Prevention of Venous Thromboembolism in Surgical Hospitalized Patients

Publication Date: December 3, 2019

Recommendation

Mechanical vs pharmacological prophylaxis for patients undergoing major surgery

For patients undergoing major surgery, the ASH guideline panel suggests the following:

Using pharmacological prophylaxis or mechanical prophylaxis (conditional recommendation based on low certainty in the evidence of effects. (2, ⊕⊕oo)
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For patients who do not receive pharmacologic prophylaxis, using mechanical prophylaxis over no mechanical prophylaxis. (2, ⊕ooo)
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For patients who receive mechanical prophylaxis, using intermittent compression devices over graduated compression stockings (conditional recommendation based on very low certainty in the evidence of effects. (2, ⊕ooo)
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For patients who receive pharmacologic prophylaxis, using combined prophylaxis with mechanical and pharmacological methods over prophylaxis with pharmacological agents alone (conditional recommendation based on very low certainty in the evidence of effects. (2, ⊕ooo)
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Depending on the risk of VTE and bleeding based on the individual patient and the type of surgical procedure, using combined prophylaxis or mechanical prophylaxis alone (conditional recommendation based on low certainty in the evidence of effects. (2, ⊕⊕oo)
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Remarks: For patients considered at high risk of bleeding, the balance of effects may favor mechanical methods over pharmacological prophylaxis. For patients considered at high risk for VTE, combined prophylaxis is particularly favored over mechanical or pharmacological prophylaxis alone.

Prophylactic insertion of an inferior vena cava filter

For patients undergoing major surgery, the ASH guideline panel suggests against using inferior vena cava (IVC) filters for prophylaxis of VTE (conditional recommendation based on very low certainty in the evidence of effects. (2, ⊕ooo)
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Timing of antithrombotic prophylaxis

For patients undergoing major surgery, the ASH guideline panel suggests using extended antithrombotic prophylaxis over short-term antithrombotic prophylaxis. (2, ⊕ooo)
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The ASH guideline panel further suggests using early or delayed antithrombotic prophylaxis (conditional recommendation based on very low certainty in the evidence of effects. (2, ⊕ooo)
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Remarks: Extended prophylaxis was generally considered as beyond 3 weeks (range, 19-42 days) compared with short-term prophylaxis, which was considered as up to 2 weeks (range, 4-14 days). Twelve hours following surgery was arbitrarily selected to be the cutoff point between early and late postoperative antithrombotic administration.

Orthopedic surgery

For patients undergoing total hip arthroplasty or total knee arthroplasty, the ASH guideline panel suggests using aspirin (ASA) or anticoagulants. (2, ⊕ooo)
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When anticoagulants are used, the panel suggests using direct oral anticoagulants (DOACs) over low-molecular-weight heparin (LMWH). (2, ⊕⊕⊕o)
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The panel suggests using any of the DOACs approved for use. (2, ⊕⊕oo)
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If a DOAC is not used, the panel suggests using LMWH rather than warfarin (2, ⊕ooo)
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and recommends LMWH rather than unfractionated heparin (UFH). (1, ⊕⊕⊕o)
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For patients undergoing hip fracture repair, the ASH guideline panel suggests using pharmacological prophylaxis over no pharmacological prophylaxis (2, ⊕ooo)
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and suggests using LMWH or UFH. (2, ⊕ooo)
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Major general surgery

For patients undergoing major general surgery, the ASH guideline panel suggests using pharmacological prophylaxis over no pharmacological prophylaxis (2, ⊕⊕oo)
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and suggests using LMWH or UFH. (2, ⊕ooo)
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Laparoscopic cholecystectomy

For patients undergoing laparoscopic cholecystectomy, the ASH guideline panel suggests against using pharmacological prophylaxis. (2, ⊕ooo)
Remark: Patients with other risk factors for VTE (such as history of VTE, thrombophilia, or malignancy) may benefit from pharmacological prophylaxis.
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Major neurosurgical procedures

For patients undergoing major neurosurgical procedures, the ASH guideline panel suggests against using pharmacological prophylaxis. (2, ⊕ooo)
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For the subset of patients undergoing major neurosurgical procedures for whom pharmacological prophylaxis is used, the ASH guideline panel suggests using LMWH over UFH. (2, ⊕ooo)
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Remarks: Patients undergoing major neurosurgical procedures are expected to receive prophylaxis with mechanical methods. Pharmacological prophylaxis may be warranted in a higher-risk subgroup of patients, such as those experiencing prolonged immobility following surgery. In addition, pharmacological prophylaxis could be considered for patients undergoing major neurosurgical procedures that carried a lower risk for major bleeding and in those patients with persistent mobility restrictions after the bleeding risk declines following surgery.

Urological procedures

For patients undergoing transurethral resection of the prostate (TURP), the ASH guideline panel suggests against using pharmacological prophylaxis. (2, ⊕ooo)
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For the subset of patients undergoing TURP for whom pharmacological prophylaxis is used, the ASH guideline panel suggests using LMWH or UFH. (2, ⊕ooo)
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Remark: Patients with other risk factors for VTE (such as history of VTE, thrombophilia, or malignancy) may benefit from pharmacological prophylaxis.
For patients undergoing radical prostatectomy, the ASH guideline panel suggests against using pharmacological prophylaxis. (2, ⊕ooo)
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For patients undergoing radical prostatectomy in whom pharmacological prophylaxis is used, the ASH guideline panel suggests using LMWH or UFH. (2, ⊕ooo)
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Remark: Patients undergoing an extended node dissection and/or open radical prostatectomy may have a higher VTE risk and may potentially benefit from pharmacological prophylaxis.

Cardiac or major vascular surgery

For patients undergoing cardiac or major vascular surgery, the ASH guideline panel suggests using pharmacological prophylaxis or no pharmacological prophylaxis. (2, ⊕ooo)
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When pharmacological prophylaxis is used, the panel suggests using LMWH or UFH. (2, ⊕ooo)
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Major trauma

For patients experiencing major trauma and who are at low to moderate risk for bleeding, the ASH guideline panel suggests using pharmacological prophylaxis over no pharmacological prophylaxis. (2, ⊕ooo)
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For patients experiencing major trauma and who are at high risk for bleeding, the ASH guideline panel suggests against pharmacological prophylaxis. (2, ⊕ooo)
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For patients experiencing major trauma in whom pharmacological prophylaxis is used, the ASH guideline panel suggests using LMWH or UFH. (2, ⊕⊕oo)
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Major gynecological surgery

For patients undergoing major gynecological surgery, the ASH guideline panel suggests using pharmacological prophylaxis over no pharmacological prophylaxis. (2, ⊕ooo)
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and suggests using LMWH or UFH. (2, ⊕ooo)
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Recommendation Grading

Disclaimer

Overview

Title

Prevention of Venous Thromboembolism in Surgical Hospitalized Patients

Authoring Organization

Publication Month/Year

December 3, 2019

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery.

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Prevention, Management

Diseases/Conditions (MeSH)

D054556 - Venous Thromboembolism, D020246 - Venous Thrombosis, D013502 - General Surgery

Keywords

anticoagulation, surgery, Venous Thromboembolism, Anticoagulation

Source Citation

Blood Adv (2019) 3 (23): 3898–3944.