PREVENTION AND TREATMENT OF VENOUS THROMBOEMBOLISM

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PREVENTION AND TREATMENT OF VENOUS
THROMBOEMBOLISM Nicolaides AN, Fareed J,
Kakkar AK, Breddin HK, Goldhaber SZ, Hull R,
Kakkar VV, Michiels JJ, Myers K, Samana M,
Sasahara A, Kalodiki E.
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Definition of risk categories General surgery
The definition of risk categories in general
surgical patients using FUT and in hospital
pulmonary embolism.
Category Frequency of calf vein thrombosis Frequency of proximal vein thrombosis Frequency of Fatal PE
High Risk 40 80 10 30 gt1
Moderate Risk 10 40 1 10 0.1 1
Low Risk lt10 lt1 lt0.1
Although based on old studies the percentages
shown in this table are still used to define the
category of risk
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Risk categories Non-orthopaedic patients
Risk Category General Surgery Gynaecology Obstetrics
High Major General Surgery, agegt60 Major Gynaecological Surgery, agegt60 History of DVT/PE
High Major General Surgery, age 40-60 cancer or history of DVT/PE Major Gynaecological Surgery, age 40-60 cancer or history of DVT/PE
High Thrombophilia Thrombophilia Thrombophilia
Moderate Major General Surgery, age 40-60 without other risk factors Major Gynaecological Surgery, age 40-60 Age gt35 years Cesarean section Obesity
Moderate Minor Surgery, age gt60 Major Gynaecological Surgery, agelt40 on oestrogen therapy
Moderate Minor Surgery, age 40-60 with history of DVT/PE or on oestrogen therapy Minor Surgery, age gt60
Low Major General Suregery, age lt40 No other risk factors Minor Gynaecological Surgery, age lt40 without any other risk factors Age lt35 years Without any risk factors
Low Minor Surgery, age 40-60 No other risk factors Minor Gynaecological Surgery, age 40-60 without any other risk factors
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General surgery and vascular surgery Moderate
risk

• Moderate risk patients are those gt 40 years
  undergoing major surgery for benign disease
• LDUH 5000U commenced preoperatively and
  continued twice or 3 times daily (Grade A)
• LMWH initiated and dosed according to
  manufacturers recommendations for moderate risk
  patients are recommended (Grade A)
• An alternative method, especially in patients at
  risk for or with active bleeding, is IPC with GEC
  compression used continuously until the patient
  is ambulant (Grade A)

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General surgery and vascular surgery high risk

• LDUH (5000U commenced 2h before operation and
  continued post-operatively 3 times a day (Grade
  A)
• LMWH initiated and dosed according to the
  manufacturers recommendations (Grade A)
• Both may be combined with mechanical methods
  (GEC or IPC) (Grade B)
• Fondaparinux (one study) is a (Grade B)
  recommendation

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General surgery and vascular surgery

• Prophylactic subcutaneous LDUH, LMWH, or IPC
  with GEC are
• recommended only in patients with additional risk
  factors
• (Grade C)

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Urological surgery

• IPC with GEC (Grade B)
• LDUH giving 5000U commenced 2h before operation
  and continued 3 times a day in the postoperative
  period (Grade A)
• LMWH initiated and dosed according to the
  manufacturers recommendations (Grade C)

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Gynaecological surgery

• LMWH (Grade A)
• LDUH (5000IU 8 hourly) (Grade A)
• IPC (throughout hospital stay) (Grade B)
• LMWH or LDUH combined with IPC or GEC stockings
  provides optimal prophylaxis (Grade B)

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Orthopaedic surgery Hip replacement

• LMWH, fondaparinux, oral anticoagulant therapy,
  IPC or FIT combined with GEC (Grade A). LMWH or
  fondaparinux are preferred for in-hospital
  prevention.
• IPC or FIT combined with GEC stockings are an
  equivalent alternative to LMWH for those
  concerned about bleeding.
• Recombinant hirudin - used in HIT patients
  (Grade A)
• LMWH initiated either before or after operation
  (Grade A)
• Fondaparinux should be started 6-8 h after
  surgery
• Prophylaxis should be continued for 4-6 weeks
  with LMWH (Grade A) or fondaparinux (Grade C,
  extrapolation from hip fracture trial).

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Orthopaedic surgery Knee replacement

• LMWH or warfarin (less effective) (Grade A)
• Fondaparinux (Grade B)
• IPC or FIT plus GEC stockings are alternatives
  but
• more studies are needed (Grade B)

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Orthopaedic surgery Hip fracture

• LMWH, fondaparinux, adjusted dose VKA (INR
  range 2-3), or LDUH (Grade A)
• IPC or FIT combined with GEC should be used when
  there are contraindications for pharmacological
  prophylaxis (Grade B)
• If surgery is likely to be delayed, prophylaxis
  should be initiated with LMWH or IPC or FIT plus
  GEC as close to the fracture as possible (Grade C)

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Orthopaedic/trauma surgery

• LMWH starting as soon as bleeding risk is
  acceptable (Grade A)
• IPC in the presence of contraindications to LMWH
  (Grade B) and continued until full ambulation

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Elective spine surgery

• IPC initiated before operation (Grade B)
• LMWH initiated after operation (Grade B)
• Duration during hospitalisation (Grade C)

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Spinal chord surgery

• IPC and GEC in combination with LMWH (Grade B)
• Initiation
• IPC and GEC on admission
• LMWH when bleeding risk is acceptable (Grade C)
• Duration
• LMWH and IPC for three months
• Continuation with GEC indefinitely (Grade C)

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Neurosurgery

• IPC with or without graduated elastic compression
  stockings (Grade A)
• Addition of LMWH is associated with an increase
  of efficacy (Grade A)

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Critical care

• LDUH or LMWH unless contraindicated (Grade A)
• For patients with contraindications to
  pharmacological prophylaxis, GEC stockings IPC
  are an alternative (Grade C)
• In the absence of contraindications, combined
  mechanical plus pharmacologic prophylaxis (Grade
  C)

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Cancer

• In surgical patients with cancer, LDUH (5000IU
  8-hourly commenced prior to operation) or LMWH
  (Grade A)
• For patients at high risk for development of
  thromboembolic disease in the post-discharge
  period, prolonged thromboprophylaxis with
  enoxaparin 40 mg once daily for up to 4 weeks
  after operation (Grade B)
• In ambulant non-surgical cancer patients with
  advanced breast cancer receiving chemotherapy
  (see above) Use VKA to maintain an INR of
  between 1.3 and 1.9 (Grade B)

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Inferior vena cava filters

• IVC filters are indicated in patients with PE or
  proximal DVT who have contraindications to
  anticoagulation or who have suffered recurrent PE
  while receiving adequate therapeutic
  anticoagulation (Grade B)
• Consider filter placement in patients with major
  trauma or pelvic fracture (Grade C)
• Indications for insertion and removal of
  retrievable IVC filters have not yet been
  established