Thrombotic Event Prevention in Patients Undergoing Posterior Lumbar Arthrodesis: our experiencie. A retrospective case series study. / Prevención de eventos trombóticos en pacientes sometidos a cirugía de artrodesis lumbar por vía posterior: experiencia en nuestro centro. Estudio retrospectivo de casos.

INTRODUCTION: There is no generalized consensus regarding perioperative prophylaxis of venous thromboembolism (VTE), either on using or timing it in patients undergoing spine surgery. VTE is a current concern because, even though being an uncommon event, it can cause serious complications. The aim of the present study is to propose guidelines for the prevention of thrombotic events in posterior spinal surgery, either as deep vein thrombosis or pulmonary thromboembolism. If the number of patients getting prophylaxis drugs is reduced a subsequent reduction of the incidence of epidural hematoma can be expected. MATERIALS AND METHODS: A number of 235 patients who had undergone posterior spinal arthrodesis in the previous five years were studied. Mechanical thromboprophylaxis measures consisting of compression stockings were applied in all of them. Anticoagulant drugs were also applied whenever risk factors for thrombosis were observed. Early weight-bearing was resumed immediately after surgery. Demographic, clinical, and surgical variables were collected, as well as complications appearing during the follow-up period, that was scheduled at one, two, four, six and twelve months after the surgery. Thrombotic events, if present, were diagnosed by clinical and imaging tests such as ultrasound and CT angiography. RESULTS: From the total 235 patients of this series, one hundred and fifty-three cases met the study inclusion criteria. A total of four thrombotic events appeared, one in the form of deep vein thrombosis and other three in the form of pulmonary thromboembolism. These last patients suffering an embolism died because of it. None of the variables studied had statistical significance for the occurrence of a thrombotic event. All four patients who suffered thrombotic events were receiving anticoagulant drugs, in addition to mechanical compression stockings, because of the presence of risk factors for thrombosis. CONCLUSIONS: By applying the fore mentioned protocol, adequate prevention of thromboembolic events was achieved in this study population of patients undergoing posterior spinal surgery.

Tromboprofilaxis en COVID-19. Nuevas evidencias / COVID-19 thromboprophylaxis: New evidences

Recientes publicaciones han puesto en duda la eficacia de la utilización de dosis terapéuticas o intermedias de heparina de bajo peso molecular (HBPM) en pacientes COVID-19, especialmente en los pacientes más graves. Con el objetivo de actualizar estas recomendaciones se ha realizado una revisión no sistemática en las principales bases de datos médicas. Se seleccionaron un total de 14 ensayos clínicos aleatorizados, 14 metaanálisis y las recomendaciones de 12 sociedades científicas, estratificadas según el tipo de paciente (ambulatorio, hospitalizado, ingresado en cuidados críticos o post-alta). Se ha analizado la eficacia de HBPM y también de otras aproximaciones terapéuticas (rivaroxabán, apixabán, sulodexida, ácido acetilsalicílico e inhibidores P2Y12). Los hallazgos recomiendan utilizar dosis estándar de HBPM como tromboprofilaxis en los pacientes COVID-19 hospitalizados críticos y dosis terapéutica en hospitalizados no críticos si el riesgo de sangrado es bajo. En los pacientes ambulatorios y dados de alta del hospital podría utilizarse HBPM a dosis profiláctica si existen factores de riesgo trombótico y el riesgo hemorrágico es bajo. No se recomienda asociar antiagregantes plaquetarios a la HBPM salvo indicación previa.(AU)

Recent publications have questioned the efficacy of using therapeutic or intermediate doses of low molecular weight heparin (LMWH) in COVID-19 patients, especially in the most severe patients. In order to update these recommendations, a non-systematic review has been carried out in the main medical databases. A total of 14 randomized clinical trials, 14 meta-analyses and the recommendations of 12 scientific societies were selected, stratified according to the type of patient (outpatient, hospitalized, admitted to critical care or post-discharge). The efficacy of LMWH and other therapeutic approaches (rivaroxaban, apixaban, sulodexide, acetylsalicylic acid and P2Y12 inhibitors) has been analyzed. The findings recommend using standard doses of LMWH as thromboprophylaxis in critically hospitalized COVID-19 patients and therapeutic doses in non-critically hospitalized patients with low bleeding risk. In outpatients and those discharged from the hospital, LMWH could be used at a prophylactic dose if there are thrombotic risk factors, and the bleeding risk is low. It is not recommended to associate antiplatelet agents with LMWH unless previously indicated.(AU)

COVID-19 thromboprophylaxis. New evidence.

Recent publications have questioned the efficacy of using therapeutic or intermediate doses of low molecular weight heparin (LMWH) in COVID-19 patients, especially in the most severe patients. In order to update these recommendations, a non-systematic review has been carried out in the main medical databases. A total of 14 randomized clinical trials, 14 meta-analyses and the recommendations of 12 scientific societies were selected, stratified according to the type of patient (outpatient, hospitalized, admitted to critical care or post-discharge). The efficacy of LMWH and other therapeutic approaches (rivaroxaban, apixaban, sulodexide, acetylsalicylic acid and P2Y12 inhibitors) has been analyzed. The findings recommend using standard doses of LMWH as thromboprophylaxis in critically hospitalized COVID-19 patients and therapeutic doses in non-critically hospitalized patients if the risk of bleeding is low. In outpatients and those discharged from the hospital, LMWH could be used at a prophylactic dose if there are thrombotic risk factors, and the bleeding risk is low. It is not recommended to associate antiplatelet agents with LMWH unless previously indicated.

[Recommendations for thromboembolic disease in oncological processes. A view from primary care]. / Recomendaciones sobre enfermedad tromboembólica venosa en procesos oncológicos. Una visión desde la medicina de familia.

