Prevention Of VTE In Nonorthopedic Surgical Patients

Publication Date: February 1, 2012

Recommendations

Risk Stratification, Rationale for Prophylaxis, and Recommendations in General, Abdominal-Pelvic, Bariatric, Vascular, and Plastic and Reconstructive Surgery

For general and abdominal-pelvic surgery patients at very low risk for VTE ( <0.5%; Rogers score, <7; Caprini score, 0), we recommend that
  • no specific pharmacologic
(1, B)
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  • or mechanical
(2, C)
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prophylaxis be used other than early ambulation.
For general and abdominal-pelvic surgery patients at low risk for VTE (~1.5%; Rogers score, 7-10; Caprini score, 1-2), we suggest mechanical prophylaxis, preferably with IPC, over no prophylaxis. (2, C)
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For general and abdominal-pelvic surgery patients at moderate risk for VTE (~3.0%; Rogers score, >10; Caprini score, 3-4) who are not at high risk for major bleeding complications, we suggest
  • LMWH,
(2, B)
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  • LDUH,
(2, B)
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  • or mechanical prophylaxis, preferably with IPC,
(2, C)
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over no prophylaxis.
For general and abdominal-pelvic surgery patients at moderate risk for VTE ( ~3.0%; Rogers score, >10; Caprini score, 3-4) who are at high risk for major bleeding complications or those in whom the consequences of bleeding are thought to be particularly severe, we suggest mechanical prophylaxis, preferably with IPC, over no prophylaxis. (2, C)
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For general and abdominal-pelvic surgery patients at high risk for VTE ( ~6.0%; Caprini score, ≥5) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with
  • LMWH
(1, B)
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  • or LDUH
(1, B)
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over no prophylaxis.
We suggest that mechanical prophylaxis with ES or IPC should be added to pharmacologic prophylaxis. (2, C)
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For high-VTE-risk patients undergoing abdominal or pelvic surgery for cancer who are not otherwise at high risk for major bleeding complications, we recommend extended-duration pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis. (1, B)
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For high-VTE-risk general and abdominal-pelvic surgery patients who are at high risk for major bleeding complications or those in whom the consequences of bleeding are thought to be particularly severe, we suggest use of mechanical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated. (2, C)
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For general and abdominal-pelvic surgery patients at high risk for VTE ( ~6%; Caprini score, ≥5) in whom both LMWH and unfractionated heparin are contraindicated or unavailable and who are not at high risk for major bleeding complications, we suggest
  • low-dose aspirin,
(2, C)
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  • fondaparinux
(2, C)
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  • or mechanical prophylaxis, preferably with IPC,
(2, C)
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over no prophylaxis.
For general and abdominal-pelvic surgery patients, we suggest that an IVC filter should not be used for primary VTE prevention. (2, C)
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For general and abdominal-pelvic surgery patients, we suggest that periodic surveillance with venous compression ultrasonography (VCU) should not be performed. (2, C)
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Target Population: Cardiac Surgery

For cardiac surgery patients with an uncomplicated postoperative course, we suggest use of mechanical prophylaxis, preferably with optimally applied IPC, over either.
  • or pharmacologic prophylaxis.
(2, C)
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  • no prophylaxis
(2, C)
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For cardiac surgery patients whose hospital course is prolonged by one or more nonhemorrhagic surgical complications, we suggest adding pharmacologic prophylaxis with LDUH or LMWH to mechanical prophylaxis. (2, C)
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Target Population: Thoracic Surgery

For thoracic surgery patients at moderate risk for VTE who are not at high risk for major bleeding, we suggest
  • LDUH,
(2, B)
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  • LMWH
(2, B)
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  • or mechanical prophylaxis with optimally applied IPC
(2, C)
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over no prophylaxis.
For thoracic surgery patients at high risk for VTE who are not at high risk for major bleeding, we suggest
  • LDUH
(1, B)
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  • or LMWH
(1, B)
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over no prophylaxis.
In addition, we suggest that mechanical prophylaxis with ES or IPC should be added to pharmacologic prophylaxis. (2, C)
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For thoracic surgery patients who are at high risk for major bleeding, we suggest use of mechanical prophylaxis, preferably with optimally applied IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated. (2, C)
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Target Population: Craniotomy

For craniotomy patients, we suggest that mechanical prophylaxis, preferably with IPC, be used over
  • no prophylaxis
(2, C)
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  • or pharmacologic prophylaxis
(2, C)
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For craniotomy patients at very high risk for VTE (eg, those undergoing craniotomy for malignant disease), we suggest adding pharmacologic prophylaxis to mechanical prophylaxis once adequate hemostasis is established and the risk of bleeding decreases. (2, C)
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Target Population: Spinal Surgery

For patients undergoing spinal surgery, we suggest mechanical prophylaxis, preferably with IPC, over
  • no prophylaxis,
(2, C)
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  • unfractionated heparin
(2, C)
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  • or LMWH.
(2, C)
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For patients undergoing spinal surgery at high risk for VTE (including those with malignant disease and those undergoing surgery with a combined anterior-posterior approach), we\ suggest adding pharmacologic prophylaxis to mechanical prophylaxis once adequate hemostasis is established and the risk of bleeding decreases. (2, C)
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Target Population: Major Trauma, Including Traumatic Brain Injury, Acute Spinal Cord Injury, and Traumatic Spine Surgery

For major trauma patients, we suggest use of
  • LDUH,
(2, C)
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  • LMWH
(2, C)
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  • or mechanical prophylaxis, preferably with IPC.
(2, C)
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over no prophylaxis.
For major trauma patients at high risk for VTE (including those with acute spinal cord injury, traumatic brain injury, and spinal surgery for trauma), we suggest adding mechanical prophylaxis to pharmacologic prophylaxis (2, C)
when not contraindicated by lower-extremity injury.
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For major trauma patients in whom LMWH and LDUH are contraindicated, we suggest mechanical prophylaxis, preferably with IPC, over no prophylaxis (2, C)
when not contraindicated by lower-extremity injury.
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We suggest adding pharmacologic prophylaxis with either LMWH or LDUH when the risk of bleeding diminishes or the contraindication to heparin resolves. (2, C)
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For major trauma patients, we suggest that an IVC filter should not be used for primary VTE prevention. (2, C)
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For major trauma patients, we suggest that periodic surveillance with VCU should not be performed. (2, C)
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Recommendation Grading

Disclaimer

Overview

Title

Prevention Of VTE In Nonorthopedic Surgical Patients

Authoring Organization

Publication Month/Year

February 1, 2012

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

We developed recommendations for thromboprophylaxis in nonorthopedic surgical patients

Target Patient Population

Patients requires non-orthopedic surgery

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D000925 - Anticoagulants, D013502 - General Surgery, D003107 - Colorectal Surgery, D013903 - Thoracic Surgery, D013518 - Surgery, Plastic, D000079645 - Perioperative Medicine, D011315 - Preventive Medicine, D019990 - Perioperative Care, D059035 - Perioperative Period

Keywords

anticoagulation, surgery, antiplatelet agents, perioperative care, Antithrombotic Agents, Anticoagulation

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
199
Literature Search Start Date
January 1, 2005
Literature Search End Date
December 31, 2010