Chest
Prevention of Venous Thromboembolism
Section snippets
Why isn't thromboprophylaxis used more widely?
Many physicians believe that the overall incidence of VTE amonghospitalized and postoperative patients has decreased over the pastdecades, to a point where the incidence is too low to considerprophylaxis. These physicians frequently cite informal, retrospectivesurveys of their own clinical services (or their personal experience)and the rare occurrence of fatal PE diagnosed by autopsy at theirhospital to bolster this argument. In fact, the incidence of VTE mayhave declined in recent years,40 and
Risk Factor Stratification
Knowledge of specific risk factors in patient groups or inindividual patients forms the basis for the appropriate use ofprophylaxis. Clinical risk factors include the following: increasingage; prolonged immobility, stroke, or paralysis; previous VTE; cancerand its treatment; major surgery (particularly operations involving theabdomen, pelvis, and lower extremities); trauma (especially fracturesof the pelvis, hip, or leg); obesity; varicose veins; cardiacdysfunction; indwelling central venous
Important Issues Related to Thromboprophylaxis Data
Although we have attempted to provide an unbiased overview of theavailable data about thromboprophylaxis, we recognize that there areimportant limitations of the evidence largely due to the number andquality of the studies that form the basis for our recommendations.These caveats include the following points.
General Surgery
The overall incidence of thromboembolic end points in generalsurgical patients was calculated by pooling data from the controlgroups of published English-language trials of thromboprophylaxis(Table 4). In most studies, the majority of patients had elective GIsurgery. However, some of the patient populations were moreheterogeneous and included individuals also undergoing gynecologic, thoracic, urologic, or vascular operations. Almost all patients wereolder than 40 years. The overall incidence of
Orthopedic Surgery
Clinical trials and cohort studies have provided a clearer pictureof the natural history of acute VTE associated with major orthopedicsurgery of the lower extremity and have also provided considerableinformation to guide decisions about prophylaxis. Based on the resultsof contrast venography, performed on either control patients orpatients randomized to receive placebo, the prevalence of total DVT at7 to 14 days after total hip replacement (THR), total knee replacement(TKR), and hip fracture
Neurosurgery
Patients undergoing elective neurosurgical procedures are known tobe at increased risk of postoperative DVT and PE.428, 429, 430 The control groups of randomized trials, which include a broad spectrumof neurosurgery patients, found that 22% of these patients had FUTevidence of DVT (Table 13) and 5% had proximal DVT.431, 432, 433, 434, 435, 436, 437 Risk factors thatappear to increase DVT rates in neurosurgery patients includeintracranial (vs spinal) surgery, malignant (vs benign) tumors,
Burns
One would expect that burn patients would be at significant riskfor VTE because of the presence of a systemic hypercoagulablestate,542 prolonged bedrest, and repeated surgicalprocedures, frequent sepsis, the common use of central venous lines, and premorbid risk factors. A number of autopsy studies havedemonstrated that burn patients commonly have DVT453, 454 and PE453, 543, 544, 545 at the time of death, although fatal PEhas been described in only 0.1 to 0.5% ofpatients.545, 546, 547, 548
Medical Conditions
In contrast to surgical patients, prevention of VTE has been lesswell studied in hospitalized medical patients.555, 556, 557, 558 Although the trials are generally limited in number and smaller insize, there are now sufficient data to make recommendations aboutprophylaxis for many nonsurgical patient groups (Table 17).
Prophylaxis Implementation Strategies
VTE is an important health-care problem, resulting in significantmortality, morbidity, and resource expenditures. Despite the need foradditional data, we believe that there is sufficient evidence torecommend the routine use of thromboprophylaxis for many hospitalizedpatient groups. These include patients undergoing major general, gynecologic, and urologic surgery, lower extremity arthroplasty and hipfracture repair, neurosurgery, patients admitted with major trauma orSCI, and medical patients
General Recommendations
- 1.
We recommend that every hospital develop a formalstrategy that addresses the prevention of thromboembolic complications.This should generally be in the form of a written thromboprophylaxispolicy especially for high-risk groups.
- 2.
For all patient groups, we do not recommend aspirinfor prophylaxis, because other measures are more efficacious (grade1A).
- 3.
In all patients having spinal puncture or epiduralcatheters placed for regional anesthesia or analgesia, we recommendthat antithrombotic therapy or
General Surgery
- 1.
In low-risk general surgery patients (Table 2) who areundergoing minor procedures, are < 40 years of age, and have noadditional risk factors, we recommend the use of no specificprophylaxis other than early ambulation (grade 1C).
- 2.
Moderate-risk general surgery patients are those undergoingminor procedures but have additional thrombosis risk factors, thosehaving nonmajor surgery between the ages of 40 and 60 years with noadditional risk factors, or those undergoing major operations who areyounger
Elective Hip Replacement
- 1.
For patients undergoing elective THR surgery, we recommendeither SC LMWH therapy (started 12 h before surgery, 12 to 24h after surgery, or 4–6 h after surgery at half the usual high-riskdose and then continuing with the usual high-risk dose the followingday), or adjusted-dose warfarin (INR target = 2.5, range 2.0 to 3.0;started preoperatively or immediately after surgery) (all grade1A).
- 2.
Adjusted-dose heparin therapy (started preoperatively) is anacceptable but more complex alternative (grade 2A).
Neurosurgery
- 1.
We recommend the use of IPC with or without ES inpatients undergoing intracranial neurosurgery (grade 1A).
- 2.
LDUH or postoperative LMWH are acceptable alternatives (grade2A because of concerns about clinically important intracranialhemorrhage).
- 3.
The combination of physical (ES or IPC) and pharmacologic (LMWHor LDUH) prophylaxis modalities may be more effective than eithermodality alone in high-risk patients (grade 1B).
Trauma
- 1.
Trauma patients with an identifiable risk factor forthromboembolism should receive
Acute MI
- 1.
We recommend that most patients with acute MI receiveprophylactic or therapeutic anticoagulant therapy with SC LDUH or IVheparin (grade 1A).
Ischemic Stroke
- 1.
For patients with ischemic stroke and impaired mobility, werecommend the routine use of LDUH, LMWH, or the heparinoid, danaparoid (all grade 1A).
- 2.
If anticoagulant prophylaxis is contraindicated, we recommendmechanical prophylaxis with ES or IPC (grade 1C+).
Other Medical Conditions
- 1.
In general medical patients with risk factors for VTE(including cancer, bedrest, heart failure, severe
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Dr. Geerts receives research funding from Aventis Pharma, Pharmacia & Upjohn
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Dr. Heit receives research funding from Astra Zeneca, Aventis Pharma, Corvas, DuPont Pharma, and Wyeth-Ayerst
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Dr. Pineo receives research funding from DuPont Pharma, Emesphere Technologies, Leo Pharma, and Pharmacia & Upjohn. Dr. Pineo also serves on the advisory boards for Pharmacia & Upjohn and DuPont Pharma
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Dr. Colwell receives research funding from and serves as consultant for Rhone-Poulenc Rorer, Pharmacia & Upjohn, and Astra Zeneca
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Dr. Anderson receives research funding from and serves as consultant for Aventis Pharma