Venous thromboembolic disease (VTE) is a frequent complication in patients diagnosed with cancer and a cause of morbidity and mortality. Approximately 20% of thromboembolic episodes develop in association with active cancer. On the other hand, it is estimated that about 2-12% of cases, the thromboembolic episode is the first manifestation of an occult cancer, diagnosed at that time or subsequently, which offers an opportunity for early diagnosis and treatment. There are multiple factors that contribute to increase the risk of VTE in oncological patients in relation to specific characteristics of the patient, the tumor and the treatments. Knowledge of these risk factors will contribute to early diagnosis when signs of VTE appear, as well as the assessment of thromboprophylaxis if indicated. The diagnosis of VTE in patients with cancer does not differ of those who do not suffer from it. Regarding the treatment of VTE in these patients, low molecular weight heparin (LMWH), direct acting anticoagulants (DACs) and antivitamin K (VKA) are the most commonly used, although the dosing regimen and length are not clear yet. The management of these patients should be interdisciplinary and early, so the primary care physician plays a key role in this process as he/she is liaise with his/her patients. It is also necessary to update knowledge in order to improve the care of these patients. For these reasons, this document has been prepared by the Working Group on Vasculopathies of the Spanish Society of Primary Care Physicians (SEMERGEN) whose objective is to present the available information regarding the management of VTE that may appear in oncological patients, as well as the assessment of thromboprophylaxis and treatment, if appropriate, from an approach focused on a primary care field.

Eficacia de la tromboprofilaxis con heparina de bajo peso molecular en pacientes críticos con COVID-19: estudio observacional, prospectivo y multicéntrico / Effectiveness of thromboprophylaxis with low molecular weight heparin in critically ill patients with COVID-19. An observational prospective, multicenter study

Introducción: Los pacientes COVID-19 presentan una coagulopatía caracterizada por una elevada incidencia de complicaciones tromboembólicas. Ante la controversia existente sobre el manejo de la tromboprofilaxis, se llevó a cabo un estudio con el objetivo de analizar el efecto de las diferentes dosis de heparina de bajo peso molecular (HBPM) utilizadas en los pacientes críticos con COVID-19. Material y métodos: Se evaluaron datos del Reg-COVID-19. Se compararon 2 grupos de pacientes según la dosis de HBPM administrada: profilaxis y tratamiento. El objetivo primario fue determinar si había relación de la dosis de HBPM con la mortalidad. Los objetivos secundarios incluyeron la incidencia de eventos trombóticos y hemorrágicos, la duración de la estancia en la UCI, la ventilación mecánica invasiva y los parámetros trombóticos e inflamatorios. Resultados: Se analizaron datos de 720 pacientes, 258 en el grupo de profilaxis y 462 en el de tratamiento. La proteína C reactiva, la ventilación mecánica invasiva y el tratamiento con tocilizumab o corticosteroides se relacionaron con la elección de la dosis de HBPM. La incidencia de complicaciones hemorrágicas (66/720, 9,2%) y trombóticas (69/720, 9,6%) fue similar en ambos grupos, al igual que el curso temporal de los eventos trombóticos, que ocurrieron antes que los hemorrágicos (9 [3-18] y 12 [6-19] días, respectivamente). La mortalidad fue menor en el grupo de profilaxis (25,2 frente al 35,1%), pero al aplicar un modelo de ponderación de probabilidad inversa, no se encontraron diferencias entre los grupos. Conclusión: No se encontraron efectos beneficiosos ni perjudiciales relacionados con la administración de dosis profilácticas o terapéuticas de HBPM en pacientes críticos COVID-19, con una tasa similar de complicaciones hemorrágicas o trombóticas. A partir de estos resultados, consideramos que son necesarios más estudios para determinar el protocolo óptimo de tromboprofilaxis en estos pacientes.(AU)

Introduction: COVID-19 induces coagulopathy associated with an increase of thromboembolic events. Due to the lack of agreement on recommendations for thromboprophylactic management, the aim of this study was to study the dosages of LMWH used in critically ill COVID-19 patients assessing the effect on their outcome. Metohds: We evaluated data of the Reg-COVID19. According to LMWH dose two groups were analyzed: prophylaxis and treatment. Primary outcome was the relationship of LMWH dosage with mortality. Secondary outcomes included the incidence of thrombotic and bleeding events, length of ICU stay, invasive mechanical ventilation, and thrombotic and inflammatory parameters. Results: Data of 720 patients were analyzed, 258 in the prophylaxis group and 462 in the treatment group. C Reactive Protein, invasive mechanical ventilation, tocilizumab and corticosteroid treatments were related with the choice of LMWH dose. Hemorrhagic events (66/720, 9.2%) and thrombotic complications (69/720, 9.6%) were similar in both groups (P=.819 and P=.265), as was the time course of the thrombotic events, earlier than hemorrhagic ones (9 [3-18] and 12 [6-19] days respectively). Mortality was lower in prophylaxis group (25.2% versus 35.1%), but once an inverse probability weighting model was applied, we found no effect of LMWH dose. Conclusion: We found no benefit or harm with the administration of therapeutic or prophylactic LMWH dose in COVID19 critically ill patients. With a similar rate of hemorrhagic or thrombotic events, the LMWH dose had no influence on mortality. More studies are needed to determine the optimal thromboprophylaxis protocol for critically ill patients.(AU)

Effectiveness of thromboprophylaxis with low molecular weight heparin in critically ill patients with COVID-19. An observational prospective, multicenter study.

