Investigating the Incidence of Pulmonary Embolism and Related Risk Factors Despite Administrating Prophylaxis to All Surgical Patients

Document Type : Original Article

Authors

Department of General Surgery, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran

Abstract

Background: Pulmonary embolism (PE) is a life-threatening condition or complication that continues to pose a significant risk of morbidity and mortality.
 
Objectives: This study aims to identify the perioperative risk factors associated with PE and to examine its prevalence and consequences in patients who have undergone major surgery. 
 
Methods: This cross-sectional analytical study reviewed the medical records of 30 consecutive patients admitted to the general surgery ward who developed in-hospital PE. The study aimed to extract risk factors, including demographic and clinical features, such as body mass index (BMI), smoking history, hospitalization history, hypertension, cardiovascular complications, history of oral contraception pill (OCP) usage, diabetes, history of cancer, trauma, intensive care unit (ICU) hospitalization, and the type of surgery.
 
Results: Among all PE patients, 19.7% had a normal BMI, and tobacco use was reported in 50% of these patients. Only 16.7% of PE patients had a history of OCP usage. Pulmonary and breast cancer were reported in 56.6% and 6.7% of PE patients, respectively. The most common comorbidities among PE patients were hypertension (23.3%), followed by cardiovascular issues (16.7%) and diabetes mellitus (6.7%). The majority of PE patients had ICU hospitalization (93.3%). Forty percent of PE patients experienced trauma, with 15% having hip with limb fractures, 13% experiencing chest trauma, and 12% having abdominal visceral trauma. Almost 30% of the PE patients who were admitted for general surgery and developed in-hospital PE died before discharge.
 
Conclusion: PE is one of the most common adverse events after surgery, despite the use of thromboprophylaxis. The major risk factors in patients with postoperative PE were found to be old age, smoking history, trauma, and cardiovascular problems.
 

Keywords

Main Subjects


1. Goldhaber SZ. Venous thromboembolism: epidemiology and magnitude of the problem. Best Pract Res Clin Haematol. 2012;25(3):235-242.
https://doi.org/10.1016/j.beha.2012.06.007
PMid:22959540
 
2. Belohlávek J, Dytrych V, Linhart A. Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. Exp Clin Cardiol 2013;18:129-38.
 
3. Kwok CS, Wong CW, Lovatt S, Myint PK, Loke YK. Misdiagnosis of pulmonary embolism and missed pulmonary embolism: A systematic review of the literature. Health Sciences Review. 2022 Mar 15:100022.
https://doi.org/10.1016/j.hsr.2022.100022
 
4. Jiménez D, Bikdeli B, Quezada A, Muriel A, Lobo JL, de Miguel-Diez J, Jara-Palomares L, Ruiz-Artacho P, Yusen RD, Monreal M. Hospital volume and outcomes for acute pulmonary embolism: multinational population based cohort study. bmj. 2019 July 29;366.
https://doi.org/10.1136/bmj.l4416
PMid:31358508 PMCid:PMC6661688
 
5. Dobson GP. Trauma of major surgery: A global problem that is not going away. Int J Surg. 2020 Sep;81:47-54. doi: 10.1016/j.ijsu.2020.07.017. Epub 2020 July 29.
https://doi.org/10.1016/j.ijsu.2020.07.017
PMid:32738546 PMCid:PMC7388795
 
6. Tekalign T, Balta H, Kelbiso L. Magnitude of postoperative mortality and associated factors among patients who underwent surgery in Wolaita Sodo teaching and referral hospital, SNNPR region, Ethiopia. Afr Health Sci. 2021 Dec;21(4):1842-1848. doi: 10.4314/ahs.v21i4.42.
https://doi.org/10.4314/ahs.v21i4.42
PMid:35283960 PMCid:PMC8889848
 
7. Dencker, E.E., Bonde, A., Troelsen, A. et al. Postoperative complications: an observational study of trends in the United States from 2012 to 2018. BMC Surg 21, 393 (2021). https://doi.org/10.1186/s12893-021-01392-z
https://doi.org/10.1186/s12893-021-01392-z
PMid:34740362 PMCid:PMC8571843
 
