Deep vein thrombosis guidelines for patients undergoing surgery

Associate Editors-in-Chief: Ujjwal Rastogi, MBBS [mailto:urastogi@perfuse.org]

A. Recommendations for general surgery
1. For low-risk general surgery patients who are undergoing minor procedures and have no additional thromboembolic risk factors, we recommend against the use of specific thromboprophylaxis other than early and frequent ambulation(Grade 1A).

2. For moderate-risk general surgery patients who are undergoing a major procedure for benign disease, we recommend thromboprophylaxis with LMWH, LDUH, or fondaparinux (each Grade 1A).

3. For higher-risk general surgery patients who are undergoing a major procedure for cancer, we recommend thromboprophylaxis with LMWH, LDUH three times daily, or fondaparinux (each Grade 1A).

4. For general surgery patients with multiple risk factors for VTE who are thought to be at particularly high risk, we recommend that a pharmacologic method (ie, LMWH, LDUH three times daily, or fondaparinux) be combined with the optimal use of a mechanical method (ie, graduated compression stockings [GCS] and/or IPC) [Grade 1C].

5. For general surgery patients with a high risk of bleeding, we recommend the optimal use of mechanical thromboprophylaxis with properly fitted GCS or IPC (Grade 1A). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).

6. For patients undergoing major general surgical procedures, we recommend that thromboprophylaxis continue until discharge from hospital (Grade 1A). For selected high-risk general surgery patients, including some of those who have undergone major cancer surgery or have previously had VTE, we suggest that continuing thromboprophylaxis after hospital discharge with LMWH for up to 28 days be considered (Grade 2A).

B. Recommendations for Vascular surgery
1. For patients undergoing vascular surgery who do not have additional thromboembolic risk factors, we suggest that clinicians not routinely use specific thromboprophylaxis other than early and frequent ambulation (Grade 2B).

2. For patients undergoing major vascular surgery procedures who have additional thromboembolic risk factors, we recommend thromboprophylaxis with LMWH, LDUH, or fondaparinux (Grade 1C).

C. Recommendations for Gynecologic surgery
1. For low-risk gynecologic surgery patients who are undergoing minor procedures and have no additional risk factors, we recommend against the use of specific thromboprophylaxis other than early and frequent ambulation (Grade 1A).

2. For gynecology patients undergoing entirely laparoscopic procedures, we recommend against routine thromboprophylaxis, other than early and frequent ambulation (Grade 1B).

3. For gynecology patients undergoing entirely laparoscopic procedures in whom additional VTE risk factors are present, we recommend the use of thromboprophylaxis with one or more of LMWH, LDUH, IPC, or GCS (Grade 1C).

4. For all patients undergoing major gynecologic surgery, we recommend that thromboprophylaxis be used routinely (Grade 1A).

5. For patients undergoing major gynecologic surgery for benign disease without additional risk factors, we recommend LMWH (Grade 1A), LDUH (Grade 1A), or IPC started just before surgery and used continuously while the patient is not ambulating (Grade 1B).

6. For patients undergoing extensive surgery for malignancy and for patients with additional VTE risk factors, we recommend routine thromboprophylaxis with LMWH (Grade 1A), or LDUH three times daily (Grade 1A), or IPC, started just before surgery and used continuously while the patient is not ambulating (Grade 1A). Alternative considerations include a combination of LMWH or LDUH plus mechanical thromboprophylaxis with GCS or IPC, or fondaparinux (all Grade 1C).

7. For patients undergoing major gynecologic procedures, we recommend that thromboprophylaxis continue until discharge from hospital (Grade 1A). For selected high-risk gynecology patients, including some of those who have undergone major cancer surgery or have previously had VTE, we suggest that continuing thromboprophylaxis after hospital discharge with LMWH for up to 28 days be considered (Grade 2C).

D. Recommendations for Urologic surgery
1. For patients undergoing transurethral or other low-risk urologic procedures, we recommend against the use of specific thromboprophylaxis other than early and frequent ambulation (Grade 1A).

2. For all patients undergoing major, open urologic procedures, we recommend that thromboprophylaxis be used routinely (Grade 1A).

