Prevention of Venous Thromboembolism in Surgical and Medical Patients and Long-Distance Travelers in Latin America
Summary of Recommendations
For patients undergoing major general surgery, the ASH Latin American Guideline Panel suggests thromboprophylaxis over no prophylaxis. (C, L)
- The panel considered that for patients undergoing major general surgery at average risk of bleeding, pharmacological and mechanical prophylaxis are reasonable alternatives. However, pharmacological prophylaxis is probably easier to implement.
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For patients undergoing surgery following major trauma, the ASH Latin American Guideline Panel suggests thromboprophylaxis over no prophylaxis. (C, VL)
- For patients who are actively bleeding or at high risk of bleeding, mechanical prophylaxis may be preferable over pharmacological prophylaxis.
- It is important to consider that patients who remain hospitalized after surgery may have an increased risk of thrombosis due to the lack of ambulation (see recommendations about thromboprophylaxis in acutely and critically ill patients).
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For patients undergoing laparoscopic cholecystectomy, the ASH Latin American Guideline Panel suggests against thromboprophylaxis. (C, VL)
- Patients who are not admitted to hospital or stay just 1 or 2 nights likely do not benefit from thromboprophylaxis. However, patients who remain hospitalized after the surgery may benefit from prophylaxis, especially if they are at high risk of VTE.
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For patients undergoing transurethral resection of the prostate (recommendation 4) or radical prostatectomy (recommendation 5), the ASH Latin American Guideline Panel suggests against thromboprophylaxis. (C, VL)
- The risk of bleeding after a transurethral resection or radical prostatectomy is likely higher than after major general surgery. Therefore, for a patient at an average risk of VTE, the undesirable consequences of pharmacological thromboprophylaxis likely outweigh its potential benefits.
- If VTE risk remains as an important concern, mechanical prophylaxis may be an appropriate alternative.
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For patients undergoing major neurosurgical procedures, the ASH Latin American Guideline Panel suggests thromboprophylaxis over no prophylaxis. (C, VL)
- Most patients undergoing major neurosurgical procedures are likely at high risk of VTE and simultaneously at high risk of bleeding. Thus, decisions regarding the use of prophylaxis and its modality should be done on an individual basis.
- If the risk of bleeding is considered high, mechanical prophylaxis may be a better initial alternative. It is important to consider that bleeding risk will change over time; thus, the decision regarding the use of pharmacological or mechanical prophylaxis should be evaluated periodically.
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In surgical patients in whom thromboprophylaxis is preferred, the ASH Latin American Guideline Panel suggests either mechanical or pharmacological prophylaxis. (C, L)
- This recommendation applies to the populations discussed in recommendations 1 to 6.
- Pharmacological prophylaxis might be a better alternative for patients at high risk of VTE. However, patients with an increased risk of bleeding may be better off with mechanical prophylaxis. The individual decision should be made considering the specific clinical circumstances (ie, risk of VTE and bleeding), the patient’s values and preferences, and the availability of the options. Also, given that the risks of VTE and bleeding may change over time, the decision should be reassessed frequently.
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For surgical patients in whom mechanical thromboprophylaxis is preferred, the ASH Latin American Guideline Panel suggests mechanical compression devices over compression stockings. (C, L)
- This recommendation applies to the populations discussed in recommendations 1 to 6.
- Mechanical devices may not be available in all settings in Latin America. However, since the difference between mechanical devices and compression stockings is likely small, compression stockings are a reasonable alternative for patients for whom mechanical prophylaxis is preferred and where there is limited availability of devices.
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In surgical patients in whom pharmacological thromboprophylaxis is preferred, the ASH Latin American Guideline Panel suggests short prophylaxis (7 to 10 days) over extended prophylaxis (30 days). (C, VL)
- This recommendation applies to the populations discussed in recommendations 1 to 6.
- For patients at average risk of VTE, a short prophylaxis likely will be enough. However, patients with an increased risk of VTE, such as patients undergoing cancer or orthopedic surgery, may benefit from extended prophylaxis. Furthermore, patients requiring longer immobilization might need extended thromboprophylaxis as well.
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In surgical patients in whom pharmacological thromboprophylaxis is preferred, the ASH Latin American Guideline Panel suggests delayed prophylaxis (12 hours after surgery) over early administration (before surgery or within 12 hours post-surgery). (C, VL)
- The time of initiation should be assessed on an individual basis, with the surgical team considering the risk of VTE and risk of bleeding.
