HSC Section 3 - Trauma, Critical Care and Sleep Medicine

M OUBAYED ET AL .

FIGURE 4. (A) Forest plot (I 2 5 53.8%) and (B) funnel plot comparing venous thromboembolism incidence in squamous cell carcinoma or free flap reconstruction patients to other otolaryngology–head and neck surgery patients. 95% CI, confidence interval. [Color figure can be viewed at wileyonlinelibrary.com]

true incidence of VTE in OHNS patients without any form of prophylaxis, and that this incidence could be potentially slightly higher than the estimates we calculat- ed. According to the CHEST guidelines, addition of sequential compressive devices to any type of prophylaxis attributes a relative risk of 0.48 of VTE, thus reducing the risk by over 50%. 1 According to our data, patients with SCC or who underwent free flap reconstruction have a 0.9% risk of VTE and other OHNS patients have a 0.1% risk of VTE. When adjusted for potential use of sequential compressive devices with the aforementioned relative risk, SCC or free flap reconstruction would be classified most likely in the low category (1.8%), and all other OHNS patients in the very low category (0.2% risk of VTE). Compared with other nonorthopedic surgical specialties, OHNS patients are definitely at the lowest end of the spectrum for VTEs. According to the CHEST guidelines, in the absence of any prophylaxis, the risk of a VTE is 0.5% in nonorthopedic outpatient surgery (although these did not include OHNS), 1.5% in spinal surgery for non- malignant disease, 3.0% in gynecologic noncancer sur- gery, cardiac surgery, most thoracic surgery, spinal

surgery for malignant disease, and 6.0% in bariatric sur- gery, gynecologic cancer surgery, pneumonectomy, crani- otomy, traumatic brain injury, and trauma surgery. 1 OHNS SCC or free flap surgery falls in the low-risk cate- gory, and OHNS non-SCC or free flap surgery falls in the very low-risk category. This low incidence might be explained by early ambulation and short duration of sur- gery in non-SCC or free flap patients, and is higher in patients with SCC or who underwent free flap reconstruc- tion because these patients are older, have longer duration of surgery, prolonged immobility, and the presence of cancer. The risk of bleeding that we have identified is nonne- gligible and should be considered when introducing che- moprophylaxis in OHNS patients. As we have shown, there is a significant increase in bleeding complications in OHNS patients when introducing chemoprophylaxis (Fig- ure 3B). This must be weighed against the very low or low incidence of VTEs, and might be justifiable in the presence of SCC or free flap reconstructions. However, these decisions must be taken on a case-by-case basis. Although heterogeneity for these studies was consider- able, our point estimate and CI is rather narrow and most

HEAD & NECK—DOI 10.1002/HED JUNE 2017

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