Prevention of VTE in Nonorthopedic Surgical Patients

Abstract

(Grade 2C) prophylaxis be used other than early ambulation. For patients at low risk for VTE ( ‫ف‬ 1.5%), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC), over no prophylaxis (Grade 2C). For patients at moderate risk for VTE ( ‫ف‬ 3%) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated heparin (Grade 2B), or mechanical prophylaxis with IPC (Grade 2C) over no prophylaxis. For patients at high risk for VTE ( ‫ف‬ 6%) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or low-dose unfractionated heparin (Grade 1B) over no prophylaxis. In these patients, we suggest adding mechanical prophylaxis with elastic stockings or IPC to pharmacologic prophylaxis (Grade 2C). For patients at high risk for VTE undergoing abdominal or pelvic surgery for cancer, we recommend extended-duration, postoperative, pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B). For patients at moderate to high risk for VTE who are at high risk for major bleeding complications or those in whom the consequences of bleeding are believed to be particularly severe, we suggest use of mechanical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Grade 2C). For patients in all risk groups, we suggest that an inferior vena cava fi lter not be used for primary VTE prevention (Grade 2C) and that surveillance with venous compression ultrasonography should not be performed (Grade 2C). We developed similar recommendations for other nonorthopedic surgical populations. Conclusions: Optimal thromboprophylaxis in nonorthopedic surgical patients will consider the risks of VTE and bleeding complications as well as the values and preferences of individual patients. CHEST 2012; 141(2)(Suppl):e227S-e277SAbbreviations: CABG 5 coronary artery bypass graft; ES 5 elastic stockings; ICH 5 intracranial hemorrhage; IPC 5 intermittent pneumatic compression; IVC 5 inferior vena cava; LDUH 5 low-dose unfractionated heparin; LMWH 5 low-molecular-weight heparin; PE 5 pulmonary embolism; QALY 5 quality-adjusted life year; RR 5 risk ratio; VCU 5 venous compression ultrasonography

Incidence of Venous Thromboembolism and Benefits and Risks of Thromboprophylaxis After Cardiac Surgery: A Systematic Review and Meta‐Analysis

“…However, an increased risk of bleeding and cardiac tamponade resulting from pharmacological thromboprophylaxis remains a major concern for patients who have undergone cardiac surgery 4. Indeed, the latest American College of Chest Physicians evidence‐based clinical practice guidelines on antithrombotic therapy and prevention of thrombosis have also stressed that patients after cardiac surgery are at high risk of major bleeding complications with only moderate risk for VTE (Grade‐2C), and suggested that pharmacological VTE prophylaxis is only needed for those with prolonged hospitalization postsurgery 5. These Grade‐2C recommendations were mainly based on consensus among experts or weak evidence.…”

Preventing hospital‐acquired venous thromboembolism: Improving patient safety with interdisciplinary teamwork, quality improvement analytics, and data transparency

“…More than half of VTE events occur in association with hospitalization or major surgery; many are thought to be preventable. [1][2][3][4][5] The Centers for Medicare and Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC), and the Agency for Healthcare Research and Quality (AHRQ), 6-9 among other organizations, have identified VTE as a potentially preventable "never" event. Evidence-based guidelines and resources exist to help support hospital-acquired venous thromboembolism (HA-VTE) prevention.…”

“…Evidence-based guidelines and resources exist to help support hospital-acquired venous thromboembolism (HA-VTE) prevention. [1][2][3][4][5][6][7][8][9][10] Harborview Medical Center, a tertiary referral center with more than 17,000 patients hospitalized annually, many requiring surgery, serves one of the highest-risk populations for HA-VTE development. Despite high rates of VTE prophylaxis in accordance with an established institutional guideline, 11,12 VTE remains the most common hospital-acquired condition in our institution.…”

Postpartum venous thromboembolism prophylaxis may cause more harm than benefit: a critical analysis of international guidelines through an evidence‐based lens

“…It is now accepted that screening studies that identify asymptomatic DVT overestimate the incidence of clinical VTE and the benefit of LMWH 8, 9, 33. Although asymptomatic DVT has been reported in 10–40% of medical and surgical patients, symptomatic VTE occurs in fewer than 5% 7, 12, 17, 18. Yet screening studies of women after CD have found asymptomatic DVT in fewer than 1% (3/560) 34, 35, 36, 37, 38.…”

“…The use of scoring systems to estimate the post‐surgical incidence of VTE was qualified and a minimum risk of 3% is now deemed necessary to warrant chemoprophylaxis in abdominal/pelvic surgical patients 10, 11, 12. After orthopaedic surgery, less aggressive prophylaxis is now considered acceptable 13, 14, 15.…”