What are the recommendations for postoperative Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) prophylaxis?

Postoperative DVT and PE Prophylaxis

All postoperative patients should receive appropriate thromboprophylaxis based on their risk level, with pharmacological prophylaxis using LMWH as the preferred agent for most patients, combined with mechanical methods for high-risk patients, and continued for at least 7-10 days postoperatively. 1, 2

Risk Assessment

Risk assessment should be performed using validated tools such as:

• Caprini score for general and abdominal surgery patients 2, 3
• TESS score for trauma patients 1
• Padua score for medical patients 1

Risk Categories:

• Very low risk (<0.5%): Early ambulation only
• Low risk (1.5%): Mechanical prophylaxis with IPC
• Moderate risk (3%): LMWH or LDUH
• High risk (≥6%): LMWH or LDUH plus mechanical prophylaxis 2

Pharmacological Prophylaxis

First-line agents:

• LMWH (e.g., enoxaparin 40 mg once daily): Preferred over unfractionated heparin due to:

  • Lower incidence of DVT and PE
  • Fewer bleeding complications
  • Lower rates of complications including myocardial infarction and mortality 1, 2

• LDUH (5,000 units subcutaneously):

  • Every 8 hours (three times daily) for high-risk patients
  • Every 12 hours (twice daily) for moderate-risk patients 2

Special populations:

• Elderly patients (>65 years): LMWH preferred over UFH 1
• Renal impairment (CrCl <30 mL/min): LDUH preferred over LMWH 2
• Obesity (BMI >35 kg/m²): Consider anti-Xa monitoring for LMWH dosing 1
• Cancer patients: Higher risk requiring extended prophylaxis 1, 2

Mechanical Prophylaxis

• Intermittent pneumatic compression (IPC): Reduces DVT risk by 60% when used as monotherapy 4
• Graduated compression stockings: Not recommended as sole prophylaxis 1
• Early ambulation: Essential component for all patients 5

Indications for mechanical prophylaxis only:

• Active bleeding
• High bleeding risk
• Severe thrombocytopenia
• History of heparin-induced thrombocytopenia
• Recent intracranial hemorrhage 1, 2

Timing and Duration

• Initiation: Preoperatively or as early as possible postoperatively 1
• Standard duration: At least 7-10 days postoperatively 1, 2
• Extended duration (4 weeks): Recommended for:
  • Major abdominal or pelvic cancer surgery
  • Residual malignant disease after operation
  • Obesity
  • Previous history of VTE 1, 2

Special Surgical Populations

Cancer Surgery

• Double the risk of VTE compared to non-cancer patients
• Recommendation: Extended prophylaxis with LMWH for 4 weeks 1, 2

Orthopedic Surgery

• High risk for VTE complications
• Recommendation: Combined pharmacological (LMWH preferred) and mechanical prophylaxis 6, 5

Trauma Surgery

• Risk factors: Age >65, ICU stay, spine injury, lower extremity injury, ventilator days 1
• Recommendation: Early IPC followed by combined pharmacological and mechanical prophylaxis when bleeding risk subsides 1

Bariatric Surgery

• Risk factors: Obesity, prolonged immobility, venous stasis
• Recommendation: Weight-adjusted LMWH with consideration of anti-Xa monitoring 1

Common Pitfalls to Avoid

1. Underestimating risk: All surgical patients should be assessed for VTE risk
2. Inadequate dosing: High-risk patients require three-times-daily LDUH dosing
3. Delayed initiation: Start prophylaxis preoperatively or immediately postoperatively
4. Premature discontinuation: Continue until fully ambulatory or longer in high-risk patients
5. Relying solely on mechanical methods: Only appropriate for patients with contraindications to pharmacological prophylaxis
6. Overlooking extended prophylaxis: High-risk patients benefit from 4 weeks of prophylaxis 2

Contraindications to Pharmacological Prophylaxis

• Active bleeding
• Severe thrombocytopenia
• Recent intracranial hemorrhage
• History of heparin-induced thrombocytopenia 1, 2

In these cases, mechanical prophylaxis with IPC should be used until bleeding risk decreases 1.