INTRODUCTION: COVID-19 induces coagulopathy associated with an increase of thromboembolic events. Due to the lack of agreement on recommendations for thromboprophylactic management, the aim of this study was to study the dosages of LMWH used in critically ill COVID-19 patients assessing the effect on their outcome. METHODS: We evaluated data of the Reg-COVID19. According to LMWH dose two groups were analyzed: prophylaxis and treatment. Primary outcome was the relationship of LMWH dosage with mortality. Secondary outcomes included the incidence of thrombotic and bleeding events, length of ICU stay, invasive mechanical ventilation, and thrombotic and inflammatory parameters. RESULTS: Data of 720 patients were analyzed, 258 in the prophylaxis group and 462 in the treatment group. C Reactive Protein, invasive mechanical ventilation, tocilizumab and corticosteroid treatments were related with the choice of LMWH dose. Hemorrhagic events (66/720, 9.2%) and thrombotic complications (69/720, 9.6%) were similar in both groups (p = .819 and p = .265), as was the time course of the thrombotic events, earlier than hemorrhagic ones (9 [3-18] and 12 [6-19] days respectively). Mortality was lower in prophylaxis group (25.2% versus 35.1%), but once an inverse probability weighting model was applied, we found no effect of LMWH dose. CONCLUSION: We found no benefit or harm with the administration of therapeutic or prophylactic LMWH dose in COVID19 critically ill patients. With a similar rate of hemorrhagic or thrombotic events, the LMWH dose had no influence on mortality. More studies are needed to determine the optimal thromboprophylaxis protocol for critically ill patients.

Tromboprofilaxis precoz y evolución en embarazadas con COVID-19 / Early thromboprophylaxis and evolution in pregnant women with COVID-19

Introducción: en marzo del año 2020 se declara Pandemia, por la aparición de un nuevo Coronavirus, el SARS-CoV2 (COVID-19). Las mujeres embarazadas presentan un riesgo mayor de presentar procesos tromboembólicos, por lo que se recomienda utilizar de manera profiláctica heparina, para prevención de procesos tromboembólicos durante la infección por SARS-CoV2. Objetivo: Describir la evolución de las embarazadas con infección por SARS-CoV2 con la utilización de heparina de bajo peso molecular, Enoxaparina, ajustada al peso de manera precoz. Metodología: estudio descriptivo prospectivo, observacional, de corte transversal. Resultados: en la evolución de 30 mujeres embarazadas con infección por SARS-CoV2, las edades más frecuentes corresponden a 31 a 35 años, mayor número de infectadas en el segundo trimestre del embarazo, el índice de masa corporal predominante en rango de sobrepeso y obesidad, la dosis de enoxaparina utilizada fue de 40 mg/día, ya que se ajustó al peso de la embarazada, las comorbilidades más frecuentes correspondieron al sobrepeso y obesidad, enfermedad hipertensiva del embarazo y diabetes gestacional, la sintomatología resultó muy variada, debido a las distintas variantes del virus, con más frecuencia la rinorrea, congestión nasal, tos, anosmia, disgeusia, cefalea, fiebre y dificultad respiratoria, y la mayoría de las embarazadas no estaban vacunadas. Conclusiones: ninguna de las 30 embarazadas que recibieron heparina de bajo peso molecular (Enoxapina), ajustada al peso, y de manera precoz, con infección por SARS.CoV2, falleció, ni requirió internación en Unidad de Terapia Intensiva. Una embarazada, fue internada por disnea moderada y saturación de oxígeno menor a 95%. Las restantes embarazadas tuvieron buena evolución en su domicilio, sin ninguna complicación

Introduction: in March 2020, a Pandemic was declared, due to the appearance of a new Coronavirus, SARS-CoV2 (COVID-19). Pregnant women have a higher risk of presenting thromboembolic processes, so it is recommended to use heparin prophylactically, to prevent thromboembolic processes during SARS-CoV2 infection. Objective: to describe the evolution of pregnant women with SARS-CoV2 infection with the early use of Enoxaparin, adjusted to the weight of low molecular weight heparin. Methodology: prospective, observational, cross-sectional descriptive study. Results: in the evolution of 30 pregnant women with SARS-CoV2 infection, the most frequent ages correspond to 31 to 35 years, the highest number of infected in the second trimester of pregnancy, the predominant body mass index in the range of overweight and obesity. , the dose of enoxaparin used was 40 mg/day, since it was adjusted to the weight of the pregnant woman, the most frequent comorbidities were overweight and obesity, hypertensive disease of pregnancy and gestational diabetes, the symptoms were highly varied, due to the different variants of the virus, more frequently rhinorrhea, nasal congestion, cough, anosmia, dysgeusia, headache, fever and respiratory distress, and most of the pregnant women were not vaccinated. Conclusions: none of the 30 pregnant women who received low molecular weight heparin (Enoxapine), adjusted for weight, and early, with SARS.CoV2 infection, died or required admission to the Intensive Care Unit. A pregnant woman was hospitalized due to moderate dyspnea and oxygen saturation less than 95%. The remaining pregnant women had a good evolution at home, without any complications

Concomitant acute lower extremity arterial and deep vein thrombosis developing in a patient under anticoagulant therapy after COVID 19 infection / Trombosis arterial aguda y trombosis venosa profunda concomitantes de extremidad inferior en un paciente bajo terapia anticoagulante después de infección por COVID 19

Abstract The hypercoagulable state continues after the Coronavirus 2019 (Covid 19) infection and prophylactic anticoagulants are recommended in this period. However, arterial and venous thromboembolic events can be observed during the convalescence period after the Covid 19. Here, we present the case of acute lower extremity arterial and venous thromboembolism developed in the post-Covid 19 period in a 77-years-old patient, under therapeutic doses of anticoagulant therapy (enoxparin 1mg/kg of weight every 12 hours). The patient, who had no previous history of arterial or venous thrombosis, was taken to emergency surgery with the diagnosis of ALI (acute limb ischemia) due to acute arterial thrombosis. An arterial thrombectomy was performed with the help of a 4F Fogarty catheter inserted from the left femoral artery under local anesthesia. All distal pulses of the patient were palpable in the postoperative period. After the platelet count became >100,000 mm3, 100 mg of acetylsalicylic acid daily was added to the therapeutic dose of enoxaparin sodium treatment. The patient was discharged, uneventfully, except for a minimal diameter increase secondary to deep venous thrombosis (DVT) on the fifth postoperative day, with a combination of enoxaparin and acetylsalicylic acid treatment. Endothelial injury, chronic immuno-thrombogenicity, and increased platelet aggregation in the post-Covid 19 recovery period can cause major thrombotic events, even weeks after the recovery. Anticoagulant therapy is recommended for thromboprophylaxis when the following statuses exist: ≥65 years, critical illness, cancer, prior VTE, thrombophilia, severe immobility, and elevated D- dimer. Combination treatment with long-term antiaggregant therapy may be prudent in thromboembolic events developed under anticoagulant therapy.

