Which populations require Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) prophylaxis in the perioperative setting?

Populations Requiring DVT/PE Prophylaxis in the Perioperative Setting

All surgical patients should be risk-stratified for VTE prophylaxis based on both patient-specific and procedure-specific risk factors, with prophylaxis provided to moderate and high-risk groups. 1

Risk Stratification

Patient Risk Categories (Based on Caprini Score):

• Very Low Risk (Caprini score <0.5%):

  • Early ambulation only, no specific pharmacologic or mechanical prophylaxis needed 1

• Low Risk (Caprini score 1-2):

  • Mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC) 1

• Moderate Risk (Caprini score 3-4):

  • Pharmacologic prophylaxis with LMWH or LDUH 1
  • Mechanical prophylaxis if pharmacologic methods contraindicated 1

• High Risk (Caprini score ≥5):

  • Combination of pharmacologic prophylaxis (LMWH or LDUH) plus mechanical prophylaxis 1
  • Extended prophylaxis (4 weeks) for cancer patients undergoing abdominal/pelvic surgery 1

Specific High-Risk Populations:

1. Cancer Surgery Patients:

   • Require pharmacologic prophylaxis, preferably with LMWH 1
   • Extended prophylaxis (4 weeks) recommended for abdominal/pelvic cancer surgery 1
   • Mechanical methods should not be used as monotherapy unless pharmacologic methods are contraindicated 1

2. Orthopedic Surgery Patients:

   • High-risk orthopedic procedures (hip/knee replacement, hip fracture) require prophylaxis 1
   • Patients with cancer undergoing orthopedic surgery are at particularly high risk (14.2% DVT rate reported) 2

3. Major Abdominal/Pelvic Surgery:

   • Prophylaxis recommended, especially for procedures lasting >30 minutes 1
   • Risk factors include advanced age, higher disease stage, prolonged anesthesia, and immobilization 1

4. Cardiac Surgery:

   • Mechanical prophylaxis for uncomplicated cases 1
   • Add pharmacologic prophylaxis if hospital course prolonged by non-hemorrhagic complications 1

5. Thoracic Surgery:

   • Moderate risk: LDUH, LMWH, or IPC 1
   • High risk: LDUH or LMWH plus mechanical prophylaxis 1

6. Neurosurgery:

   • Craniotomy: Mechanical prophylaxis, preferably IPC 1
   • High-risk craniotomy (e.g., for malignancy): Add pharmacologic prophylaxis once hemostasis established 1

7. Spine Surgery:

   • Mechanical prophylaxis, preferably IPC 1
   • High-risk cases (malignancy, anterior-posterior approach): Add pharmacologic prophylaxis once hemostasis established 1

8. Trauma Patients:

   • Major trauma patients require prophylaxis with LDUH, LMWH, or IPC 1

Prophylaxis Methods

Pharmacologic Options:

• LMWH: Preferred for most surgical patients 1
• LDUH: Alternative to LMWH 1
• Fondaparinux: Option for high-risk patients when LMWH/LDUH contraindicated 1, 3
• Aspirin: Consider only when LMWH/LDUH contraindicated 1

Mechanical Options:

• IPC: Preferred mechanical method 1
• Elastic Stockings: Alternative mechanical method 1

Duration of Prophylaxis

• Standard Duration: Minimum 7-10 days postoperatively 1
• Extended Duration: 4 weeks for high-risk abdominal/pelvic cancer surgery 1
• General Guidance: Continue until patient is fully ambulatory or hospital discharge, whichever is longer 4

Special Considerations

• Bleeding Risk: For patients at high risk of bleeding, use mechanical prophylaxis until bleeding risk diminishes 1, 3
• Renal Impairment: Avoid fondaparinux in patients with CrCl <30 mL/min 3
• Low Body Weight: Patients <50kg have increased bleeding risk with fondaparinux 3
• Neuraxial Anesthesia: Timing of anticoagulant administration critical to avoid spinal/epidural hematoma 3

Not Recommended

• IVC Filters: Should not be used for primary VTE prevention 1
• Routine Surveillance Ultrasound: Not recommended for asymptomatic patients 1

Common Pitfalls

• Underutilization: Despite guidelines, VTE prophylaxis remains underused in eligible patients 4
• Delayed Initiation: Pharmacologic prophylaxis should begin 6-8 hours after surgery once hemostasis is established 3
• Inadequate Duration: Risk of VTE persists for up to 3 months after surgery, especially in high-risk patients 5
• Relying on Early Ambulation Alone: Insufficient for moderate to high-risk patients 1