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Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Online Only ArticlesPrevention of VTE in Nonorthopedic Surgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
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Summary of Recommendations
Note on Shaded Text: Throughout this guideline, shading is used within the summary of recommendations sections to indicate recommendations that are newly added or have been changed since the publication of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence Based Clinical Practice Guidelines (8th Edition). Recommendations that remain unchanged are not shaded.
3.6.1. For general and abdominal-pelvic surgery patients at very low risk for VTE (< 0.5%; Rogers
Methods
To develop recommendations for thromboprophylaxis among patients undergoing nonorthopedic surgery, we first used the population, intervention, comparator, outcome format to generate a list of questions (Table 1). Through the evidence review, we attempted to identify all relevant studies that compared one or more interventions for thromboprophylaxis with any alternative (including placebo or no treatment) among nonorthopedic surgical patients. We favored studies or systematic reviews that
Safety and Effectiveness of Interventions for Thromboprophylaxis
Alternative interventions for thromboprophylaxis that have been evaluated in studies of nonorthopedic surgical patients include elastic stockings (ES), IPC devices, low-dose unfractionated heparin (LDUH), low-molecular-weight heparin (LMWH), fondaparinux, aspirin, inferior vena cava (IVC) filters, and surveillance with venous compression ultrasonography (VCU) as summarized in Table 2, Table 3, Table 4. Characteristics and risk of bias in individual trials are summarized in Tables S2 and S3.
Risk Stratification, Rationale for Prophylaxis, and Recommendations in General, Abdominal-Pelvic, Bariatric, Vascular, and Plastic and Reconstructive Surgery
We divide the remainder of the article into sections based on surgical specialty and body region. We discuss relevant information about risk factors and risk stratification for thrombosis and bleeding, provide recommendations, and explain their rationale. Additional details are provided in the Appendix S1 and Tables S7 and S8.
Target Population: Cardiac Surgery
Of two randomized controlled trials of VTE prophylaxis in cardiac surgery patients (Appendix S1), one compared ES alone with ES plus IPC,124 and the other compared LDUH plus IPC with LDUH alone in patients who underwent cardiac surgery at a single center over a period of 10 years.125 Because direct evidence about the safety and effectiveness of prophylaxis in patients undergoing cardiac surgery is limited, we applied indirect evidence about relative risks from studies of mixed surgical patients
Target Population: Thoracic Surgery
Of two small trials in thoracic surgery, one compared LDUH 5,000 bid with LDUH 7,500 bid,136 whereas the other compared fixed-dose with weight-adjusted-dose nadroparin (Appendix S1).137 Although direct evidence about the safety and effectiveness of prophylaxis in patients undergoing thoracic surgery is limited, we believe that evidence about relative risks from studies of patients undergoing general or abdominal-pelvic surgery can be applied to thoracic surgery patients without downgrading for
Target Population: Craniotomy
Two published meta-analyses summarized the results of randomized controlled trials of pharmacologic and mechanical prophylaxis in neurosurgery, including patients undergoing craniotomy and spinal surgery.12, 10 Many of the studies were limited by small samples; open-label design; incomplete follow-up; and use of ultrasound, venography, or fibrinogen uptake scanning to identify asymptomatic DVT.
One meta-analysis summarized the results of three trials in mixed neurosurgical patients that compared
Target Population: Spinal Surgery
Six randomized trials examined interventions to prevent VTE in spinal surgery patients, most limited by small samples, unclear concealment of treatment allocation, incomplete blinding, and measurement of asymptomatic DVT (Tables S2–S4). One compared pharmacologic prophylaxis with placebo,154 one compared unfractionated heparin with LMWH,155 and three compared different methods of mechanical prophylaxis with or without pharmacologic prophylaxis.156, 157, 158 A meta-analysis summarized results of
Target Population: Major Trauma, Including Traumatic Brain Injury, Acute Spinal Cord Injury, and Traumatic Spine Surgery
Decision making about thromboprophylaxis in trauma patients poses numerous challenges. Although traumatic inflammation, fractures, immobilization, and surgical intervention contribute to the high risk of VTE, both the risk and, potentially, the dire consequences of bleeding complications weigh heavily, especially in cases of visceral, spinal, and head injury.
Seven randomized controlled trials of LMWH thromboprophylaxis in trauma limited enrollment to patients with isolated lower-extremity
Suggestions for Good Clinical Practice
The following general considerations for good clinical practice apply to thromboprophylaxis in all surgical groups:
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It may be advisable for every institution to have a formal, written policy for preventing VTE in surgical patients.
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Adherence with IPC often is less than optimal and, therefore, should be monitored actively. Portable, battery-powered devices capable of recording and reporting proper wear time may facilitate monitoring. Efforts should be made to achieve at least 18 h of use
Recommendations for Research
Most of the recommendations in this guideline are based on low-quality evidence. Many older randomized controlled trials were limited by small samples, incomplete blinding, unclear concealment of treatment allocation, and measurement of surrogate outcomes. Future randomized trials should enroll representative samples (ideally in community settings) and be adequately powered to show differences in patient-important outcomes, including objectively confirmed, symptomatic VTE events and clearly
Acknowledgments
Author contributions: As Topic Editor, Dr Gould oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.
Dr Gould: contributed as topic editor and resource consultant.
Dr Garcia: contributed as deputy editor.
Dr Wren: contributed as frontline clinician.
Dr Karanicolas: contributed as panelist.
Dr Arcelus: contributed as panelist.
Dr Heit: contributed as panelist.
Dr Samama: contributed as panelist.
Financial/nonfinancial
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Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants was also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.
Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://chestjournal.chestpubs.org/content/141/2_suppl/1S.
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