Resumen El estado de hipercoagulabilidad continúa después de la infección por Coronavirus 2019 (Covid-19) y la anticoagulación profiláctica se recomienda durante este período. Sin embargo, eventos tromboembólicos arteriales y venosos se pueden observar durante el período de convalecencia posterior al Covid-19. Se presenta el caso de trombosis venosa profunda (TVP) y arterial agudas de una extremidad inferior en una paciente de 77 años, bajo terapia anticoagulante (enoxparin 1mg/kg de peso, cada 12 horas), en el período post- Covid 19. La paciente, sin historia previa de trombosis arterial ni venosa, fue llevada a cirugía de emergencia con el diagnóstico de isquemia aguda de extremidades por trombosis arterial aguda. Se le realizó trombectomía arterial con la ayuda de un catéter Fogarty 4F insertado desde la arteria femoral izquierda bajo anestesia local. Todos los pulsos distales del paciente fueron palpables en el periodo postoperatorio. Después de que las plaquetas llegaron a ser mayores a100.000 mm3, 100 mg de ácido acetilsalicílico diarios se añadieron a la dosis terapéutica del tratamiento con enoxaparina sódica. La paciente fue dada de alta sin incidencias, excepto por un mínimo aumento de diámetro secundario a la TVP, al quinto día postoperatorio con la combinación de enoxaparina y ácido acetilsalicílico. La lesión endotelial, la inmunotrombogenicidad crónica y la agregación plaquetaria aumentada en el período de recuperación posterior a Covid-19 pueden causar eventos trombóticos importantes incluso semanas después de la recuperación. La combinación con terapia antiagregante a largo plazo puede ser prudente en los casos de eventos tromboembólicos desarrollados en pacientes con terapia anticoagulante.

Tromboprofilaxis en pacientes hospitalizados: implementación de un programa multifacético / Thromboprophylaxis in hospitalized patients: implementation of a multifacetical program

Resumen La enfermedad tromboembólica venosa es la causa prevenible más frecuente de muerte hospitalaria. A pesar de contar con evidencia y recomendaciones sobre la utilidad de la tromboprofilaxis, la adherencia por parte de los médicos a las mismas es muy variable, y frecuentemente subóptima. El objetivo de este estudio fue evaluar un programa institucional con estrategias multifacéticas dirigido a médicos, sobre tromboprofilaxis en internación y estimar el cambio en la adecuación de la tromboprofilaxis antes y después de la intervención. La intervención se mantuvo durante 6 años, fue múltiple, utilizando acciones pasivas como car telería, y activas, como educación médica continua, confección y adopción de una guía institucional de práctica clínica y un sistema de soporte informático para la decisión clínica. La adecuación basal de la tromboprofilaxis mejoró de 59% a 82% después de la intervención y se mantuvo en el tiempo. La mejora en la adecuación se asoció a una reducción de los sangrados mayores, en particular en pacientes intervenidos quirúrgicamente.

Abstract Venous thromboembolic disease is the most common preventable cause of hospital death. Despite the existence of evidence of the usefulness of thromboprophylaxis and recommendations, adherence by physicians to them is highly variable, and frequently suboptimal. The objective was to evaluate the change in the adequacy of thromboprophylaxis before and after an intervention on thromboprophylaxis with multifaceted strategies for physicians. The intervention was a 6 years institutional program with multiple strategies: passive actions such as posters and active actions as continuous medical education, adaptation of an institutional clinical practice guide and a computerized clinical decision support system. The baseline adequacy of thromboprophylaxis improved from 59% to 82% and was maintained over time. The improvement in fitness was associated with a reduction in major bleeding, particularly in patients undergoing surgery.

Impacto del perfil mutacional sobre el riesgo trombótico en pacientes con cáncer / Impact of the mutation profile on thrombotic risk in cancer patients

Los pacientes con cáncer presentan un riesgo elevado de trombosis, que condiciona una elevada morbimortalidad. Se han desarrollado diversas escalas predictivas para la identificación de aquellos con alto riesgo trombótico, incorporando datos clínicos y biológicos, pero, en general, no permiten una selección óptima de los sujetos candidatos para recibir tromboprofilaxis. Estudios recientes demuestran que el perfil mutacional tiene un alto impacto sobre el riesgo trombótico, lo que va a facilitar el desarrollo de nuevos modelos predictivos de trombosis en pacientes con cáncer (AU)

Patients with cancer present with an elevated risk of thrombosis, which entails high morbidity and mortality. Various predictive scales that incorporate clinical and biological data have been developed to identify those at high risk of thrombosis, but, in general, they do not allow for the optimal selection of subjects who are candidates for thromboprophylaxis. Recent studies have demonstrated that the mutation profile has a high impact on the risk of thrombosis; this will facilitate developing new predictive models of thrombosis in patients with cancer (AU)

Impact of the mutation profile on thrombotic risk in cancer patients.

Patients with cancer present with an elevated risk of thrombosis, which entails high morbidity and mortality. Various predictive scales that incorporate clinical and biological data have been developed to identify those at high risk of thrombosis, but, in general, they do not allow for the optimal selection of subjects who are candidates for thromboprophylaxis. Recent studies have demonstrated that the mutation profile has a high impact on the risk of thrombosis; this will facilitate developing new predictive models of thrombosis in patients with cancer.

