1. PREVENTION AND TREATMENT OF VENOUS THROMBOEMBOLISM
LIFEBLOOD
THE
Thrombosis
CHARITY
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.

2. 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%
>1%
Moderate Risk
10 – 40%
1 – 10%
0.1 – 1%
Low Risk
<10%
<1%
<0.1%
*Although based on old studies the percentages shown in this table are still used to define the category of risk

3. Non-orthopaedic patients
Risk categories –
Non-orthopaedic patients
Risk Category
General Surgery
Gynaecology
Obstetrics
High
Major General Surgery, age>60
Major Gynaecological Surgery, age>60
History of DVT/PE
Major General Surgery, age & cancer or history of DVT/PE
Major Gynaecological Surgery, age & cancer or history of DVT/PE
Thrombophilia
Moderate
Major General Surgery, age without other risk factors**
Major Gynaecological Surgery, age 40-60
Age >35 years
Cesarean section
Obesity
Minor Surgery, age >60
Major Gynaecological Surgery, age<40 on oestrogen therapy
Minor Surgery, age with history of DVT/PE or on oestrogen therapy
Low
Major General Suregery, age <40 No other risk factors**
Minor Gynaecological Surgery, age <40 without any other risk factors**
Age <35 years
Without any risk factors
Minor Surgery, age 40-60
No other risk factors**
Minor Gynaecological Surgery, age without any other risk factors**

4. General surgery and vascular surgery –
Moderate risk
Moderate risk patients are those > 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)

5. 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 manufacturer’s recommendations (Grade A)
Both may be combined with mechanical methods (GEC or IPC) (Grade B)
Fondaparinux (one study) is a (Grade B) recommendation

6. General surgery and vascular surgery
Prophylactic subcutaneous LDUH, LMWH, or IPC with GEC are
recommended only in patients with additional risk factors
(Grade C)

7. 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 manufacturer’s recommendations (Grade C)

8. 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)

9. 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).

10. 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)

11. 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)

12. 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

13. Elective spine surgery
IPC initiated before operation (Grade B)
LMWH initiated after operation (Grade B)
Duration: during hospitalisation (Grade C)

14. 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)

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

16. 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)

17. 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)

18. 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