. 脾臟損傷治療方式的專家共識(2014版). 臨床肝膽病雜志, 2015, 31(7): 1002-1003.
13.	Schroer WC, Calvert GT, Diesfeld PJ, et al. Effects of increased surgical volume on total knee arthroplasty complications. J Arthroplasty, 2008, 23(6 Suppl 1): 61-67.
14.	Galat DD, McGovern SC, Larson DR, et al. Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg (Am), 2009, 91(1): 48-54.
15.	Gross JB. Estimating allowable blood loss: corrected for dilution. Anesthesiology, 1983, 58(3): 277-280.
16.	Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery, 1962, 51(2): 224-232.
17.	李曉強, 王深明. 深靜脈血栓形成的診斷和治療指南 (第2版). 中國醫學前沿雜志 (電子版), 2013, 5(3): 53-57.
18.	顏軍江, 張淑芳, 曹振剛. 圍術期深靜脈血栓形成的流行病學調查和相關危險因素探討. 農墾醫學, 2017, 39(4): 306-309.
19.	中華醫學會骨科學分會. 中國骨科大手術靜脈血栓栓塞癥預防指南. 中華骨科雜志, 2016, 36(2): 65-71.
20.	Lu JP, Knudson MM, Bir N, et al. Fondaparinux for prevention of venous thromboembolism in high-risk trauma patients: a pilot study. J Am Coll Surg, 2009, 209(5): 589-594.
21.	Lee DH, Barmparas G, Fierro N, et al. Splenectomy is associated with a higher risk for venous thromboembolism: A prospective cohort study. Int J Surg, 2015, 24(Pt A): 27-32.
22.	劉鋼, 潘廷. 脾切除術后凝血機制的變化對骨折手術治療的影響. 貴州醫藥, 2012, 36(2): 119-120.
23.	Cervera R, Asherson RA, Acevedo ML, et al. Antiphospholipid syndrome associated with infections: clinical and microbiological characteristics of 100 patients. Ann Rheum Dis, 2004, 63(10): 1312-1317.
24.	但剛, 吳艾霖, 劉媛, 等. 骨折患者內固定術后血小板相關參數檢測的臨床意義. 西南國防醫藥, 2011, 21(9): 950-952.
25.	陳治學, 殷力, 張翼, 等. TKA術后應用阿司匹林、低分子肝素鈣和利伐沙班預防VTE療效分析. 醫藥論壇雜志, 2019, 40(3): 31-33.
26.	王英芬, 謝霖, 劉啟宏. 低分子肝素鈣聯合阿司匹林治療產后下肢深靜脈軟血栓形成的臨床研究. 現代實用醫學, 2016, 28(5): 605-607.
27.	Cines DB, Rauova L, Arepally G, et al. Heparin-induced thrombocytopenia: an autoimmune disorder regulated through dynamic autoantigen assembly/disassembly. J Clin Apher, 2007, 22(1): 31-36.
28.	Assadian A, Senekowitsch C, Hagmüller GW, et al. Effects of enoxaparin and unfractionated heparin on platelet activity and reactivity during carotid endarterectomy. Vascular, 2008, 16(3): 161-166.
29.	裴瑋娜, 謝瑞芹, 崔煒, 等. 不同途徑應用低分子肝素對血小板活性的影響及阿司匹林的干預作用. 中國循環雜志, 2010, 25(1): 51-54.
30.	楊昕, 文立成, 曹永平, 等. 人工膝關節置換術后血栓性事件和血小板變化關系的研究. 中國矯形外科雜志, 2016, 24(3): 226-229.
31.	Woon CYL, Shah RR, Pardi BM, et al. Aspirin alone is not enough to prevent deep venous thrombosis after total joint arthroplasty. Orthopedics, 2019, 42(1): 48-55.
32.	楊健勝, 關萬寧, 鄧自立, 等. 阿司匹林預防髖關節置換術后深靜脈血栓形成. 中華關節外科雜志 (電子版), 2019, 13(5): 526-529.
33.	葉志強, 張海峰, 王晶, 等. 低分子肝素鈣與阿司匹林預防老年股骨粗隆間骨折術后深靜脈血栓形成的效果觀察. 貴州醫藥, 2018, 42(6): 682-684.
34.	夏智昌. 低分子肝素聯合阿司匹林預防骨科術后深靜脈血栓形成的臨床觀察. 內蒙古中醫藥, 2009, 28(15): 28-29.
35.	王守寶, 楊峰, 郝成俊. 低分子肝素聯合阿司匹林預防老年髖部骨折術后下肢深靜脈血栓形成效果觀察. 臨床合理用藥, 2017, 10(1A): 88-89.