Utilización de tromboprofilaxis en el período grávido - puerperal por Ginecólogos y Residentes de Ginecología del Uruguay

Resumen: Introducción: La enfermedad tromboembólica venosa en el período grávido - puerperal es una de las primeras causas de morbi-mortalidad materna. No existe un consenso acerca de las directivas para su abordaje, por lo que el objetivo de esta investigación fue conocer cómo se desempeñan los Ginecólogos y Residentes de Ginecología del Uruguay, con respecto a distintos factores de riesgo, la indicación de tromboprofilaxis y las herramientas disponibles. Metodología: Se realizó de julio a octubre del 2020, un estudio observacional, descriptivo, transversal donde se incluyeron a Ginecólogos y Residentes de Ginecología del Uruguay, mediante una encuesta electrónica anónima a través de la plataforma Survey Monkey. Resultados: Se obtuvo un n de 159 encuestados. El 57,3% refirió pensar sistemáticamente en factores de riesgo para enfermedad tromboembólica venosa. Las guías más utilizadas para la clasificación del riesgo e indicación de tromboprofilaxis fueron la American College of Obstestricians and Gynecologists con un 81,0% y la Royal College of Obstestricians and Gynaecologists con un 13,0%. La herramienta terapéutica con mayor disponibilidad es la heparina de bajo peso molecular y la menos utilizada es la compresión neumática intermitente. Conclusiones: Existen inconsistencias entre la clasificación de riesgo e indicación de tromboprofilaxis en diferentes situaciones clínicas. Existe un porcentaje no despreciable de profesiones que no piensan sistemáticamente en factores de riesgo para eventos tromboembólicos durante el período grávido - puerperal.

Abstract: Introduction: One of the main causes of maternal morbity and mortality in the pregnant - puerperal period is venous thromboembolic disease. There is no consensus on the guidelines to address this illness. The main objective of this research was to know how Gynecologists and Gynecology Residents of Uruguay perform, in reference to considering potential risk factors, indication for thromboprophylaxis and the tools available. Methodology: An observational, descriptive, cross-sectional study carried out from July to October 2020, including Gynecologists and Gynecology Residents of Uruguay, through an anonymous online survey using the Survey Monkey platform. Results: A final n of 159 respondents was obtained. 57.3% of which referred to think systematically about risk factors for venous thromboembolic disease. The most popular guidelines for risk classification and indication of thromboprophylaxis were the American College of Obstestricians and Gynaecologists with 81.0% and the Royal College of Obstestricians and Gynaecologists with 13.0%. The most chosen therapeutic tool was low molecular weight heparin, and the least preferred one was intermittent pneumatic compression. Conclusions: There are incoherences between the risk classification and the actual indication of thromboprophylaxis in different clinical situations. There´s still a non-negligible percentage of professionals that do not systematically consider risk factors for thromboembolic events during the pregnant-puerperal period.

Resumo: Introdução: A doença tromboembólica venosa no período gestação - puerpério é uma das principais causasde morbidadee mortalidade materna. Nãohá consenso sobre as diretrizes para o seu abordagem, por issoo objetivo desta pesquisa foi saber como encarao os ginecologistas e os residentes em ginecologia do Uruguai, no que dizrespeito à fatores de risco, indicação de tromboprofilaxia e as ferramentas disponíveis. Metodologia: Estudo observacional, descritivo e transveral realizado de julho a outubro de 2020, que incluiu ginecologistas e residentes em ginecologia do Uruguai. Um levantamento eletrônico anónimo foi desenvuelto através da plataforma SurveyMonkey. Resultados: Foram estudados 159 entrevistados. 57,3% relataram pensarsobre fatores de risco para doença tromboembólica venosa. As diretrizesmais utilizadas para classificação de risco e indicação de tromboprofilaxia foram o American College of Obstestricians and Gynecologists com 81,0% e o Royal College of Obstestricians and Gynaecologists com 13,0%. A ferramenta mais selecionada é heparina de baixo peso molecular e a menos utilizada é a compressão pneumática intermitente. Conclusões: Há inconsistências entre a classificação de risco e a indicação de tromboprofilaxia em diferentes situações clínicas. Ainda há um numero consideravel de profisionais que não pensam sistematicamente em fatores de risco para eventos tromboembólicos durante o período gravidez - puerperal.

Tromboprofilaxis, anticoagulación y coagulopatía en tiempos de pandemia: recomendación de la ACATA, ACMI, SCC CCV y ACMV / Thromboprophylaxis, anticoagulation and coagulopathy in times of pandemic: The ACATA, ACMI, SCC CCV and ACMV recommendation

Resumen Introducción La enfermedad por coronavirus 2019 (COVID-19) puede predisponer a tromboembolia venosa o trombosis arterial debido a una respuesta inflamatoria aumentada, hipoxia, inmovilización y coagulación intravascular diseminada; hasta en un 20 a 50% de pacientes hospitalizados con COVID-19 tienen alteraciones hematológicas relacionadas con coagulopatía (dímero D elevado, tiempo de protrombina prolongado, trombocitopenia y/o fibrinógeno bajo). Evaluaciones post mortem evidencian depósitos trombóticos microvasculares típicos, ricos en plaquetas en vasos pequeños de pulmones y otros órganos. Objetivo Brindar una aproximación práctica y actualizada en el manejo del paciente con riesgo elevado o que presentan eventos tromboembólicos en el marco de la actual pandemia por COVID-19. Material y métodos: Se realizó una revisión narrativa que incluyó estudios observacionales descriptivos. Se efectuó una búsqueda de la literatura de evidencia médica en diferentes buscadores como Science Direct y PubMed, usando las palabras claves “thromboprophylaxis”, “anticoagulation”, “thrombosis”, “anticoagulant”, “COVID-19”, “SARS-CoV-2”, “coronavirus”. Posteriormente se escribieron las recomendaciones generales referentes al tema. Conclusiones Existen diferentes formas en las que la pandemia por COVID-19 puede predisponer al desarrollo de enfermedades trombóticas o tromboembólicas, el efecto directo o indirecto de este virus relacionado con la tormenta de citocinas que precipita el inicio del síndrome de respuesta inflamatoria sistémica y predispone al desarrollo de eventos trombóticos; también las intervenciones disponibles pueden tener interacciones farmacológicas con antiagregantes y/o anticoagulantes.

