What is the recommended anaesthetic management for a patient with deep vein thrombosis (DVT) undergoing lower limb surgery?

Anaesthetic Management for Patients with DVT Undergoing Lower Limb Surgery

For patients with deep vein thrombosis (DVT) undergoing lower limb surgery, the recommended anaesthetic management should include continued anticoagulation therapy with appropriate perioperative bridging, early mobilization, and avoidance of techniques that might increase thrombotic risk.

Preoperative Management

• Anticoagulation therapy should be maintained throughout the perioperative period with appropriate bridging to minimize thrombotic risk while balancing bleeding risk 1, 2
• Direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, or rivaroxaban are preferred over vitamin K antagonists for most patients without cancer 1, 2
• For patients with cancer-associated thrombosis, low-molecular-weight heparin (LMWH) may be preferred 1, 2
• Avoid interrupting anticoagulation when possible, as stopping anticoagulation increases risk of recurrent thrombosis 1
• If anticoagulation must be interrupted for surgery, implement appropriate bridging therapy based on thrombotic risk 1

Intraoperative Management

• Regional anaesthesia considerations:

  • Regional techniques may be used with caution if anticoagulation can be appropriately managed according to guidelines 1
  • Timing of neuraxial procedures must be coordinated with anticoagulant dosing to minimize bleeding risk 2
  • Consider general anaesthesia if regional techniques pose excessive bleeding risk due to anticoagulation 1

• Avoid techniques that increase DVT risk:

  • Minimize tourniquet time when possible 3
  • Maintain normothermia to prevent vasoconstriction 1
  • Ensure adequate hydration to maintain blood flow 1

Postoperative Management

• Early mobilization is strongly recommended over bed rest to reduce thrombotic risk 1
• Resume therapeutic anticoagulation as soon as hemostasis is assured 1, 2
• For patients with proximal DVT provoked by surgery, continue anticoagulation for 3 months 1, 2
• For unprovoked DVT, consider extended anticoagulation therapy based on risk-benefit assessment 1
• Avoid inferior vena cava (IVC) filters unless there is a contraindication to anticoagulation 1, 2

Special Considerations

• Higher risk of recurrent DVT exists with delayed surgery, with risk increasing proportionally to delay time 4
• Age ≥70 years is an independent risk factor for postoperative DVT development 3
• Above-knee amputations have higher DVT risk (37.5%) compared to below-knee amputations (21.2%) 3
• Wound complications may be more common with routine anticoagulation compared to risk-stratified approaches 5

Monitoring

• Perform regular assessment for signs of bleeding or recurrent thrombosis 2
• For patients on extended anticoagulation therapy, reassess the need for continued therapy periodically (e.g., annually) 1, 2
• Monitor for post-thrombotic syndrome, which can be disabling in some cases 6

Common Pitfalls to Avoid

• Discontinuing anticoagulation without bridging can significantly increase thrombotic risk 1
• Relying on clinical examination alone to detect DVT is unreliable as many patients with DVT are asymptomatic 4
• Delaying surgery beyond 24 hours increases DVT risk despite prophylactic anticoagulation 4
• Overlooking the need for extended anticoagulation in high-risk patients 1