A Three-year Retrospective Study Looking at Preventing Hospital Acquired Thrombosis.

BACKGROUND: Hospital-acquired venous thromboembolism (HA-VTE) is defined as cases of venous thromboembolism (VTE) that occur in a hospital and within ninety days of a hospital admission. Deep vein thromboses (DVTs) most commonly occur within the deep veins of the pelvis and legs. If the thrombus dislodges and travels to the lungs, it can result in a pulmonary embolus (PE). VTE is associated with significant morbidity and mortality, accounting for almost 10% of all hospital deaths. If risk factors are correctly identified and VTE prophylaxis is prescribed, VTE can be a preventable condition. In 2010, NHS England launched The National Venous Thromboembolism Prevention Programme. This included NICE guidance, and a VTE risk assessment tool, which must be completed for at least 95% of patients on admission. The National Thrombosis Survey, published by Thrombosis UK, studied how this program was implemented locally, and audited HA-VTE prevention strategies nationally. OBJECTIVES: Using the Thrombosis Survey and NICE guidance as an aide, this study collects data about hospital-acquired DVT (HA-DVT) at the Queen Elizabeth Hospital in Gateshead (QEH) and aims to: 1. Identify cases of HA-DVT and understand the clinical circumstances surrounding these cases 2. Assess the quality of VTE preventative measures at QEH 3. Outline potential improvement in reducing the incidence of HA-VTE at this hospital Methods: This retrospective cohort study used electronic records to identify all cases of DVT between April 2019 and April 2022 at QEH. Cases of HA-DVT were defined as: a positive ultrasound doppler report and either the case occurring in the 90 days following an inpatient stay, or beyond two days into an admission. For these cases of HA-DVT, we recorded the: reason for admission; admitting specialty; presence of an underlying active cancer and deaths occurring within 90 days of diagnosis. We assessed the quality of VTE preventative measures, by recording the: completion of VTE risk assessments; prescription of weight-adjusted pharmacological VTE prophylaxis and provision of VTE prophylaxis on discharge. For HA-DVT cases occurring within 90 days of an inpatient stay, the preventative measures were assessed on the original admission. Electronic records were used to record the completion rate of the National VTE risk assessment tool for all inpatients during this time frame. RESULTS: The VTE risk assessment tool was completed for 98.5% of all admissions. One hundred and thirty-five cases of HA-DVT were identified between April 2019 and April 2022. Sixteen patients with HA-DVT did not have VTE prophylaxis prescribed on admission. Eleven of these patients had a clearly documented reason why anticoagulation was avoided. In HA-DVT cases where pharmacological VTE prophylaxis was prescribed, 23% were prescribed an inappropriate dose for their weight. If anticoagulation was required on discharge, this was prescribed appropriately in 94% of cases. About 31% of the patients with HA-DVT had an underlying active malignancy. Thirty-nine patients died within 90 days of the DVT being diagnosed; in only 1 case was VTE thought to be a contributing factor to death. CONCLUSION: The hospital exceeded the national standard of VTE risk assessment completion on admission (greater than 95%). For almost a quarter of patients with HA-DVT, the dose of thromboprophylaxis prescribed was not appropriate for weight. In five cases of HA-DVT, thromboprophylaxis was omitted with no clear justification. HA-DVT often affects the most clinically vulnerable patients and is associated with a high mortality.

Emphysematous cystitis: a cause of hematuria post angioplasty.

Emphysematous cystitis (EC) is a rare, severe, urinary tract infection caused by gas-producing bacteria. It is characterized by the accumulation of air inside the bladder wall and/or lumen and is common among elderly diabetic females. This case of a 90-year-old female, who underwent bilateral iliac angioplasty and stenting, is the first published correlation between iliac angioplasty and the development of EC. The endovascular procedure performed was a success, but later on, she was confused and developed frank haematuria with a fall in haemoglobin levels. CT revealed severe EC with abundant gas tracking outside of urinary bladder into the extraperitoneal space. She was catheterized and empirical antibiotics were started and converted based on the culture sensitivities. Frequent follow-up ensured the resolution of a conservatively managed case. It is essential to increase the awareness of EC associated with angioplasties among the healthcare staff, particularly those undertaking vascular procedures.

Common femoral artery aneurysm repair using bifurcated graft.

Common femoral artery aneurysms are rare, and surgical repair is indicated if they are significantly large, or if they are symptomatic (thrombosis causing limb ischaemia and compression of surrounding structures). Synthetic grafts are preferred, especially in cases involving large aneurysms, or the bifurcation of the common femoral artery. We present a case of bilateral common femoral artery aneurysms extending into the bifurcation repaired using a synthetic graft which is traditionally used for an axillobifemoral bypass. This technique was employed due to the specific anatomical relationship between the profunda femoris and the superficial femoral artery in our patient. We will also review the current literature on the operative approaches to repair of common femoral artery aneurysms.

Management options in the treatment of femoral pseudoaneurysms secondary to intravenous drug abuse: A case series.

INTRODUCTION: Infected femoral pseudoaneurysms are a common presentation in intravenous drug users with little consensus as to the optimum management of these patients. Whilst emergency revascularisation options are available, excision and ligation of the femoral artery remains the most common operative intervention but risks leaving the patient with critical ischaemia or intermittent claudication. This case series reviewed the outcomes of 4 patients who underwent excision-ligation without revascularisation of an infected femoral pseudoaneurysm at a district general hospital. PRESENTATION: Four patients (2 male, 2 female) with infected femoral pseudoaneurysms presented via the emergency room with diagnosis confirmed with contrast cross-sectional imaging. All patients underwent emergency excision and ligation of the pseudoaneurysm without revascularisation. One patient returned to theatre with critical ischaemia necessitating a hindquarter amputation. The remaining 3 patients were discharged without claudication symptoms. CONCLUSION: With the identification of suitable patients and pre-operative optimisation, revascularisation can be performed in the emergency setting with an extra-anatomical bypass appearing to confer the best results. Currently endovascular approaches appear to be used only as a bridge to a future definitive revascularisation procedure, however, there are several case reports documenting successful outcomes when using a stent graft alongside a prolonged course of antibiotics. For the majority of patients, excision-ligation without revascularisation is both safe and effective as few are left with symptoms of limb ischaemia.

Antihypertensive and antioxidant action of amlodipine and vitamin C in patients of essential hypertension.

The etiology of essential hypertension includes increased oxidative stress. The role of antihypertensive drug amlodipine as an antioxidant and the benefit of addition of vitamin C, an antioxidant to antihypertensive therapy were studied. Forty male patients of essential hypertension were randomly divided into two groups and treated with 5 mg amlodipine. In addition one group also received 1000 mg vitamin C (as two 500 mg tablets) once daily for three months. Although blood pressure decreased in both groups, the systolic blood pressure in patients given vitamin C was less (126.4 +/- 7.47) compared to the other group (130.9 +/- 7.27). A decrease in malondialdehyde, an increase in erythrocyte sodium-potassium adenosine triphosphatase (Na(+) K(+) ATPase) and an increase in the superoxide dismutase levels were observed in both groups. The increase in SOD was statistically more in the patients given vitamin C in addition to amlodipine (0.1717 +/- 0.0150 compared to 0.152 +/- 0.0219 units/100 ml assay). In spite of the known antihypertensive, antioxidant activity, similarity in correcting endothelial dysfunction independently, giving the two drugs together and early introduction of vitamin C perhaps decreases oxidative stress and augments the antioxidant status. This may prevent further vascular damage due to oxidative stress, leading to a better prognosis in essential hypertension patients.