Abstract Introduction Coronavirus 19 infection can predispose to VTE or arterial thrombosis due to a heightened inflammatory response, hypoxia, immobility and DIC. Up to 20-50% of hospitalized patients with COVID-19 have hematological disorders related to coagulopathies (elevated D-dimer, prolonged PT, thrombocytopenia and/or low fibrinogen). Post-mortem examinations show typical platelet-rich microvascular thrombotic deposits in the small vessels of the lungs and other organs. Objective To provide a practical, updated approach to the treatment of patients at high risk for or with ongoing thromboembolic events in the current COVID-19 pandemic setting. Material and methods A narrative review was performed including descriptive observational studies. A search of the medical evidence literature was carried out in different search engines such as ScienceDirect and PubMed, using the following key words: “thromboprophylaxis”, “anticoagulation”, “thrombosis”, “anticoagulant”, “COVID-19”, “SARS-CoV-2”, and “coronavirus”, and general recommendations on the topic were subsequently composed. Conclusions The are various ways in which the COVID-19 pandemic may predispose to the development of thrombotic or thromboembolic diseases. The virus may have a direct or indirect effect related to the cytokine storm which triggers the onset of systemic inflammatory response syndrome and predisposes to the development of thrombotic events. The available interventions may also have pharmacological interactions with antiplatelet drugs and/or anticoagulants.

Trombosis venosa profunda y trombofilia congénita / Deep-vein thrombosis and congenital thrombophilia

Introducción: La trombofilia es un desorden de la hemostasia congénito o adquirido que predispone al desarrollo de trombosis. Las trombofilias congénitas más frecuentes son las deficiencias de antitrombina III, proteína C y proteína S, el factor V Leiden, la mutación del gen de la protrombina (G20210A) y las mutaciones de la enzima metilentetrahidrofolato reductasa (MTHFR). Objetivo: Describir el manejo anestésico en un paciente portador de trombofilia congénita. Presentación del caso: Se reporta un paciente de 19 años de edad con antecedentes de historia familiar y personal de trombosis venosa profunda, tratamiento con doble antiagregación plaquetaria y asociación de tres mutaciones para trombofilia congénita, G20210A, A1298C MTHFR y C677T MTHFR que recibe anestesia espinal para una herniorrafia inguinal. Se mantiene tratamiento con aspirina, se suspende clopidogrel 7 días antes de la cirugía y durante ese tiempo se administra fraxiparina 0.6 Uds. subcutánea diarias hasta 12 h antes de la cirugía, se utiliza medias elásticas, deambulación precoz y reinicio de clopidogrel 24 h después de la cirugía, con evolución satisfactoria. Conclusiones: La tromboprofilaxis en pacientes portadores de trombofilia congénita es mandatoria, por eso resulta determinante la utilización de heparina de bajo peso molecular junto al resto de las medidas de prevención de la trombosis venosa profunda(AU)

Introduction: Thrombophilia is a congenital or acquired hemostasis disorder that predisposes to thrombosis development. The commonest congenital thrombophilias are deficiencies of antithrombin III, protein C and protein S, factor V Leiden, prothrombin gene mutation (G20210A), and methylenetetrahydrofolate reductase (MTHFR) mutations. Objective: To describe the anesthetic management in a patient with congenital thrombophilia. Case presentation: The case is reported of a 19-year-old patient with a family and personal history of deep-vein thrombosis, treatment with double antiplatelet therapy and association of three mutations for congenital thrombophilia (G20210A, A1298C MTHFR and C677T MTHFR), who receives spinal anesthesia for an inguinal herniorrhaphy. Aspirin treatment is maintained. Clopidogrel is suspended seven days before surgery. During this time, fraxiparin is administered subcutaneously in 0.6-mL units daily, up to twelve hours before surgery. Elastic stockings are used, early ambulation is allowed, and clopidogrel is restarted 24 hours after surgery, with satisfactory evolution. Conclusions: Thromboprophylaxis in patients with congenital thrombophilia is mandatory, a reason why the use of low-molecular-weight heparin, together with the rest of the prevention measures against deep-vein thrombosis, is decisive(AU)

[Knowledge of thromboprophylaxis-COVID-19 in healthcare professionals in Spain]. / Conocimiento de la tromboprofilaxis-COVID-19 en los profesionales sanitarios en España.

INTRODUCTION: Patients suffering from coronavirus infection have an increased risk of venous thromboembolic disease (VTE) associated with COVID-19, which confers a higher risk of mortality. For this reason, it is necessary to analyze the knowledge and the different actions in the management of thromboprophylaxis in work environments. MATERIAL AND METHODS: Observational, descriptive and cross-sectional study with data collection through a Google® form with 19 questions for professionals involved in the care of COVID-19. 414 surveys were received. The quantitative variables were represented with means and standard deviation and the qualitative variables with percentages and confidence intervals. RESULTS: 414 surveys analyzed. 58.2% were women. The most participatory age group was 56-65 years. 95.2% stated that COVID-19 patients had a higher risk of VTE and peripheral arterial microthrombosis. 93.6% considered that outpatient COVID-19 patients should receive thromboprophylaxis. 60.5% of the physicians did not know any protocol for the evaluation of thrombotic risk in these patients. Low molecular weight heparin was considered the main treatment for thromboprophylaxis. CONCLUSIONS: The majority of doctors consider that COVID-19 patients have a higher risk of suffering VTE and peripheral arterial microthrombosis than the general population, however more than a third do not assess the thrombotic risk and a significant percentage claim not to know protocols to evaluate said risk. The survey highlights the training needs of our professionals in thromboprophylaxis so that our patients receive healthcare with the highest possible quality.

[COVID-19 and thromboprophylaxis: Recommendations for our clinical practice in Primary Care]. / COVID-19 y tromboprofilaxis: recomendaciones para nuestra práctica clínica en Atención Primaria.

