**10. Discussion**

Pathophysiology and Clinical Aspects of 164 Venous Thromboembolism in Neonates, Renal Disease and Cancer Patients

would have used prophylaxis? For example, the recommended program for a non-displaced fracture of the tibia states that prophylaxis against VTE is not necessary; yet the frequency of DVT in these patients is 15 %. If we were to extend the program of prophylaxis to encompass ambulatory patients with a walking cast, these patients would only rarely suffer

In 15 cases without fractures or operation, the diagnosis of VTE was missed. The claim was approved in 12 cases (Table 6). These cases were evenly distributed among primary and

The remaining 45 cases were a broad selection of the many different causes there may be for acquiring VTE, as well as a few that had a prophylaxis or a treatment of VTE that wasn't up

Rare or miscellaneous N N approved Upper extremity 20 10 Sinus thrombosis 11 9 Venous puncture or catheterization 4 4 Wrong prophylaxis or treatment 4 4 VTE i spite of correct treatment 3 0 Mesenteric venous thrombosis 2 1 Paradox embolism 1 1 45 29

The cases of cerebral sinus thrombosis were all caused by birth control medication. Three of the cases of venous puncture were caused by blood donation; such claims are nearly always

There were 83 claims that went on to the appeal board, and of these 15 had the decision of the DPIA altered. The changes of decisions nearly all concerned the size of the compensation. One claim went on to the high court. It concerned a male of 33 years, who had a percutaneous endoscopic ligature of the spermatic veins for a *hydrocele testis*. Afterwards he suffered a hemorrhage in the scrotal sac and a venous thrombosis in the leg. The compensation in the DPIA was € 95.165, and this decision was upheld both before the

 N Approved Hospitals 7 6 Primary sector 8 6 15 12

DVT, and some lives would be spared.

secondary practice. Three patients died as result of the injury

Table 6. The number of missed or overlooked diagnosis of VTE.

to the standard of the experienced specialist (Table 7).

Table 7. Rare or miscelleanous patients.

appeal board and in the high court.

approved by the DPIA. Two of the 45 patients died.

**8. Missed diagnosis** 

**9. Miscellaneous** 

The standard prophylaxis in Denmark is usually given only for the duration of admittance to hospital, or until the patient is well mobilized. During recent times, a number of studies have suggested that this is not enough, and that prophylaxis should be given for 6 or 8 weeks after surgery (3, 4). The price would be manageable, and the logistics could probably be overcome. Why do we accept that hundreds and hundreds of patients go without prophylaxis for the period they are at risk?

Also, it is not rare to see a patient described as "well mobilized" and therefore have his prophylaxis discontinued, when in fact he is only out of bed for a few hours a day and then only sitting in a chair. The sitting position, if anything, increases the stasis of blood in the veins of the legs, and therefore probably also increases the risk of VTE. The development of tablets for VTE prophylaxis may change this state of affairs in the future, since it will make the administration of medication simpler (5, 6).

The treatment of VTE goes hand in hand with the prevention of the disease. When you have seen the damage that VTE can do to patients, you are likely to go far to prevent a single case. There exists well-proven mechanical as well as biochemical methods with very few side effects. All of these 688 cases must be viewed as potentially preventable with the exception of the 3 cases, where VTA occurred in spite of the fact that correct prophylaxis was given. Off course it is not possible to prevent all cases, which you can se by the fact that these 3 cases occurred. But this must not be given as an excuse to omit prophylaxis.

It is inexcusable to perform major invasive treatment without prophylaxis, and probably the medical profession should consider extending the indications as well as the duration of prophylaxis. The cost of doing this will be balanced against the gain from not having to treat the VTE-cases and the tax returns from the survivors of complications to VTE (7).

It should probably also be considered to screen the women for coagulation deficits before they are placed on contraceptive medication. Certainly, it is clear from our records, that the medical profession should consider the differential diagnosis of VTE in patients on contraceptive drugs more often.

For the DPIA it is also a question whether you should approve claims from women, who have a coagulation defect like Leiden factor-5 mutation? There were only 17 cases where our patients had been tested positive for this genetic defect. The true number is probably much higher. Normally, the DPIA does not approve claims, when a patient has a disposition to the injury. It can be argued, however, that the experienced specialist would not prescribe contraceptive drugs to a patient with Leiden-5 mutation. It is therefore the normal practice of the DPIA to approve these claims.

The fractures that are treated by non-invasive means are by no means immune from VTE. A recent metaanalysis of the question of prophylaxis to these patients (8) states that ambulatory patients with temporary lower leg immobilization who are over 50, in a rigid cast, non-weight bearing or with a severe injury should be considered as a risk group for VTE. The present opinion is however, that the VTE in these cases is caused by the trauma and not the treatment. The patient that dies from PE probably doesn't care. We think that it should be seriously considered to include these patients in an anti-VTE program.

We realize that there are many claims that never comes to the knowledge of the DPIA. The reasons for this are many: Ignorance of the law, resignation in the face of a serious disease complicated by the injury, the bother of the application procedure, fear of alienating the physician etc. We have tried several methods in order to achieve a more precise estimate of this problem (9, 10). Our best estimate is now that there are at least 4 – 5 patient injuries for each claim.

The risk of VTE increases with malignancy, infections, reoperations and surgery close to the large veins. The prophylaxis should be adjusted accordingly. It is about time that the medical profession starts to realize that posttraumatic or postoperative VTE is not an inevitable event. It may be prevented by a number of quite effective measures, but a change in attitude from the medical profession is required.