1. 李科研, 許家祥. 四肢骨折合并脾破裂行脾切除術后骨折內固定手術時機探討. 中國實用醫藥, 2016, 11(18): 83-84.
2. 黎介壽, 吳孟超, 黃志強. 普通外科手術學. 2版. 北京:人民軍醫出版社, 2005: 975.
3. 高志成. 脾切除術后血小板驟增35例分析. 西南軍醫, 2008, 10(2): 29-30.
4. 李鐵漢, 唐波, 田大廣, 等. 脾切除術后門靜脈系統血栓形成的臨床分析. 腹部外科, 2010, 23(6): 341-343.
5. Caprini JA. Risk assessment as a guide to thrombosis prophylaxis. Curr Opin Pulm Med, 2010, 16(5): 448-452.
6. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: 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.
7. Tan TL, Foltz C, Huang R, et al. Potent anticoagulation does not reduce venous thromboembolism in haigh-risk patients. J Bone Joint Surg (Am), 2019, 101(7): 589-599.
8. Nadi S, Vreugdenburg TD, Atukorale Y, et al. Safety and effectiveness of aspirin and enoxaparin for venous thromboembolism prophylaxis after total hip and knee arthroplasty: a systematic review. ANZ J Surg, 2019, 89(10): 1204-1210.
9. 潘維亮, 張淑華, 徐朝陽, 等. 阿司匹林和低分子肝素對下肢骨折患者圍術期血凝狀態的不同影響. 濟寧醫學院學報, 2008, 31(1): 51-52.
10. 李曉東, 安可英, 孫國鋒, 等. 低分子肝素預防老年髖關節周圍骨折圍術期下肢深靜脈血栓的研究. 重慶醫學, 2013, 42(25): 2964-2965, 2968.
11. 李興杰, 王鵬, 楊明. 外傷性多發性肋骨骨折合并脾破裂的急診診斷及臨床治療. 世界復合醫學, 2022, 8(2): 120-123, 127.
12. 中華醫學會外科學分會脾功能與脾臟外科學組. 脾臟損傷治療方式的專家共識(2014版). 臨床肝膽病雜志, 2015, 31(7): 1002-1003.
13. Schroer WC, Calvert GT, Diesfeld PJ, et al. Effects of increased surgical volume on total knee arthroplasty complications. J Arthroplasty, 2008, 23(6 Suppl 1): 61-67.
14. Galat DD, McGovern SC, Larson DR, et al. Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg (Am), 2009, 91(1): 48-54.
15. Gross JB. Estimating allowable blood loss: corrected for dilution. Anesthesiology, 1983, 58(3): 277-280.
16. Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery, 1962, 51(2): 224-232.
17. 李曉強, 王深明. 深靜脈血栓形成的診斷和治療指南 (第2版). 中國醫學前沿雜志 (電子版), 2013, 5(3): 53-57.
18. 顏軍江, 張淑芳, 曹振剛. 圍術期深靜脈血栓形成的流行病學調查和相關危險因素探討. 農墾醫學, 2017, 39(4): 306-309.
19. 中華醫學會骨科學分會. 中國骨科大手術靜脈血栓栓塞癥預防指南. 中華骨科雜志, 2016, 36(2): 65-71.
20. Lu JP, Knudson MM, Bir N, et al. Fondaparinux for prevention of venous thromboembolism in high-risk trauma patients: a pilot study. J Am Coll Surg, 2009, 209(5): 589-594.
21. Lee DH, Barmparas G, Fierro N, et al. Splenectomy is associated with a higher risk for venous thromboembolism: A prospective cohort study. Int J Surg, 2015, 24(Pt A): 27-32.
22. 劉鋼, 潘廷. 脾切除術后凝血機制的變化對骨折手術治療的影響. 貴州醫藥, 2012, 36(2): 119-120.
23. Cervera R, Asherson RA, Acevedo ML, et al. Antiphospholipid syndrome associated with infections: clinical and microbiological characteristics of 100 patients. Ann Rheum Dis, 2004, 63(10): 1312-1317.
24. 但剛, 吳艾霖, 劉媛, 等. 骨折患者內固定術后血小板相關參數檢測的臨床意義. 西南國防醫藥, 2011, 21(9): 950-952.
25. 陳治學, 殷力, 張翼, 等. TKA術后應用阿司匹林、低分子肝素鈣和利伐沙班預防VTE療效分析. 醫藥論壇雜志, 2019, 40(3): 31-33.
26. 王英芬, 謝霖, 劉啟宏. 低分子肝素鈣聯合阿司匹林治療產后下肢深靜脈軟血栓形成的臨床研究. 現代實用醫學, 2016, 28(5): 605-607.
27. Cines DB, Rauova L, Arepally G, et al. Heparin-induced thrombocytopenia: an autoimmune disorder regulated through dynamic autoantigen assembly/disassembly. J Clin Apher, 2007, 22(1): 31-36.
28. Assadian A, Senekowitsch C, Hagmüller GW, et al. Effects of enoxaparin and unfractionated heparin on platelet activity and reactivity during carotid endarterectomy. Vascular, 2008, 16(3): 161-166.
29. 裴瑋娜, 謝瑞芹, 崔煒, 等. 不同途徑應用低分子肝素對血小板活性的影響及阿司匹林的干預作用. 中國循環雜志, 2010, 25(1): 51-54.
30. 楊昕, 文立成, 曹永平, 等. 人工膝關節置換術后血栓性事件和血小板變化關系的研究. 中國矯形外科雜志, 2016, 24(3): 226-229.
31. Woon CYL, Shah RR, Pardi BM, et al. Aspirin alone is not enough to prevent deep venous thrombosis after total joint arthroplasty. Orthopedics, 2019, 42(1): 48-55.
32. 楊健勝, 關萬寧, 鄧自立, 等. 阿司匹林預防髖關節置換術后深靜脈血栓形成. 中華關節外科雜志 (電子版), 2019, 13(5): 526-529.
33. 葉志強, 張海峰, 王晶, 等. 低分子肝素鈣與阿司匹林預防老年股骨粗隆間骨折術后深靜脈血栓形成的效果觀察. 貴州醫藥, 2018, 42(6): 682-684.
34. 夏智昌. 低分子肝素聯合阿司匹林預防骨科術后深靜脈血栓形成的臨床觀察. 內蒙古中醫藥, 2009, 28(15): 28-29.
35. 王守寶, 楊峰, 郝成俊. 低分子肝素聯合阿司匹林預防老年髖部骨折術后下肢深靜脈血栓形成效果觀察. 臨床合理用藥, 2017, 10(1A): 88-89.

Chinese Journal of Reparative and Reconstructive Surgery

Low molecular weight heparin combined with aspirin to prevent perioperative venous thromboembolism in patients with splenic rupture and lower extremity fracture

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