Prophylaxis For Venous Thromboembolism

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Contents 1 Indications 2 Management 3 More General Terms 4 Additional Terms 5 References

Indications

• surgery
• acute spinal cord injury with leg paralysis
• multiple trauma
• hospitalization, immobilization
• hypercoagulability
• recurrent deep vein thrombosis

Management

• general surgery

• low risk:* no prophylaxis
• moderate risk:*

• unfractionated heparin

• all surgical patients except those undergoing

• knee replacement,
• hip replacement
• neurosurgery

• 5000 U SC 2 hours preoperatively
• 5000 U SC every 8 hours postoperatively

• high risk:* (a or b)

• unfractionated heparin as for moderate risk
• dalteparin

• 2500 U SC 2 hours preoperatively

• 2500-5000 U SC QD postoperatively
• very high risk:* (a or b, plus c or d)

• unfractionated heparin as for moderate risk
• dalteparin as for high risk
• intermittent pneumatic compression (intraoperatively)
• perioperative warfarin, INR 2.0-3.0

• pharmacologic prophylaxis preferable to intermittent compression devices unless risks of bleeding outweigh benefits [12]
• do not use compression stockings for prophylaxis [12]

• total hip replacement (1 + 2) or 3

• postoperative enoxaparin 30-40 mg SC every 12 hours for 30 days, begun 12-24 hours preoperatively
• fondaparinux ( Arixtra)

• more effective than LMW heparin following orthopedic surgery [1]
• 2.5 mg SC QD

• intermittent pneumatic compression# for 10 days
• warfarin

• begun preoperatively
• adjusted to INR 2.0-3.0 postoperatively
• continued for 4-5 weeks

• may be safely carried out with INR < 2.0
• enoxaparin 40 mg SC QD for 1 month [2]

• total knee replacement (1 + 2) [5]

• postoperative enoxaparin 30 mg SC every 12 hours for 30 days begun 12-24 hours preoperatively
• fondaparinux ( Arixtra)

• more effective than LMW heparin following orthopedic surgery [1]
• 2.5 mg SC QD

• intermittent pneumatic compression# for 10 days
• may be safely carried out with INR < 2.0
• warfarin continued for 30 days is alternative [1]
• aspirin 162 mg/day if other options not viable [15]

• hip fracture surgery (1 or 2)

• enoxaparin 30 mg SC every 12 hours begun 12 hours preoperatively for 30 days + pneumatic compression device# for 10 days [5]
• fondaparinux ( Arixtra)

• more effective than LMW heparin following orthopedic surgery [1]
• 2.5 mg SC QD

• warfarin adjusted to INR 2.0-3.0
• aspirin 162 mg/day if other options not viable [15]

• neurosurgery (1 or 2, or 1 & 2)

• intermittent pneumatic compression
• LMW heparin or warfarin

• acute spinal cord injury with leg paralysis (1 or 2 or 3)

• unfractionated heparin SC adjusted to aPTT 1.5 x control 6 hours after dose
• warfarin adjusted to INR of 2.0-3.0
• intermittent pneumatic compression plus unfractionated heparin 5000 U SC every 12 hours

• multiple trauma (1, then 2 or 3)

• intermittent pneumatic compression until bleeding is unlikely
• enoxaparin 30 mg SC every 12 hours
• warfarin adjusted to INR of 2.0-3.0

• myocardial infarction

• unfractionated heparin 5000 U SC every 12 hours

• stroke

• heparin, LMW heparin, warfarin contraindicated in patients with hemorrhagic stroke
• ischemc stroke

• ischemic stroke with paralysis

• unfractionated heparin 5000 U SC every 12 hours

• neither unfractionated heparin nor LMW heparin significantly effects mortality [12]

• mechanical prophylaxis provides no benefit & results in clinically important harm to patients with stroke

• medical patient expected to be at best rest for at least 4 days, especially the elderly with chronic disease [6]

• unfractionated heparin 5000 U SC every 12 hours
• low molecular weight heparin ( LMW heparin)
• no apparent benefit of LMW heparin over unfractionated heparin in ICU patients [11]
• high-risk acutely ill patients may benefit from extended prophylaxis [10]
• neither unfractionated heparin nor LMW heparin significantly effects mortality [12,13]

• cataracts or lens implantation

• excessive bleeding does not occur when INR < 2.5

• arthroplasty, gastrectomy, cholecystectomy, major gynecologic may be safely carried out with INR < 2.0
• hypercoagulability of malignancy:

• long-term LMW heparin for cancer patients with subsequent transition to warfarin after 3-6 months if necessary [1,8]
• cancer surgery: enoxaparin 40 mg SC QD for 1 month [3]

• coagulation factor deficiency

• LMW heparin

• recurrent deep vein thrombosis

• anticoagulation with warfarin, INR = 2.0-3.0 (90% effective)
• low-intensity anticoagulation, INR = 1.5-2.0 (75% effective)
• risk of bleeding no different [4]

