Venous thromboembolism (VTE; deep venous thrombosis and pulmonary embolism [PE]) is common in the postoperative setting with over half of this population at moderate risk for VTE. PE is one of the most common preventable causes of in-hospital deaths following surgery. [1]
Nonorthopedic surgeries include
Approach to the prevention of VTE in nonorthopedic surgical patients is, for the most part, in keeping with recommendations from several societies, including the American College of Chest Physicians (ACCP) and the American Society of Hematology (ASH).
Rates of symptomatic VTE derived from untreated groups in randomized trials have ranged from 0.5 to 1.6 percent, higher among those undergoing surgery for malignancy (up to 3.7 percent). However, several studies report that VTE risk is wide in this population since it encompasses a broad range of surgeries from laparoscopic appendectomy to open pelvic surgery for cancer. []
Although there have been many attempts to quantitate VTE risks, no one method has been found to be universally acceptable and many physicians use a gestalt assessment. Nonetheless, the most widely used model is the Modified Caprini Risk Assessment Model (ie, Caprini score modified by the ACCP. The Rogers score is less frequently used and has not been externally validated.
Using the Caprini score, patients undergoing surgical procedures are classified according to their estimated baseline risk (EBR) for VTE in the absence of thromboprophylaxis as:
Very low risk – Caprini score 0; corresponding to an EBR <0.5 percent
Low risk – Caprini score 1 to 2; corresponding to an EBR of about 1.5 percent
Moderate risk – Caprini score 3 to 4; corresponding to an EBR of about 3 percent
High risk – Caprini score ≥5; corresponding to an EBR of at least 6 percent
This model is has been validated, and is therefore, only applicable to patients undergoing general (eg, breast, thyroid, parathyroid) and abdominal/pelvic surgery (eg, gastrointestinal, urologic, gynecologic), including those who are critically ill. Although not validated in other populations, it is considered by most experts as acceptable for use in those undergoing bariatric and vascular surgery. In addition, this model underwent further modification for patients undergoing plastic/reconstructive surgery since a validation study reported a lower risk of VTE for a given Caprini score in this population (0.6 percent among those with a score of 3 to 4, 1.3 percent with a score of 5 to 6, 2.7 percent with a score 7 to 8, and 11.3 percent with a score of >8).
Venous thromboembolism (VTE; deep venous thrombosis and pulmonary embolism [PE]) is common in the postoperative setting with over half of this population at moderate risk for VTE. PE is one of the most common preventable causes of in-hospital deaths following surgery. [1]
General/abdominal/pelvic surgery – 1 percent
Following assessment, bleeding risk can be categorized as either low or high.
Low bleeding risk – In general, patients undergoing general, abdominal-pelvic, bariatric, vascular, and thoracic surgery that is uncomplicated tend to have lower rates of bleeding (<2 percent) when compared with other patients.
High bleeding risk – Patients undergoing cardiac surgery and patients with major trauma, especially involving the brain and spine, are at highest risk of bleeding (>3 percent). Patients in this category also include those in whom the consequences of bleeding are considered potentially devastating; for example, patients undergoing neurosurgical procedures where thromboprophylaxis may result in spinal or intracranial hemorrhage and patients undergoing plastic/reconstructive surgery where thromboprophylaxis may result in injury or rejection of grafted tissue due to bleeding. Similarly, patients with one or more individual risk factors for bleeding are considered at high risk of bleeding postoperatively.
Recommend early and frequent ambulation rather than pharmacologic or mechanical methods of prophylaxis. Most very low-risk patients are able to ambulate easily after surgery. Mechanical methods may be employed in the unusual circumstance where unexpected issues occur during the procedure (eg, bleeding, more extensive surgery, which intrinsically change the risk category) or the patient has a complication and requires admission.
Since there are no randomized trials comparing ambulation with other methods, this approach is largely based upon the rationale that the baseline rate of VTE in this population is too low (<0.5 percent) to warrant prophylaxis. In addition, indirect data from studies evaluating the risk of VTE in orthopedic patients have also suggested that the risk of VTE is lowered by 70 percent in those who ambulate on or before the second postoperative day.
