Guideline:
Practice parameters for the prevention of venous thromboembolism
Bibliographic Source(s)
- Stahl TJ Gregorcyk SG Hyman NH Buie WD Standards Practice Task Force of The American Society of Colon and Rectal. Practice parameters for the prevention of venous thrombosis. Dis Colon Rectum 2006 Oct;49(10):1477-83. [51 references] PubMed
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Practice parameters for the prevention of venous thromboembolism. The Standards Task Force of the American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000 Aug;43(8):1037-47.
Guideline Category
Prevention
Risk Assessment
Intended Users
Health Care Providers
Patients
Physicians
Guideline Objective(s)
To provide practice parameters for the prevention of venous thrombosis
Target Population
Patients undergoing surgery of the colon and rectum
Interventions and Practices Considered
- Assessment of risk category (low moderate high or highest)
- Physical prophylactic measures including early ambulation elastic stockings and intermittent pneumatic compression (IPC) devices
- Chemical prophylaxis including low-dose unfractionated heparin (LDUH) or low-molecular-weight heparin (LMWH)
Major Outcomes Considered
- Efficacy of venous thromboembolism (VTE) prophylaxis
- Risk and rates of venous thromboembolism
- Adverse effects associated with chemical prophylaxis
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Not stated
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Levels of Evidence
- Meta-analysis of multiple well-designed controlled studies; randomized trials with low false-positive and low false-negative errors (high power)
- At least one well-designed experimental study; randomized trials with high false-positive or high false-negative errors or both (low power)
- Well-designed quasi-experimental studies such as nonrandomized controlled single-group preoperative-postoperative comparison cohort time or matched case-control series
- Well-designed nonexperimental studies such as comparative and correlational descriptive and case studies
- Case reports and clinical examples
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Grades of Recommendations
- Evidence of Type I or consistent findings from multiple studies of Type II III or IV
- Evidence of Type II III or IV and generally consistent findings
- Evidence of Type II III or IV but inconsistent findings
- Little or no systematic empirical evidence
Cost Analysis
In numerous well-performed studies and several meta-analyses comparing the efficacy of venous thromboembolism (VTE) prophylaxis between low-molecular-weight-heparin (LMWH) and low-dose-unfractionated heparin (LDUH) for VTE prophylaxis unfractionated heparin has been shown to be equally effective and more cost-effective.
Method of Guideline Validation
Not stated
Description of Method of Guideline Validation
Not stated
Major Recommendations
The levels of evidence (I-V) and the grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.
Treatment Recommendations
- Patients undergoing anorectal procedures who are younger than 40 years of age and have no additional risk factors (see Table 1 in the original guideline document for a list of risk factors) for venous thromboembolism (VTE) require no specific prophylaxis. Level of Evidence: V; Grade of Recommendation: D
- Patients undergoing anorectal procedures who are older than 40 and/or have additional risk factors for VTE should be considered for prophylaxis on a case-by-case basis. Level of Evidence: V; Grade of Recommendation: D
Patients in the moderate-risk to high-risk group (see original guideline document for a description of each of the four risk categories: low-risk moderate-risk high-risk and highest risk) are appropriately considered for prophylaxis based on the number of risk factors the length and magnitude of the planned surgery and the risk of bleeding. The appropriate means of prophylaxis would be mechanical compression or heparin (low-dose unfractionated heparin [LDUH] or low-molecular-weight heparin [LMWH]). Because of the frequent outpatient nature of this type of surgery and the potential for bleeding in many anorectal procedures mechanical prophylaxis may be preferable in most cases.
- Patients in the moderate-risk to high-risk categories for VTE undergoing abdominal surgery should receive prophylaxis with LDUH or LMWH. Patients at risk for bleeding may receive mechanical prophylaxis instead. Level of Evidence: I; Grade of Recommendation: A
Mechanical methods may be chosen in patients in whom the risk of bleeding is judged to outweigh the benefit of prophylactic heparin.
- Patients in the highest-risk category for VTE should receive both mechanical and heparin prophylaxis. Level of Evidence: I; Grade of Recommendation: A
In this high-risk group mechanical prophylaxis adds further protection compared with heparin alone.
