What are the guidelines for Deep Vein (DE) Thrombosis prophylaxis in the perioperative period?

From the Guidelines

Perioperative deep vein thrombosis (DVT) prophylaxis guidelines recommend that patients undergoing major abdominopelvic surgery should receive pharmacologic prophylaxis with low-molecular-weight heparin (LMWH) or low-dose unfractionated heparin (LDUH) for at least 7 to 10 days postoperatively, with extended-duration prophylaxis up to 4 weeks considered for high-risk patients, such as those with cancer or a history of VTE 1.

Key Recommendations

• For patients at low risk for VTE, mechanical prophylaxis with intermittent pneumatic compression (IPC) is suggested over no prophylaxis 1.
• For patients at moderate risk for VTE, LMWH, LDUH, or mechanical prophylaxis with IPC is recommended over no prophylaxis 1.
• For patients at high risk for VTE, pharmacologic prophylaxis with LMWH or LDUH is recommended over no prophylaxis, with extended-duration prophylaxis up to 4 weeks considered for high-risk patients 1.
• The American Society of Clinical Oncology (ASCO) recommends that patients with cancer undergoing major surgical intervention should receive pharmacologic thromboprophylaxis with either UFH or LMWH unless contraindicated 1.

Considerations

• The risk of VTE and bleeding should be assessed for each patient, and the decision to extend prophylaxis should be made on a case-by-case basis 1.
• The use of inferior vena cava filters and surveillance with venous compression ultrasonography is not recommended for primary VTE prevention 1.
• LMWH is recommended for the initial 5 to 10 days of treatment of established deep vein thrombosis and pulmonary embolism, as well as for long-term secondary prophylaxis for at least 6 months 1.

From the FDA Drug Label

2.2 Deep Vein Thrombosis Prophylaxis Following Hip Fracture, Hip Replacement, and Knee Replacement Surgery 5.1 Neuraxial Anesthesia and Post-operative Indwelling Epidural Catheter Use

The perioperative guidelines for fondaparinux (SQ) include:

• Dosing information for deep vein thrombosis prophylaxis following hip fracture, hip replacement, and knee replacement surgery
• Warnings regarding neuraxial anesthesia and post-operative indwelling epidural catheter use 2 Key points to consider are:
• Neuraxial anesthesia: use with caution
• Post-operative indwelling epidural catheter: use with caution When using fondaparinux (SQ) for perioperative deep vein thrombosis prophylaxis, it is essential to follow the recommended dosing regimen and be aware of the potential risks associated with neuraxial anesthesia and post-operative indwelling epidural catheter use.

From the Research

Perioperative DE Guidelines

• The prevention of venous thromboembolism (VTE) in surgical patients is crucial, as it is a common complication of surgical procedures 3.
• The risk for VTE in surgical patients is determined by the combination of individual predisposing factors and the specific type of surgery 3.
• Prophylaxis with mechanical and pharmacological methods has been shown to be effective and safe in most types of surgery and should be routinely implemented 3, 4, 5.

Recommendations for Specific Surgeries

• For patients undergoing general, gynecologic, vascular, and major urologic surgery, low-dose unfractionated heparin or low-molecular-weight heparin (LMWH) are the options of choice 3.
• For low-risk urologic surgery, early postoperative mobilization of patients is the only intervention warranted 3.
• For higher-risk patients, including those undergoing elective hip or knee replacement and surgery for hip fracture, vitamin K antagonists, LMWH, or fondaparinux are recommended 3, 6.
• For patients undergoing neurosurgery, graduated elastic stockings are effective and safe and may be combined with LMWH to further reduce the risk of VTE 3.
• For patients undergoing major orthopedic surgeries, pharmacological thromboprophylaxis with or without mechanical devices is recommended, with LMWHs, direct oral anticoagulants, and aspirin as first-line options 6.

Guidelines from Professional Societies

• The American Society of Hematology (ASH) has published guidelines for the prevention of VTE in surgical hospitalized patients, including recommendations for major surgery, orthopedic surgery, and other specific types of surgery 5.
• The ASH guidelines recommend mechanical prophylaxis over no prophylaxis, pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters for patients undergoing major surgery 5.
• The guidelines also recommend pharmacological prophylaxis over no prophylaxis for patients undergoing major general surgery, using LMWH or unfractionated heparin 5.