• bed-bound patients in nursing home or at home

• risk of DVT is high
• absence of evidence for benefit of prophylaxis [9]

• low-risk patients

• rosuvastatin & other statins may further reduce risk [7]

• life-long anticoagulation for:

• 2 or more spontaneous episodes of DVT
• 1 spontaneous, life-threatening venous thromoembolism
• 1 spontaneous venous thromboembolism in a patient with hypercoagulability

• * see perioperative risk stratification
• # TED hose not effective [5]

More General Terms

• prophylaxis (prevention, ppx)

Additional Terms

• deep vein thrombosis (DVT)
• perioperative risk stratification (relative risk of non-cardiac surgeries)

References

1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, American College of Physicians, Philadelphia 1998, 2006, 2009
2. Journal Watch 22(9):69, 2002 Journal Watch 16(20):158, 1996 N Engl J Med 335:696, 1996
3. Journal Watch 22(9):69, 2002 Bergqvist D et al Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med 346:975, 2002 PMID: [1]
4. Prescriber's Letter 10(9):49 2003
5. Journal Watch 24(19):151, 2004 Silbersack Y, Taute BM, Hein W, Podhaisky H. Prevention of deep-vein thrombosis after total hip and knee replacement. Low-molecular-weight heparin in combination with intermittent pneumatic compression. J Bone Joint Surg Br. 2004 Aug;86(6):809-12. PMID: [2]
6. Cohen AT, Davidson BL, Gallus AS, Lassen MR, Prins MH, Tomkowski W, Turpie AG, Egberts JF, Lensing AW; ARTEMIS Investigators. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial. BMJ. 2006 Feb 11;332(7537):325-9. Epub 2006 Jan 26. PMID: [3]
7. Glynn RJ et al A randomized trial of rosuvastatin in the prevention of venous thromboembolism. N Engl J Med 2009 Mar 29 PMID: &dopt=Abstract
   - Prescriber's Letter 16(5) 2000 Statins for Venous Thromboembolism Prevention Detail-Document#: [4] (subscription needed) [5]
8. Lee AY et al Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med. 2003 Jul 10;349(2):146-53 PMID: [6]
9. Gatt ME et al Is prolonged immobilization a risk factor for symptomatic venous thromboembolism in elderly bedridden patiens? Results of a historical cohort study. Thromb Haemost 2005 91(3):538 PMID: [7]
   - Bosson JL et al Deep vein thrombosis in elderly patients hospitalized in subacute care facilities: a multicenter cross-sectional study of risk factors, prophylaxis, and prevalence. Arch Intern Med 2003, 163(21):2613 PMID: [8]
10. Hull RD et al. Extended-duration venous thromboembolism prophylaxis in acutely ill medical patients with recently reduced mobility: A randomized trial. Ann Intern Med 2010 Jul 6; 153:8. PMID: [9]
11. Cook D et al for The PROTECT Investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group Dalteparin versus Unfractionated Heparin in Critically Ill Patients New Engl J Med March 22, 2011 <PubMed> PMID: [10] <Internet> [11]
12. Lederle FA et al Venous Thromboembolism Prophylaxis in Hospitalized Medical Patients and Those With Stroke: A Background Review for an American College of Physicians Clinical Practice Guideline Annals of Internal Medicine November 1, 2011 155(9):602-615 <PubMed> PMID: [12] <Internet> [13]
    - Qaseem A et al Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians Annals of Internal Medicine November 1, 2011 155(9):625-682 [14]
13. Kakkar AK et al. Low-molecular-weight heparin and mortality in acutely ill medical patients. N Engl J Med 2011 Dec 29; 365:2463 PMID: [15]
14. Guyatt GH et al Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines CHEST February 2012 vol. 141 no. 2 suppl 7S-47S <PubMed> PMID: [16] <Internet> [17]
    - Alonso-Coello P et al Antithrombotic Therapy in Peripheral Artery Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Chest. 2012 Feb;141(2 Suppl):e669S-90S. PMID: [18]
15. Prescriber's Letter 19(3): 2012 COMMENTARY: Aspirin for VTE Prophylaxis After Hip or Knee Replacement CHART: Drug Options for VTE Prophylaxis After Hip or Knee Replacement Detail-Document#: [19] (subscription needed) [20]
16. National Guideline Clearinghouse Venous thromboembolism prophylaxis. Institute for Clinical Systems Improvement ngc-guideline: [21]
    - Thromboprophylaxis during pregnancy, labour and after vaginal delivery. (Royal College of Obstetricians and Gynaecologists) ngc-guideline: [22]
    - Venous thromboembolism. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. National Collaborating Centre for Acute Care ngc-guideline: [23]
    - Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults. National Institute for Health and Clinical Excellence (NICE) ngc-guideline: [24]
    - Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice guideline from the American College of Physicians. American College of Physicians ngc-guideline: [25]

prophylaxis for venous thromboembolism