8. Desciak MC, Martin DE. Perioperative pulmonary embolism: diagnosis and anesthetic management. Journal of Clinical Anesthesia. 2011 Mar 1;23(2):153-65.
https://doi.org/10.1016/j.jclinane.2010.06.011
PMid:21377083
 
9. Temgoua MN, Tochie JN, Noubiap JJ, Agbor VN, Danwang C, Endomba FTA, Nkemngu NJ. Global incidence and case fatality rate of pulmonary embolism following major surgery: a protocol for a systematic review and meta-analysis of cohort studies. Syst Rev. 2017 December 4;6(1):240. doi: 10.1186/s13643-017-0647-8.
https://doi.org/10.1186/s13643-017-0647-8
PMid:29202836 PMCid:PMC5716368
 
10. Howard L. Acute pulmonary embolism. Clinical Medicine. 2019 May;19(3):243.
https://doi.org/10.7861/clinmedicine.19-3-247
PMid:31092519 PMCid:PMC6542219
 
11. Kim JY, Lee YS, Park HO, Shin IW. Management of perioperative acute massive pulmonary embolism: A case series. Clin Case Rep. 2021 March 28;9(5):e04078. doi: 10.1002/ccr3.4078.
https://doi.org/10.1002/ccr3.4078
PMid:34084497 PMCid:PMC8142415
 
12. Aiping Y, Shuangyin Z, Yanhong X, Rongzhi Z. Management of intraoperative acute pulmonary embolism in a patient with subarachnoid haemorrhage undergoing femoral fracture repair. J Int Med Res. 2019 Oct;47(10):5307-5311. doi: 10.1177/0300060519874158.
https://doi.org/10.1177/0300060519874158
PMid:31552755 PMCid:PMC6833381
 
13. Beyer J, Wessela S, Hakenberg OW, et al. Incidence, risk profile and morphological pattern of venous thromboembolism after prostate cancer surgery. J Thromb Haemost 2009;7:597-604.
https://doi.org/10.1111/j.1538-7836.2009.03275.x
PMid:19143928
 
14. Arcelus JI, Kudrna JC, Caprini JA. Venous thromboembolism following major orthopedic surgery: what is the risk after discharge? Orthopedics 2006;29:506-16.
https://doi.org/10.3928/01477447-20060601-16
PMid:16786943
 
15. Albrecht MH, Bickford MW, Nance Jr JW, Zhang L, De Cecco CN, Wichmann JL, Vogl TJ, Schoepf UJ. State-of-the-art pulmonary CT angiography for acute pulmonary embolism. American Journal of Roentgenology. 2017 Mar;208(3):495-504.
https://doi.org/10.2214/AJR.16.17202
PMid:27897042
 
16. Lau BD, Haut ER. Practices to prevent venous thromboembolism: a brief review. BMJ Qual Saf. 2014;23:187-95.
https://doi.org/10.1136/bmjqs-2012-001782
PMid:23708438 PMCid:PMC3932749
 
17. JCS Joint Working Group. Guidelines for the diagnosis, treatment and prevention of pulmonary thromboembolism and deep vein thrombosis (JCS 2009). Circ J. 2011;75(5):1258-81. doi: 10.1253/circj.cj-88-0010.
https://doi.org/10.1253/circj.CJ-88-0010
PMid:21441695
 
18. Heit JA: The epidemiology of venous thromboembolism in the community. Arterioscler Thromb Vasc Biol 2008, 28:370-372.
https://doi.org/10.1161/ATVBAHA.108.162545
PMid:18296591 PMCid:PMC2873781
 
19. Irmak B, KARADAĞ M, Emre NY. The risk factors for preoperative and postoperative deep vein thrombosis in surgical patients. Clinical and Experimental Health Sciences. 2022 Mar 3;12(1):120-7.
https://doi.org/10.33808/clinexphealthsci.839430
 