- Patients who need hospitalization for a significant period of time before surgery might benefit from prophylaxis (see recommendations about thromboprophylaxis in acutely and critically ill patients).
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In acutely medically ill patients, the ASH Latin American Guideline Panel suggests against routinely use of heparins (UFH or low-molecular-weight heparin [LMWH]). (C, L)
- In the majority of patients admitted to hospital for noncritical medical conditions, the risk of VTE is likely small, especially if they are able to walk or perform physical therapy. In those cases, the benefit of prophylaxis with heparins may be very small. In contrast, pharmacological prophylaxis may be appropriate for individuals at increased risk of VTE, such as bedridden patients or those with previous VTE events or major risk factors.
- The panel emphasizes that the risk of VTE and bleeding may change over time. Thus, a frequent assessment of the potential benefits and harms of thromboprophylaxis is needed.
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In acutely critically ill patients, the ASH Latin American Guideline Panel suggests the use of heparins (UFH or LMWH) over no use. (C, M)
- It is important to consider that the risk of VTE or risk of bleeding may change during a hospital stay. Thus, a frequent assessment is needed.
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In acutely critically and medically ill patients who require pharmacologic prophylaxis, the ASH Latin American Guideline Panel suggests either UFH or LMWH. (C, L)
- The difference between LMWH and UFH in patient-important outcomes (thrombotic events and bleeding) is very small in magnitude. Therefore, UFH may be a reasonable alternative in settings where the price of LMWH is a barrier. In situations where access to LMWH is not a concern, this option probably represents a more convenient alternative for patients and providers.
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In acutely critically and medically ill patients who cannot receive pharmacological prophylaxis, the ASH Latin American Guideline Panel suggests using mechanical prophylaxis over no prophylaxis. (C, M)
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In acutely critically and medically ill patients who need mechanical prophylaxis, the ASH Latin American Guideline Panel suggests using either pneumatic compression devices or graduated compression stockings. (C, VL)
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In acutely critically and medically ill patients who require pharmacological thromboprophylaxis, the ASH Latin American Guideline Panel suggests using a short period of prophylaxis (inpatients) over an extended period (inpatients and extended-duration outpatients). (C, M)
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In chronically ill patients, the ASH Latin American Guideline Panel suggests against using thromboprophylaxis. (C, VL)
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In acutely ill patients who require pharmacological thromboprophylaxis, the ASH Latin American Guideline Panel suggests using LMWH over DOACs. (C, M)
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For long-distance travelers (>4 hours) with low risk of VTE, the ASH Latin American Guideline Panel suggests against thromboprophylaxis. Recommendation 21: However, for long-distance travelers with high risk of VTE, the ASH Latin American Guideline Panel suggests thromboprophylaxis with compression stockings or LMWH. (C, VL)
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Recommendation Grading
Overview
Title
Prevention of Venous Thromboembolism in Surgical and Medical Patients and Long-Distance Travelers in Latin America
Authoring Organization
American Society of Hematology
Publication Month/Year
June 28, 2022
Document Type
Guideline
Country of Publication
US
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Prevention
Diseases/Conditions (MeSH)
D054556 - Venous Thromboembolism
Keywords
VTE, Venous Thromboembolism, VTE Prophylaxis, travel medicine, venous thromboembolic event (VTE), latin america
Source Citation
Neumann I, Izcovich A, Aguilar R, Basantes GL, Casais P, Colorio CC, Esposito MCG, Lázaro PPG, Pereira J, Meillon-García LA, Rezende SM, Serrano JC, Valle MLT, Vera F, Karzulovic L, Rada G, Schünemann HJ. American Society of Hematology, ABHH, ACHO, Grupo CAHT, Grupo CLAHT, SAH, SBHH, SHU, SOCHIHEM, SOMETH, Sociedad Panameña de Hematología, Sociedad Peruana de Hematología, and SVH 2022 guidelines for prevention of venous thromboembolism in surgical and medical patients and long-distance travelers in Latin America. Blood Adv. 2022 Jun 28;6(12):3636-3649. doi: 10.1182/bloodadvances.2021006482. PMID: 35195676.