The new coronavirus (SARS-CoV-2) is responsible for a severe acute respiratory syndrome. Among its manifestations, it can develop a thrombotic disease, both venous and arterial, due to excessive inflammation that affects the vascular system, with platelet activation and endothelial dysfunction, among other mechanisms. Thrombosis is associated with SARS-CoV-2 infection, increasing its severity and conferring a worse prognosis. Our performance as Family Physicians can contribute important actions in the management and control of this severe complication. Considering that many of our patients already receive antithrombotic or anticoagulant therapy, the fact that they may develop a COVID-19 infection will have implications for the choice, dosage and control of their treatment. In this document we review, with the information currently available, the relationship between disease caused by SARS-CoV-2 and thrombosis, as well as its management with a focus on Primary Care.

Prophylaxis of venous thromboembolism disease in patients with cancer. / Profilaxis de la enfermedad tromboembólica venosa en pacientes con cáncer.

Thrombotic risk should always be assessed in the various clinical scenarios of patients with cancer. Thromboprophylaxis with low-molecular-weight heparin is recommended above other anticoagulants for most patients with cancer who are hospitalised. However, the safety of primary thromboprophylaxis in this context is unknown; however, thromboprophylaxis can be completed with mechanical methods. Thromboprophylaxis in outpatients who are treated with chemotherapy is not indicated, except for outpatients who have other factors that determine a high thrombotic risk. In these cases, prophylaxis such as apixaban, rivaroxaban and low-molecular-weight heparin may be employed, provided there are no significant risk factors for bleeding or drug interactions. In patients undergoing oncologic surgery, thromboprophylaxis should be started before the surgery, continuing for at least 7 to 10 days and, in cases of major surgery, even up to 4 weeks. Drug prophylaxis is not routinely recommended to prevent upper extremity thrombosis in patients who carry central venous catheters.

Respuesta a diferentes escenarios y complicaciones hematológicas en COVID-19 / Response to different scenarios and hematological complications in COVID-19.

Las enfermedades infecciosas emergentes y reemergentes son desafíos constantes para la salud pública en todo el mundo. Los casos recientes de neumonía de causa desconocida en Wuhan, China, han llevado al descubrimiento de un nuevo tipo de Coronavirus (2019-nCoV), que son virus de Ácido Ribonucleico (RNA) envueltos, de forma común encontrados en humanos, otros mamíferos y aves, capaces de causar enfermedades respiratorias, entéricas, hepáticas y neurológicas 1. La amenaza a la salud de la infección por Coronavirus 2 asociado al SRAS (SARS-CoV-2) y la enfermedad que produce el mismo llamada Enfermedad por Coronavirus (COVID-19) ya está estable- cida con sus tasas de infección y mortalidad de manera considerable más altas si se lo compara con otros virus respiratorios adquiridos en la comunidad 2. En tal sentido es necesario dar una respuesta por parte de la Unidad Técnica de Hematología en relación a esta pandemia con el ánimo de aportar al manejo integral de estos pacientes, homogeneizar criterios clínicos, lidiar de mejor manera con la incertidumbre en el diagnóstico y tratamiento de COVID-19. El SARS CoV-2 y su enfermedad COVID-19, en la mayoría de pacientes tiene una presentación con síntomas leves. Sin embargo, en el 5% de los casos diagnosticados requerirán de una Unidad de Cuidados Intensivos (UCI)3, ya que presentan Síndrome de Dificultad Respiratoria Aguda (SDRA), shock séptico, Insuficiencia Multiorgánica y coagulopatía hemorrágica, así como trombótica, incluyendo Coagulación Intravascular Diseminada (CID), alcanzado en las salas de UCI una tasa mortalidad por COVID-19 entre el 22% al 62% en algunas series 4. Adicional, se ha observado que el grupo de pacientes con mala evolución presentan un estado hiperinflamatorio, asemejándose al cuadro clínico descrito de una linfohistiocitosis hemofagocítica secundaria, que en este caso sería desencadenada por SARS CoV-2 5. Un grupo de Hematólogos de diferentes hospitales de la ciudad de Quito: Especialidades Carlos Andrade Marín-Instituto Ecuatoriano de Seguridad Social (HECAM-IESS), Metropolitano; y, hospitales de la ciudad de Guayaquil: Teodoro Maldonado Carbo-IESS, Hospital Luis Vernaza y Clínica Gilbert, basados en la evidencia científica disponible y experticia profesional, elaboraron éste protocolo con las recomendaciones según los diferentes escenarios y complicaciones hematológicas.

Emerging and reemerging infectious diseases are constant challenges to public health worldwide. Recent cases of pneumonia of unknown cause in Wuhan, China have led to the discovery of a new type of Coronavirus (2019-nCoV), which are enveloped ribonucleic acid (RNA) viruses, commonly found in humans, other mammals, and birds, capable of cause respiratory, enteric, liver and neurological diseases 1. The health threat of SARS-associated coronavirus 2 (SARS-CoV-2) and the disease that produces it called COVID-19 has already been established with its considerably higher infection and mortality rates compared to other respiratory viruses acquired in the community 2. In this sense, it is necessary to give a response from the Hematology Technical Unit in relation to this pandemic in order to contribute to the comprehensive management of these patients, homogenize clinical criteria, better deal with uncertainty in the diagnosis and treatment of COVID-19. SARS CoV-2 and its disease COVID-19, in the majority of patients have a presentation with mild symptoms. However, in 5% of diagnosed cases they will require an Intensive Care Unit (ICU) 3, since they present Acute Respiratory Distress Syndrome (ARDS), septic shock, Multiple Organ Failure and hemorrhagic coagulopathy, as well as thrombotic, including Coagulation Disseminated Intravascular (DIC), achieved in the ICU wards a mortality rate for COVID-19 between 22% and 62% in some series 4. Additionally, it has been observed that the group of patients with poor evolution present a hyperinflammatory state, resembling the clinical picture of secondary hemopha- gocytic lymphohistiocytosis, which in this case would be triggered by SARS CoV-2 5. The group of Hematologists from the hospitals of the city of Quito: Specialties Carlos Andrade Marín HECAM-IESS, Metropolitano; and, hospitals in the city of Guayaquil: Teodoro Maldonado Carbo-IESS, Luis Vernaza Hospital and Gilbert Clinic, based on the available scientific evidence and professional expertise, prepared this protocol with the recommendations according to the different hematological scenarios and complications.