3. For patients undergoing major, open urologic procedures, we recommend routine thromboprophylaxis with LDUH twice daily or three times daily (Grade 1B), GCS and/or IPC started just before surgery and used continuously while the patient is not ambulating (Grade 1B), LMWH (Grade 1C), fondaparinux (Grade 1C), or the combination of a pharmacologic method (ie, LMWH, LDUH, or fondaparinux) with the optimal use of a mechanical method (ie, GCS and/or IPC) [Grade 1C].

4. For urologic surgery patients who are actively bleeding, or who are at very high risk for bleeding, we recommend the optimal use of mechanical thromboprophylaxis with GCS and/or IPC at least until the bleeding risk decreases (Grade 1A). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).

E. Recommendations for Laparoscopic surgery
1. For patients undergoing entirely laparoscopic procedures who do not have additional thromboembolic risk factors, we recommend against the routine use of thromboprophylaxis, other than early and frequent ambulation (Grade 1B).

2. For patients undergoing laparoscopic procedures in whom additional VTE risk factors are present, we recommend the use of thromboprophylaxis with one or more of LMWH, LDUH, fondaparinux, IPC, or GCS (all Grade 1C).

F. Recommendations for Bariatric surgery
1. For patients undergoing inpatient bariatric surgery, we recommend routine thromboprophylaxis with LMWH, LDUH three times daily, fondaparinux, or the combination of one of these pharmacologic methods with optimally used IPC (each Grade 1C).

2. For patients undergoing inpatient bariatric surgery, we suggest that higher doses of LMWH or LDUH than usual for nonobese patients be used (Grade 2C).

G. Recommendations for Thoracic surgery
1. For patients undergoing major thoracic surgery, we recommend routine thromboprophylaxis with LMWH, LDUH, or fondaparinux (each Grade 1C).

2. For thoracic surgery patients with a high risk of bleeding, we recommend the optimal use of mechanical thromboprophylaxis with properly fitted GCS and/or IPC (Grade 1C).

H. Recommendations for Coronary artery bypass surgery
1. For patients undergoing coronary artery bypass graft (CABG) surgery, we recommend the use of thromboprophylaxis with LMWH, LDUH, or optimally used bilateral GCS or IPC (Grade 1C).

2. For patients undergoing CABG, we suggest the use of LMWH over LDUH (Grade 2B).

3. For patients undergoing CABG with a high risk of bleeding, we recommend the optimal use of mechanical thromboprophylaxis with properly fitted bilateral GCS or IPC (Grade 1C).

1. Elective Hip Replacement
1. For patients undergoing elective total hip replacement (THR), we recommend the routine use of one of the following anticoagulant options:(1) LMWH (at a usual high-risk dose, started 12 h before surgery or 12 to 24 h after surgery, or 4 to 6 h after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day); (2) Fondaparinux (2.5 mg started 6 to 24 h after surgery); or (3) Adjusted-dose VKA started preoperatively or the evening of the surgical day (international normalized ratio [INR] target, 2.5; INR range, 2.0 to 3.0) (all Grade 1A).

2. For patients undergoing THR, we recommend against the use of any of the following:aspirin, dextran, LDUH, GCS, or venous foot pump (VFP) as the sole method of thromboprophylaxis(all Grade 1A).

3. For patients undergoing THR who have a high risk of bleeding, we recommend the optimal use of mechanical thromboprophylaxis with the VFP or IPC (Grade 1A). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).

2. Elective Knee Replacement
1. For patients undergoing TKR, we recommend routine thromboprophylaxis using LMWH (at the usual high-risk dose), fondaparinux, or adjusted-dose VKA (INR target, 2.5; INR range, 2.0 to 3.0) (all Grade 1A).

2. For patients undergoing TKR, the optimal use of IPC is an alternative option to anticoagulant thromboprophylaxis (Grade 1B).

3. For patients undergoing TKR, we recommend against the use of any of the following as the only method of thromboprophylaxis: aspirin (Grade 1A), LDUH (Grade 1A), or VFP (Grade 1B).

4. For patients undergoing TKR who have a high risk of bleeding, we recommend the optimal use of mechanical thromboprophylaxis with IPC (Grade 1A) or VFP (Grade 1B). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).

3. Knee Arthroscopy
1. For patients undergoing knee arthroscopy who do not have additional thromboembolic risk factors, we suggest that clinicians not routinely use thromboprophylaxis other than early mobilization (Grade 2B).

2. For patients undergoing arthroscopic knee surgery who have additional thromboembolic risk factors or following a complicated procedure, we recommend thromboprophylaxis with LMWH (Grade 1B).

