venous%20thromboembolism%20-%20prevention
VENOUS THROMBOEMBOLISM - PREVENTION
Venous thromboembolism is comprised of pulmonary embolism and deep venous thrombosis and is associated with significant morbidity and mortality.
All patients admitted for major trauma, surgery or acute medical illness should be assessed for risk of venous thromboembolism and bleeding before starting prophylaxis for venous thromboembolism.
Decision on which type of prophylaxis to be given must be individualized for each patient.

Prevention

Specific Group Recommendations for Patients at Moderate to High Risk for VTE


SPECIFIC GROUP DEPENDING ON RISK FACTOR FOR VTE RECOMMENDED PREVENTION
Moderate-risk general surgery
  • Major surgery for benign disease
  • Any of the following would be appropriate:
  • LDUH
  • LMWH
  • Fondaparinux
  • High-risk general surgery
  • Major procedure for cancer
  • Any of the following would be appropriate:
  • LDUH 8 hourly
  • LMWH
  • Fondaparinux
  • High-risk general surgery patients with multiple risk factors Any of the following would be appropriate:
  • LDUH 8 hourly
  • LMWH
  • Fondaparinux

  • Combined with:
  • GCS and/or IPC
  • Patients with high risk of bleeding
  • General surgery
  • Urologic surgery
  • Critical care patients
  • GCS and/or IPC until bleeding decreases then substitute or add pharmacological thromboprophylaxis
  • Major vascular surgery patients with additional thromboembolic risk factors Any of the following would be appropriate:
  • LDUH
  • LMWH
  • Fondaparinux

    Mechanical prophylaxis may also be added
  • Major gynecologic surgery for benign disease without additional risk factors Any of the following would be appropriate:
  • LDUH 12 hourly
  • LMWH
  • IPC started prior to surgery and continued until patient is ambulatory
  • Extensive gynecologic surgery for malignancy and for patients with additional risk factors Any of the following would be appropriate:
  • LDUH 8 hourly
  • LMWH
  • IPC started prior to surgery and continued until patient is ambulatory

    Any of the following alternatives:
  • LDUH + (IPC or GCS)
  • LMWH + (IPC or GCS)
  • Fondaparinux
  • Extensive gynecologic surgery for malignancy and for patients with additional risk factors Any of the following would be appropriate:
  • LDUH 8 hourly
  • LMWH
  • IPC started prior to surgery and continued until patient is ambulatory

    Any of the following alternatives:
  • LDUH + (IPC or GCS)
  • LMWH + (IPC or GCS)
  • Fondaparinux
  • Major open urologic procedures Any of the following would be appropriate:
  • LDUH 8-12 hourly
  • GCS and/or IPC started prior to surgery and continued until patient is ambulatory
  • LMWH
  • Fondaparinux
  • Combination of pharmacologic thromboprophylaxis with mechanical method
  • Laparoscopic procedures with additional risk factors ≥1 of the following would be appropriate:
  • LDUH
  • LMWH
  • Fondaparinux
  • GCS
  • IPC
  • Inpatient bariatric surgery Any of the following would be appropriate:
  • LMWH, higher dose for non-obese patients
  • LDUH 8 hourly, higher dose for non-obese patients
  • Fondaparinux
  • Combination of pharmacologic thromboprophylaxis with IPC
  • Major thoracic surgery Any of the following would be appropriate:
  • LMWH
  • LDUH
  • Fondaparinux
  • Coronary artery bypass surgery (CABG) Any of the following would be appropriate:
  • LMWH, preferred
  • LDUH
  • Bilateral GCS or IPC
  • Elective total hip replacement (THR) Any of the following would be appropriate:
  • Apixaban
  • LMWH
  •   -  Usual high-risk dose started 12 hours pre-op or 12-24 hours post-op, or
      -  4-6 hours post-op at half the usual high-risk dose the following day
  • Fondaparinux
  •   -  Started 6-24 hours post-op
  • Rivaroxaban
  • Warfarin, adjusted dose (INR target 2.5: INR range 2.0-3.0) started pre-op or evening of the surgical day
  • Elective THR with high risk of bleeding
  • VFP or IPC until bleeding decreases then substitute or add pharmacological thromboprophylaxis
  • Elective total knee replacement (TKR) Any of the following would be appropriate:
  • Apixaban
  • LMWH, usual high-risk dose
  • Fondaparinux
  • Rivaroxaban
  • Warfarin, adjusted dose (INR target 2.5: INR range 2.0-3.0)

    Alternative:
  • IPC
  • Hip fracture surgery (HFS) Any of the following would be appropriate:
  • Fondaparinux
  • LMWH
  • LDUH
  • Warfarin, adjusted dose (INR target 2.5: INR range 2.0-3.0)
  • Elective TKR with high risk of bleeding
    HFS with high risk of bleeding
  • VFP or IPC until bleeding decreases then substitute or add pharmacological thromboprophylaxis
  • Arthroscopic knee surgery with additional risk factor or following a complicated procedure
  • LMWH
  • Critical care patients who are at moderate risk or higher risk Any of the following would be appropriate for moderate risk:
  • LMWH
  • LDUH

    For higher risk:
  • LMWH
  • Anticoagulation contraindicated
  • GCS
  • IPC

  • Duration of Prophylaxis

    Medical Conditions

    • The optimal length of thromboprophylaxis in medical patients is yet undetermined

    Major General Surgery 

    • 7-10 days post-surgery or for length of hospitalization
      • Appropriate length of prophylaxis should be based on clinical factors (eg mobilization)
    • For patients who have undergone major cancer surgery or have previous VTE 
      • Continue LMWH for up to 28 days after discharge

    Major Gynecologic Surgery

    • Continue prophylaxis until discharge
    • For high-risk patients including those who have undergone major cancer surgery or have previous VTE
      • Continue LMWH for up to 28 days after discharge

    Major Orthopedic Surgery

    • At least 10 days post-surgery
    • Extended prophylaxis for up to 35 days after THR, TKR and HFS  
    • Prolonged out-of-hospital prophylaxis should be considered for high-risk patients
      • LMWH, Fondaparinux or adjusted-dose Warfarin may be considered for extended out-of-hospital prophylaxis
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