20. Engbers M, Hylckama Vlieg A, Rosendaal F. Venous thrombosis in the elderly: incidence, risk factors and risk groups. J Thromb Haemost 2010;8(10):2105-2112.
https://doi.org/10.1111/j.1538-7836.2010.03986.x
PMid:20629943
 
21. A' vila AC, Fenili R. Incidence and risk factors for postoperative pulmonary complications in patients undergoing thoracic and abdominal surgeries. Rev Col Bras Cir. 2017 May-Jun; 44(3):284-292. https:// doi.org/10.1590/0100-69912017003011
https://doi.org/10.1590/0100-69912017003011
PMid:28767805
 
22. Nijbroek S, Schultz M, Hemmes S. Prediction of postoperative pulmonary complications. Curr Opin Anaesthesiol. 2019 Jun; 32(3):443-451. https://doi.org/10.1097/ACO.0000000000000730 PMID: 30893115
https://doi.org/10.1097/ACO.0000000000000730
PMid:30893115
 
23. Paulsen B, Gran OV, Severinsen MT, Hammerstrøm J, Kristensen SR, Cannegieter SC, Skille H, Tjønneland A, Rosendaal FR, Overvad K, Næss IA. Association of smoking and cancer with the risk of venous thromboembolism: the Scandinavian Thrombosis and Cancer cohort. Scientific Reports. 2021 Sep 21;11(1):18752.
https://doi.org/10.1038/s41598-021-98062-0
PMid:34548519 PMCid:PMC8455552
 
24. Quist-Paulsen, P. et al. Arterial cardiovascular risk factors and venous thrombosis: Results from a population-based, prospective study (the HUNT 2). Haematologica 95(1), 119-125 (2010).
https://doi.org/10.3324/haematol.2009.011866
PMid:19713225 PMCid:PMC2805742
 
25. Glynn, R. J. & Rosner, B. Comparison of risk factors for the competing risks of coronary heart disease, stroke, and venous thromboembolism. Am. J. Epidemiol. 162(10), 975-982 (2005).
https://doi.org/10.1093/aje/kwi309
PMid:16207808
 
26. Goldhaber, S. Z. et al. Risk factors for pulmonary embolism. The Framingham study. Am. J. Med. 74(6), 1023-1028 (1983).
https://doi.org/10.1016/0002-9343(83)90805-7
PMid:6859053
 
27. Tsai, A. W. et al. Cardiovascular risk factors and venous thromboembolism incidence: The longitudinal investigation of thromboembolism etiology. Arch. Int. Med. 162(10), 1182-1189 (2002).
https://doi.org/10.1001/archinte.162.10.1182
PMid:12020191
 
28. Goldhaber SZ, Bounameaux H. Pulmonary embolism and deep vein thrombosis. Lancet 2012;379(9828):1835-1846.
https://doi.org/10.1016/S0140-6736(11)61904-1
PMid:22494827
 
29. Ageno W, Becattini C, Brighton T, Selby R, Kamphuisen PW. Cardiovascular risk factors and venous thromboembolism. Circulation 2008; 117(1):93-102.
https://doi.org/10.1161/CIRCULATIONAHA.107.709204
PMid:18086925
 
30. Wang L, Pryor AD, Altieri MS, Romeiser JL, Talamini MA, Shroyer L, Telem DA. Perioperative rates of deep vein thrombosis and pulmonary embolism in normal weight vs obese and morbidly obese surgical patients in the era post venous thromboembolism prophylaxis guidelines. Am J Surg 2015;210(5):859-863.
https://doi.org/10.1016/j.amjsurg.2015.01.021
PMid:26066865
 
31. Özkaya Ö, Öztürk MB, Egemen O, Öreroğlu AR, Üsçetin İ, Tasasız K, Akan M. The approach of turkish plastic surgeons to the venous thromboembolism prophylaxis and preferred methods in prophylaxis: a survey study. Turk J PlastSurg 2013;21(2):10-15 (Turkish).
 