Joint Mexican position document on the treatment of atrial fibrillation / Posicionamiento conjunto acerca del tratamiento para fibrilación auricular

Abstract Atrial fibrillation (AF) is a frequent arrhythmia; its prevalence is near 2% in the general population; in Mexico, more than one-half million people are affected. AF needs to be considered as a public health problem. Because AF is an independent risk factor associated with mortality, due to embolic events, heart failure, or sudden death; early diagnosis is of utmost importance. In unstable patients with a recent onset of AF, electrical cardioversion should be practiced. In stable patients, once thromboembolic measures have been taken, it is necessary to assess whether it is reasonable to administer an antiarrhythmic drug to restore sinus rhythm or performed electrical cardioversion. For recidivating cases of paroxysmal and persistent presentation, the most effective strategy is performed pulmonary vein isolation with either radiofrequency or cryoballoon energy. Permanent AF is that in which recovery of sinus rhythm is not possible, the distinguishing feature of this phase is the uncontrollable variability of the ventricular frequency and could be treated pharmacologically with atrioventricular (AV) nodal blockers or with a VVIR pacemaker plus AV nodal ablation. The presence of AF has long been associated with the development of cerebral and systemic (pulmonary, limb, coronary, renal, and visceral) embolism. The prevention of embolisms in “valvular” AF should perform with Vitamin K antagonists (VKA). For patients with AF not associated with mitral stenosis or a mechanical valve prosthesis, a choice can be made between anticoagulant drugs, VKA, or direct oral anticoagulants. Antiplatelet agents have the weakest effect in preventing embolism.

Resumen La fibrilación auricular (FA) es una arritmia frecuente; su prevalencia es cercana al 2% en la población general, en México se ven afectados más de medio millón de personas por eso debe considerarse como un problema de salud pública. Debido a que la FA es un factor de riesgo independiente asociado a mortalidad, por eventos embólicos, insuficiencia cardíaca o muerte súbita, la identificación y diagnóstico temprano es de suma importancia. En el inicio reciente de FA en pacientes inestables, se debe practicar la cardioversión eléctrica. En pacientes estables, una vez que se han tomado medidas tromboembólicas, es necesario evaluar si es razonable administrar un medicamento antiarrítmico para restaurar el ritmo sinusal o realizar una cardioversión eléctrica. Para los casos que recidivan, ya sea paroxística o persistente, la estrategia más efectiva es realizar el aislamiento de la venas pulmonares con radiofrecuencia o crioablación con balón. La FA permanente es aquella en la que no es posible la recuperación del ritmo sinusal, la característica distintiva de esta fase de la FA es la variabilidad incontrolable de la frecuencia ventricular. Puede tratarse farmacológicamente con bloqueadores nodales AV o con un marcapasos VVIR mas ablación del nodo AV. La presencia de FA se ha asociado durante mucho tiempo con el desarrollo de embolia cerebral y sistémica (pulmonar, de extremidades, coronaria, renal y visceral). La prevención de embolias en la FA “valvular” debe realizarse con antagonistas de la vitamina K (AVK). Para los pacientes con FA no asociados con estenosis mitral o una prótesis valvular mecánica, se puede elegir entre medicamentos anticoagulantes, AVK o anticoagulantes orales directos (DOAC). Los agentes antiplaquetarios tienen el efecto más débil para prevenir la embolia.

Enfermedad tromboembólica venosa en el embarazo / Venous thromboembolic disease in pregnancy

Resumen: La enfermedad tromboembólica venosa como trombosis venosa profunda y tromboembolismo pulmonar, son causa importante de mortalidad materna, además se han considerado un problema de salud pública en diferentes países. La trombosis venosa profunda y el tromboembolismo pulmonar son considerados parte de una misma enfermedad con diversos síntomas clínicos que afectan al paciente. Algunas cifras epidemiológicas de la enfermedad tromboembólica venosa son que su incidencia se encuentra en torno a 167 por cada 1,000,000 personas por año, en mujeres embarazadas se presenta con una incidencia de 0.5-2.2 por 1,000 embarazos además que es de elevada mortalidad, se ha incrementado en los últimos diez años y en sus factores de riesgo podemos mencionar: trombofilia, tabaquismo, raza, hipertensión, hemorragia obstétrica, transfusiones, obesidad, cesárea principalmente. El abordaje terapéutico dependerá de la expresión clínica de la enfermedad tromboembólica venosa. Por lo que esta revisión incluye datos sobre la epidemiología, patogénesis, inflamación, factores de riesgo relacionados a la enfermedad tromboembólica venosa en el embarazo, la identificación de factores de riesgo no sólo son fundamentales para el diagnóstico, sino que también son importantes para prevenir y tratar la enfermedad.

Abstract. Venous thromboembolic disease such as deep venous thrombosis and pulmonary thromboembolism are important causes of maternal mortality and has also been considered a public health problem in different countries. Deep venous thrombosis and pulmonary thromboembolism are considered part of the same disease with various clinical symptoms that affect the patient. Some epidemiological numbers of the venous thromboembolic disease are that its incidence is around 167 for every 1,000,000 people per year, in pregnant women it appears with an incidence of 0.5-2.2 per 1,000 pregnancies besides that it is of high mortality, it has increased in the last ten years and in their risk factors we can mention: thrombophilia, smoking, race, hypertension, obstetric hemorrhage, transfusions, obesity, cesarean section mainly. The therapeutic approach will depend on the clinical expression of venous thromboembolic disease. So this review includes data on the epidemiology, pathogenesis, inflammation, risk factors related to venous thromboembolic disease in pregnancy, the identification of risk factors are not only essential for diagnosis, but are also important to prevent and treat the disease.