Risk profile and thromboprophylaxis practices among patients undergoing laparotomy at Moi Teaching and Referral Hospital, Eldoret

Abstract

Background: Venous thromboembolism (VTE) is a common preventable cause of hospital mortality worldwide. Abdominal surgery is a well-known risk factor of VTE. Venous thromboprophylaxis reduces this risk when used appropriately, but it has adverse effects. Various risk profile stratification scores have been developed to guide thromboprophylaxis. Most of these protocols are well practiced in high income countries where patient characteristics and operation setting are different from our local set up. VTE prophylaxis protocol by MTRH has been observed to be underutilized. Local research on risk profile, incidence of deep venous thrombosis (DVT) and thromboprophylaxis practice will provide an audit of our practice. Thus enabling individualization of thromboprophylaxis and development of local protocols. Objective: To describe the risk profile, thromboprophylaxis practices and clinical DVT incidence in patients undergoing laparotomy at Moi Teaching Referral Hospital, Eldoret. Methods: A prospective study was carried out in Moi Teaching and Referral Hospital on adult patients undergoing laparotomy. Consecutive sampling was used, with a minimum sample size of 325 patients. Patient‟s demographic features, risk factors of venous thromboembolism, diagnosis, intra operative findings, procedure done, thromboprophylaxis used and timing was recorded. Perioperative, 2 weeks and 4 weeks postoperative, Well‟s score was done for DVT evaluation. Doppler ultrasound of the lower limb was done on patients with a score of 2 or more to rule out DVT. Results: The mean age of participants in the study was 38years with a male to female ratio of 1.5:1. Intra-abdominal infection was the leading indication for laparotomy. All surgeries were conducted open with 75.4% of the participants stratified at high or moderate risk of developing VTE. Most, 82.7%, of the patients were mobilized within 72 hours. Enoxaparin was the only chemoprophylaxis prescribed, mostly in the post-operative period. The duration of enoxaparin administration was not standardized and no documented use of MTRH VTE risk stratification chart was observed. Moreover, 3 % of the participants received chemoprophylaxis contrary to ACCP guidelines while 12% received enoxaparin despite having relative contraindications. Only 13% and 24% of the moderate and high risk group, respectively, received chemoprophylaxis. Utilization of mechanical prophylaxis was not observed. The incidence of symptomatic DVT was 6.8%. Advanced age, Caprini score and enoxaparin prescription was associated with higher risk of symptomatic DVT development. Conclusion: The risk and incidence of VTE in laparotomy patients at MTRH is high despite the middle aged and intra-abdominal infection being operated more frequently. Poor VTE risk stratification and failure to utilize MTRH availed protocol, led to inadequate and inappropriate use of thromboprophylaxis. Recommendation: Utilization of MTRH VTE protocol by prescribers, will lead to appropriate use of prophylaxis. Availing different thromboprophylaxis options for prescriber to custom make the prophylaxis prescription. Evaluation of factors influencing MTRH VTE protocol utilization.