4. Hip fracture surgery
1. For patients undergoing HFS, we recommend routine thromboprophylaxis using fondaparinux (Grade 1A), LMWH (Grade 1B), adjusted dose VKA (INR target, 2.5; INR range, 2.0 to 3.0) [Grade 1B], or LDUH (Grade 1B).

2. For patients undergoing HFS, we recommend against the use of aspirin alone (Grade 1A).

3. For patients undergoing HFS in whom surgery is likely to be delayed, we recommend that thromboprophylaxis with LMWH or LDUH be initiated during the time between hospital admission and surgery (Grade 1C).

4. For patients undergoing HFS who have a high risk of bleeding, we recommend the optimal use of mechanical thromboprophylaxis (Grade1A). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).

5. Elective spine surgery
1. For patients undergoing spine surgery who do not have additional thromboembolic risk factors, we suggest that clinicians not routinely use specific thromboprophylaxis other than early and frequent ambulation (Grade 2C).

2. For patients undergoing spine surgery who have additional thromboembolic risk factors such as advanced age, malignancy, presence of a neurologic deficit, previous VTE, or an anterior surgical approach, we recommend that one of the following thromboprophylaxis options be used: postoperative LDUH (Grade 1B), postoperative LMWH (Grade 1B), or optimal use of perioperative IPC (Grade 1B). An alternative consideration is GCS (Grade 2B).

3. For patients undergoing spine surgery who have multiple risk factors for VTE, we suggest that a pharmacologic method (ie,LDUH or LMWH) be combined with the optimal use of a mechanical method (ie, GCS and/or IPC) (Grade 2C).

6. Isolated lower-extremity injuries distal to the knee
1. For patients with isolated lower-extremity injuries distal to the knee, we suggest that clinicians not routinely use thromboprophylaxis (Grade 2A).

Commencement of Thromboprophylaxis
1. For patients receiving LMWH as thromboprophylaxis in major orthopedic surgery, we recommend starting either preoperatively or postoperatively (Grade 1A).

2. For patients receiving fondaparinux as thromboprophylaxis in major orthopedic surgery, we recommend starting either 6 to 8 h after surgery or the next day (Grade 1A).

Screening for DVT before hospital discharge
1. For asymptomatic patients following major orthopedic surgery, we recommend against the routine use of DUS screening before hospital discharge (Grade 1A).

Duration of Thromboprophylaxis
1. For patients undergoing THR, TKR, or HFS, we recommend thromboprophylaxis with one of the recommended options for at least 10 days (Grade 1A).

2. For patients undergoing THR, we recommend that thromboprophylaxis be extended beyond 10 days and up to 35 days after surgery (Grade 1A). The recommended options for extended thromboprophylaxis in THR include LMWH (Grade 1A), a VKA (Grade 1B), or fondaparinux (Grade 1C).

3. For patients undergoing TKR, we suggest that thromboprophylaxis be extended beyond 10 days and up to 35 days after surgery (Grade 2B). The recommended options for extended thromboprophylaxis in TKR include LMWH (Grade 1C), a VKA (Grade 1C), or fondaparinux (Grade 1C).

4. For patients undergoing HFS, we recommend that thromboprophylaxis be extended beyond 10 days and up to 35 days after surgery (Grade 1A). The recommended options for extended thromboprophylaxis in HFS include fondaparinux (Grade 1A), LMWH (Grade 1C), or a VKA (Grade 1C).

Abbreviations
CABG coronary artery bypass graft; CI  confidence interval; CVC  central venous catheter;DUS  Doppler ultrasonography; DVT  deep vein thrombosis; FUT  fibrinogen uptake test; GCS  graduated compression stockings; HFS  hip fracture surgery; HIT  heparin-induced thrombocytopenia; INR  international normalized ratio; IPC  intermittent pneumatic compression; IVC  inferior vena cava; LDUH low-dose unfractionated heparin; LMWH low-molecular-weight heparin; NNH number needed to harm; NNT number needed to treat; NS not significant; OR odds ratio; PE pulmonary embolism; RAM risk assessment model; RRR relative risk reduction; SC subcutaneous; SCI spinal cord injury; THR total hip replacement; TKR total knee replacement; VFP venous foot pump; VKA vitamin K antagonist; VTE venous thromboembolism.

Guidelines Resources

 * Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)