Should a patient undergoing upper extremity orthopedic surgery under anesthesia for greater than 90 minutes receive anti-coagulation?

Anticoagulation for Upper Extremity Orthopedic Surgery Lasting >90 Minutes

Patients undergoing upper extremity orthopedic surgery under anesthesia for greater than 90 minutes do not routinely require anticoagulation for VTE prophylaxis.

Risk Assessment and Guidelines

• Current evidence-based guidelines from the American College of Chest Physicians (ACCP) focus primarily on major orthopedic surgeries of the lower extremity (hip and knee replacement, hip fracture surgery) as high-risk procedures requiring routine thromboprophylaxis 1.
• Upper extremity orthopedic procedures are not specifically classified as "major orthopedic surgery" requiring routine prophylaxis in these guidelines 1.
• Risk stratification should be performed using validated tools such as the Caprini score, which considers both patient-specific and procedure-specific factors 1, 2.

Procedure-Specific Considerations

• Upper extremity orthopedic procedures carry a significantly lower risk of VTE compared to lower extremity procedures such as hip and knee replacements 3, 2.
• The baseline risk of symptomatic VTE in contemporary major orthopedic surgery practice is approximately 4.3% up to 39 days post-surgery, but this data primarily refers to lower extremity procedures 4.
• For upper extremity procedures specifically, the risk is considerably lower due to:
  • Better post-operative mobility (patients can ambulate more easily) 2
  • Absence of direct venous injury to major lower extremity vessels 3
  • Shorter immobilization periods typically required 2

Patient-Specific Risk Factors

Consider anticoagulation only if the patient has additional significant risk factors:

• Previous history of VTE 1, 5
• Active cancer 1
• Known thrombophilia 1
• Multiple risk factors that would place them in a high-risk category (Caprini score ≥5) 1, 2

Recommended Approach

1. For most patients undergoing upper extremity orthopedic surgery >90 minutes without additional risk factors:

   • Early and frequent ambulation post-surgery 2
   • No pharmacologic prophylaxis required 1

2. For patients with additional VTE risk factors:

   • Consider mechanical prophylaxis with intermittent pneumatic compression devices (IPCD) during surgery and early post-operative period 1
   • For high-risk patients (multiple risk factors or history of VTE), consider pharmacologic prophylaxis with LMWH, with or without mechanical methods 1, 3

3. If anticoagulation is deemed necessary based on individual risk assessment:

   • LMWH is suggested as the preferred agent 1
   • Alternative options include direct oral anticoagulants (apixaban, dabigatran, rivaroxaban) if compliance with injections is a concern 1

Duration of Prophylaxis

• If prophylaxis is indicated based on individual risk factors, it should be continued until the patient is fully ambulatory 2
• Extended prophylaxis (beyond hospital discharge) is generally not necessary for upper extremity procedures unless the patient has multiple high-risk factors 5

Bleeding Risk Considerations

• If a patient requiring prophylaxis has increased bleeding risk, mechanical prophylaxis with IPCD should be used instead of pharmacologic agents until bleeding risk decreases 1
• Mechanical prophylaxis achieves 18 hours of daily compliance when possible 1

Common Pitfalls to Avoid

• Overprescribing anticoagulation for low-risk upper extremity procedures, which increases bleeding risk without significant benefit 1, 6
• Failing to identify patients with multiple risk factors who might benefit from prophylaxis despite undergoing upper extremity surgery 1, 2
• Not considering patient compliance with injectable medications if prophylaxis is prescribed for outpatient use 1

Remember that while VTE prophylaxis is critical for major lower extremity orthopedic procedures, routine anticoagulation for upper extremity procedures lasting >90 minutes is not supported by current evidence unless significant additional risk factors are present.