The risk of VTE is considered low when the baseline risk in the absence of prophylaxis is estimated to be 1.5 percent. Patients in this category include those undergoing general or abdominal/pelvic surgery with a Caprini score of 1 to 2 or patients undergoing plastic/reconstructive surgery with a Caprini score of 3 to 4. Examples include those undergoing minor elective abdominal-pelvic surgery (eg, appendectomy, laparoscopic cholecystectomy) or minor thoracic surgery (eg, diagnostic thoracoscopy, video-assisted biopsy). Other examples include patients undergoing minor vascular procedures (eg, vein ablation), and elective spine surgery (eg, spinal fusion).
For nonorthopedic surgical patients at low risk for VTE, suggest mechanical methods of VTE prophylaxis rather than pharmacologic prophylaxis or no prophylaxis. The rationale for this approach is that the risk of VTE is high enough to justify thromboprophylaxis but does not warrant the risk of bleeding associated with pharmacologic methods. Switching to pharmacologic methods may be appropriate in this with individual risk factors for VTE (eg, history of recurrent VTE or cancer).
Mechanical methods of thromboprophylaxis include intermittent pneumatic compression (IPC), graduated compression stockings (GCS, also known as elastic stockings), and the venous foot pump (VFP). Although IPC devices may be superior and are preferred by the ACCP, experts generally choose IPC or GCS since the data comparing one device over the other is fundamentally flawed.
The risk of VTE is considered moderate when the baseline risk in the absence of prophylaxis is estimated to 3 percent and high if it is at least 6 percent.
Moderate-risk surgical patients have been defined as patients undergoing general or abdomen/pelvic surgery with a Caprini score of 3 to 4 or patients undergoing plastic/reconstructive surgery with a Caprini score of 5 to 6. Patients undergoing major gynecologic and urologic surgery usually fall into the moderate risk category. In addition, patients undergoing major cardiac or thoracic surgery, bariatric surgery, and neurosurgical procedures, and patients with nonextensive trauma not involving the brain or spine are, at minimum, also considered moderate risk for VTE.
High-risk surgical patients have been defined as patients undergoing general or abdominal/pelvic surgery with a Caprini score of 5 or more or patients undergoing plastic/reconstructive surgery with a Caprini score of 7 to 8. Examples of patients in the high-risk group are those undergoing extensive thoracic or abdominal-pelvic surgery (eg, distal colorectal surgery, extensive pelvic surgery, lung cancer resection, esophagectomy, brain cancer resection), major trauma (particularly if involving the brain or spinal cord), acute spinal cord injury, or cancer surgery.
In nonorthopedic surgical patients at moderate risk for VTE and in whom the risk of bleeding is low, suggest pharmacologic prophylaxis, rather than mechanical methods, while in those at high VTE risk we recommend pharmacologic prophylaxis rather than mechanical methods. The rationale for this approach is based upon randomized trials and meta-analyses with data for patients at moderate risk being weaker than for those at high risk. For select patients in whom the risk of VTE is considered to be particularly high, suggest the addition of mechanical to pharmacologic methods (eg, multiple risk factors, surgery for cancer).
Among the available agents, low molecular weight (LMW) heparin is generally the preferred anticoagulant based upon randomized trials that report superior or similar efficacy with unfractionated heparin (UFH) or fondaparinux, although most data show no appreciable effect on mortality and limited effect on clinically relevant bleeding. For those with renal insufficiency (creatinine clearance <20 to 30 mL/min) or for those in whom cost is an issue, UFH is appropriate. For patients in whom UFH or LMW heparin is contraindicated (eg, heparin-induced thrombocytopenia [HIT]) or unavailable, fondaparinux or mechanical methods are preferred. Timing of initiation and dosing of these agents are discussed below.
Nonorthopedic surgeries include
Approach to the prevention of VTE in nonorthopedic surgical patients is, for the most part, in keeping with recommendations from several societies, including the American College of Chest Physicians (ACCP) and the American Society of Hematology (ASH).
Rates of symptomatic VTE derived from untreated groups in randomized trials have ranged from 0.5 to 1.6 percent, higher among those undergoing surgery for malignancy (up to 3.7 percent). However, several studies report that VTE risk is wide in this population since it encompasses a broad range of surgeries from laparoscopic appendectomy to open pelvic surgery for cancer.
5 days preop. Half life is 42 hours.
[1] J Douketis. S Mithoowani. Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients. Uptodate
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