- Patients undergoing laparoscopic colorectal procedures should receive VTE prophylaxis according to the same risk assessment that would be applicable for the same surgery performed as an open procedure. Level of Evidence: V; Grade of Recommendation: D
- Patients who have undergone major cancer surgery may benefit from posthospital prophylaxis with LMWH. Level of Evidence: II; Grade of Recommendation: C
The optimum duration of VTE prophylaxis is currently unknown. Although most deep vein thrombosis (DVT) occurs within the first week or two after surgery VTE complications including pulmonary embolism (PE) can occur beyond that time frame. These findings combined with shrinking hospital stays have generated an interest in the appropriate duration of VTE prophylaxis. There is evidence that in cancer-surgery patients continued prophylaxis for two to three weeks after discharge reduces the incidence of asymptomatic DVT.
Definitions
Levels of Evidence
- Meta-analysis of multiple well-designed controlled studies; randomized trials with low false-positive and low false-negative errors (high power)
- At least one well-designed experimental study; randomized trials with high false-positive or high false-negative errors or both (low power)
- Well-designed quasi-experimental studies such as nonrandomized controlled single-group preoperative-postoperative comparison cohort time or matched case-control series
- Well-designed nonexperimental studies such as comparative and correlational descriptive and case studies
- Case reports and clinical examples
Grades of Recommendations
- Evidence of Type I or consistent findings from multiple studies of Type II III or IV
- Evidence of Type II III or IV and generally consistent findings
- Evidence of Type II III or IV but inconsistent findings
- Little or no systematic empirical evidence
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations" field).
Potential Benefits
Appropriate use of practice parameters for the prevention of venous thrombosis
Potential Harms
- Low-dose unfractionated heparin (LDUH) is associated with only a modest increase in minor bleeding complications such as wound hematoma
- A potential danger has been associated with the use of heparin prophylaxis in conjunction with spinal or epidural anesthesia. The most serious potential complication is the development of a perispinal hematoma which can lead to spinal cord ischemia and paraplegia. This complication has been reported with both LDUH and LMWH but more so with LMWH. Refer to the original guideline document for detailed instructions on the use of heparin prophylaxis in conjunction with spinal or epidural anesthesia.
Qualifying Statements
These guidelines are inclusive and not prescriptive. Their purpose is to provide information on which decisions can be made rather than dictate a specific form of treatment. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Bibliographic Source(s)
- Stahl TJ Gregorcyk SG Hyman NH Buie WD Standards Practice Task Force of The American Society of Colon and Rectal. Practice parameters for the prevention of venous thrombosis. Dis Colon Rectum 2006 Oct;49(10):1477-83. [51 references] PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Society of Colon and Rectal Surgeons
Guideline Committee
Standards Practice Task Force of the American Society of Colon and Rectal Surgeons
Composition of Group that Authored the Guideline
Authors: Thomas J. Stahl MD; Sharon G. Gregorcyk MD; Neil H. Hyman MD; W. Donald Buie MD; and the Standards Practice Task Force of The American Society of Colon and Rectal Surgeons (ASCRS)
Contributing Members of the ASCRS Standards Committee: Amir L. Bastawrous MD; Gary D. Dunn MD; C. Neal Ellis MD; Phillip R. Fleshner MD; Clifford Y. Ko MD; Nancy A. Morin MD; Richard L. Nelson MD; Graham L. Newstead MD; Jason R. Penzer MD; W. Brian Perry MD; Janice F. Rafferty MD; Paul C. Shellito MD; Charles A. Ternent MD; Joe J. Tjandra MD
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Practice parameters for the prevention of venous thromboembolism. The Standards Task Force of the American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000 Aug;43(8):1037-47.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the American Society of Colon and Rectal Surgeons (ASCRS) Web site.
Print copies: Available from the ASCRS 85 W. Algonquin Road Suite 550 Arlington Heights Illinois 60005.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This summary was completed by ECRI on February 13 2001. The information was verified by the guideline developer on May 9 2002. This NGC summary was updated by ECRI Institute on May 30 2007. This summary was updated by ECRI Institute on March 14 2008 following the updated FDA advisory on heparin sodium injection. This summary was updated by ECRI Institute on December 26 2008 following the FDA advisory on Innohep (tinzaparin).
COPYRIGHT STATEMENT
American Society of Colon and Rectal Surgeons (ASCRS) parameters may be downloaded for personal use (one copy); copies for other purposes please contact the ASCRS office at (847) 290-9184.
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