From the FDA Drug Label
A number of well-controlled clinical trials have demonstrated that low-dose heparin prophylaxis, given just prior to and after surgery, will reduce the incidence of postoperative deep vein thrombosis in the legs (as measured by the I-125 fibrinogen technique and venography) and of clinical pulmonary embolism The most widely used dosage has been 5,000 units 2 hours before surgery and 5,000 units every 8 to 12 hours thereafter for seven days or until the patient is fully ambulatory, whichever is longer.
The recommended surgical thromboprophylaxis in patients with thrombophilia is low-dose heparin prophylaxis, with a dosage of 5,000 units 2 hours before surgery and 5,000 units every 8 to 12 hours thereafter for seven days or until the patient is fully ambulatory, whichever is longer 1.
- Key considerations:
- This prophylaxis should be reserved for patients over the age of 40 who are undergoing major surgery.
- Patients with bleeding disorders and those having neurosurgery, spinal anesthesia, eye surgery or potentially sanguineous operations should be excluded.
- The possibility of increased bleeding during surgery or postoperatively should be borne in mind.
From the Research
Patients with thrombophilia undergoing surgery should receive thromboprophylaxis tailored to their specific risk factors, with a recommended minimum duration of 7 days, and consideration for extended prophylaxis up to 4 weeks for high-risk procedures, as suggested by the most recent guidelines 2. The recommended thromboprophylaxis approach includes:
- Standard prophylactic doses of low molecular weight heparin (LMWH) such as enoxaparin 40mg subcutaneously once daily or 30mg twice daily, starting 12-24 hours after surgery and continuing until the patient is fully mobile or discharged.
- Mechanical prophylaxis with graduated compression stockings or intermittent pneumatic compression devices should be added for all patients, especially when pharmacological prophylaxis is contraindicated due to bleeding risk.
- For higher-risk thrombophilias or those with previous venous thromboembolism (VTE), higher doses of LMWH may be warranted, such as enoxaparin 0.5mg/kg twice daily.
- Bridging therapy with therapeutic LMWH is typically used for patients already on long-term anticoagulation, stopping oral anticoagulants 5 days before surgery and resuming when hemostasis is adequate. The use of LMWH, fondaparinux, or warfarin is supported by previous guidelines 3, 4, 5, 6, but the most recent guidelines 2 provide the most up-to-date recommendations for thromboprophylaxis in surgical patients, including those with thrombophilia. Key considerations include:
- Patient-specific risk factors, such as type of surgery, presence of additional risk factors, and history of VTE.
- Procedure-related risk factors, such as major orthopedic or abdominal/pelvic cancer surgery.
- The need for extended prophylaxis in high-risk patients, as recommended by the guidelines 2.