32. Biedka M, Ziółkowska E, Windorbska W. Acute pulmonary embolus in the course of cancer. Contemp Oncol (Pozn). 2012;16(5):388-93. doi: 10.5114/wo.2012.31766.
https://doi.org/10.5114/wo.2012.31766
PMid:23788915 PMCid:PMC3687454
 
33. Bayleyegn B, Adane T, Getawa S, Aynalem M, Kifle ZD. Coagulation parameters in lung cancer patients: A systematic review and meta-analysis. J Clin Lab Anal. 2022 Jul;36(7):e24550. doi: 10.1002/jcla.24550)
https://doi.org/10.1002/jcla.24550
PMid:35719003 PMCid:PMC9279983
 
34. Syncope as the initial presentation of pulmonary embolism in a young adult with testicular tumor: a case report and literature review. Song Z, Lv S, Qin L, Cao H, Wu H, Deng D. Medicine (Baltimore) 2018;97:0.
https://doi.org/10.1097/MD.0000000000013798
PMid:30593166 PMCid:PMC6314732
 
35. Karakida N, Yanazume S, Tokudome A, Sonoda M, Kobayashi H. Successful Treatment of a Life-Threatening Pulmonary Embolism Following Retroperitoneal Tumor Surgery. Cureus. 2022 Nov 14;14(11).)
https://doi.org/10.7759/cureus.31501
PMid:36532919 PMCid:PMC9750713
 
36. Stein PD, Matta F, Sabra MJ. Pulmonary embolism and deep venous thrombosis following laparoscopic cholecystectomy. Clinical and Applied Thrombosis/Hemostasis. 2014 Apr;20(3):233-7.
https://doi.org/10.1177/1076029613502255
PMid:23990647
 
37. Matthews BD, Williams GB. Laparoscopic cholecystectomy in an academic hospital: evaluation of changes in perioperative outcomes. JSLS. 1999 Jan-Mar;3(1):9-17
 
38. Liu Y, Han L, Li J. Consumption coagulopathy in acute aortic dissection: principles of management. J Cardiothorac Surg. 2017;12:50. et al. [PMC free article] [PubMed] [Google Scholar] [Ref list]
https://doi.org/10.1186/s13019-017-0613-5
PMid:28606160 PMCid:PMC5468986
 
39. Girerd S, Girerd N, Frimat L, Holdaas H, Jardine AG, Schmieder RE, Fellström B, Settembre N, Malikov S, Rossignol P, Zannad F. Arteriovenous fistula thrombosis is associated with increased all-cause and cardiovascular mortality in haemodialysis patients from the AURORA trial. Clinical kidney journal. 2020 Feb;13(1):116-22.).
https://doi.org/10.1093/ckj/sfz048
PMid:32082562 PMCid:PMC7025348
 
40. Bahloul M, Chelly H, Regaieg K, Rekik N, Bellil S, Chaari A, Bouaziz W, Chabchoub I, Haddar S, Ben Hamida C, Bouaziz M. Pulmonary embolism following severe traumatic brain injury: incidence, risk factors and impact outcome. Intensive Care Med. 2017;43:1433-1435.
https://doi.org/10.1007/s00134-017-4815-z
PMid:28497268
 
41. Darabadi FK, JafariZare MA, Goodarzi ZT, Namdar P. Prevalence and main determinants of early post-traumatic thromboembolism in patients requiring ICU admission. Eur J Trauma Emerg Surg. 2018;44:133-136.
https://doi.org/10.1007/s00068-017-0770-1
PMid:28791433
 
42. Canet J, Gallart L, Gomar C, Paluzie G, Vallès J, Castillo J, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology. 2010 Dec; 113(6):1338-1350. https://doi.org/10.1097/ALN.0b013e3181fc6e0a PMID: 21045639
https://doi.org/10.1097/ALN.0b013e3181fc6e0a
PMid:21045639
 
43. Nijbroek S, Schultz M, Hemmes S. Prediction of postoperative pulmonary complications. Curr Opin Anaesthesiol. 2019 Jun; 32(3):443-451. https://doi.org/10.1097/ACO.0000000000000730
https://doi.org/10.1097/ACO.0000000000000730
PMid:30893115