This is the current release of the guideline.

This guideline updates a previous version: Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Anderson FA Jr, Wheeler HB. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S.

The grading scheme is defined at the end of the "Major Recommendations" field.

General Recommendations

1. The guideline developers recommend that mechanical methods of prophylaxis be used primarily in patients who are at high risk of bleeding (Grade 1C+) or as an adjunct to anticoagulant-based prophylaxis (Grade 2A). The guideline developers recommend that careful attention be directed toward ensuring the proper use of, and optimal compliance with, the mechanical device (Grade 1C+).
2. The guideline developers recommend against the use of aspirin alone as prophylaxis against venous thromboembolism (VTE) for any patient group (Grade 1A).
3. For each of the antithrombotics agents, the guideline developers recommend that clinicians consider the manufacturer’s suggested dosing guidelines (Grade 1C).
4. The guideline developers recommend consideration of renal impairment when deciding on doses of low-molecular-weight heparin (LMWH), fondaparinux, the direct thrombin inhibitors, and other antithrombotic drugs that are cleared by the kidneys, particularly in elderly patients and those who are at high risk for bleeding (Grade 1C+).
5. In all patients undergoing neuraxial anesthesia or analgesia, the guideline developers recommend special caution when using anticoagulant prophylaxis (Grade 1C+).

General, Vascular, Gynecologic, and Urologic Surgery

General Surgery

1. In low-risk general surgery patients (see Table 5 in the original guideline document) who are undergoing a minor procedure, are <40 years of age, and have no additional risk factors, the guideline developers recommend against the use of specific prophylaxis other than early and persistent ambulation (Grade 1C+).
2. Moderate-risk general surgery patients are those patients undergoing a nonmajor procedure and are between the ages of 40 and 60 years or have additional risk factors, or those patients who are undergoing major operations and are <40 years of age with no additional risk factors. The guideline developers recommend prophylaxis with low-dose unfractionated heparin (LDUH), 5,000 U twice a day (bid), or LMWH, <3,400 U once daily (both Grade 1A).
3. Higher-risk general surgery patients are those undergoing nonmajor surgery and are >60 years of age or have additional risk factors, or patients undergoing major surgery who are >40 years of age or have additional risk factors. The guideline developers recommend thromboprophylaxis with LDUH, 5,000 U three times a day (tid), or LMWH, >3,400 U daily (both Grade 1A).
4. In high-risk general surgery patients with multiple risk factors, the guideline developers recommend that pharmacologic methods (i.e., LDUH, tid, or LMWH, >3,400 U daily) be combined with the use of graduated compression stockings (GCS) and/or intermittent pneumatic compression (IPC) (Grade 1C+).
5. In general surgery patients with a high risk of bleeding, the guideline developers recommend the use of mechanical prophylaxis with properly fitted GCS or IPC, at least initially until the bleeding risk decreases (Grade 1A).
6. In selected high-risk general surgery patients, including those who have undergone major cancer surgery, the guideline developers suggest post-hospital discharge prophylaxis with LMWH (Grade 2A).

Vascular Surgery

1. In patients undergoing vascular surgery who do not have additional thromboembolic risk factors, the guideline developers suggest that clinicians not routinely use thromboprophylaxis (Grade 2B).
2. For patients undergoing major vascular surgical procedures who have additional thromboembolic risk factors, the guideline developers recommend prophylaxis with LDUH or LMWH (Grade 1C+).

Gynecologic Surgery

1. For gynecologic surgery patients undergoing brief procedures of <30 minutes for benign disease, the guideline developers recommend against the use of specific prophylaxis other than early and persistent mobilization (Grade 1C+).
2. For patients undergoing laparoscopic gynecologic procedures, in whom additional VTE risk factors are present, the guideline developers recommend the use of thromboprophylaxis with one or more of the following: LDUH, LMWH, IPC, or GCS (all Grade 1C).
3. The guideline developers recommend that thromboprophylaxis be used in all major gynecologic surgery patients (Grade 1A).
4. For patients undergoing major gynecologic surgery for benign disease, without additional risk factors, the guideline developers recommend LDUH, 5,000 U bid (Grade 1A). Alternatives include once-daily prophylaxis with LMWH, <3,400 U/d (Grade 1C+), or IPC started just before surgery and used continuously while the patient is not ambulating (Grade 1B).
5. For patients undergoing extensive surgery for malignancy, and for patients with additional VTE risk factors, the guideline developers recommend routine prophylaxis with LDUH, 5,000 U tid (Grade 1A), or higher doses of LMWH (i.e., >3,400 U/d) [Grade 1A]. Alternative considerations include IPC alone continued until hospital discharge (Grade 1A), or a combination of LDUH or LMWH plus mechanical prophylaxis with GCS or IPC (all Grade 1C).
6. For patients undergoing major gynecologic procedures, the guideline developers suggest that prophylaxis continue until discharge from the hospital (Grade 1C). For patients who are at particularly high risk, including those who have undergone cancer surgery and are >60 years of age or have previously experienced VTE, the guideline developers suggest continuing prophylaxis for 2 to 4 weeks after hospital discharge (Grade 2C).

Urologic Surgery

1. In patients undergoing transurethral or other low-risk urologic procedures, the guideline developers recommend against the use of specific prophylaxis other than early and persistent mobilization (Grade 1C+).
2. For patients undergoing major, open urologic procedures, the guideline developers recommend routine prophylaxis with LDUH twice daily or three times daily (Grade 1A). Acceptable alternatives include prophylaxis with IPC and/or GCS (Grade 1B) or LMWH (Grade 1C+).
3. For urologic surgery patients who are actively bleeding or are at very high risk for bleeding, the guideline developers recommend the use of mechanical prophylaxis with GCS and/or IPC at least until the bleeding risk decreases (Grade 1C+).
4. For patients with multiple risk factors, the guideline developers recommend combining GCS and/or IPC with LDUH or LMWH (Grade 1C+).

Laparoscopic Surgery

1. The guideline developers recommend against routine thromboprophylaxis in these patients, other than aggressive mobilization (Grade 1A).
2. For patients undergoing laparoscopic procedures and who have additional thromboembolic risk factors, the guideline developers recommend the use of thromboprophylaxis with one or more of the following: LDUH, LMWH, IPC, or GCS (Grade 1C+).

Orthopedic Surgery

Elective Hip Arthroplasty

1. For patients undergoing elective total hip replacement (THR), the guideline developers recommend the routine use of one of the following three anticoagulants: (1) LMWH (at a usual high-risk dose, started 12 hours before surgery or 12 to 24 hours after surgery, or 4 to 6 hours after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day); (2) fondaparinux (2.5 mg started 6 to 8 hours after surgery); or (3) adjusted-dose vitamin K antagonist (VKA) started preoperatively or the evening after surgery (international normalized ratio [INR] target, 2.5; INR range, 2.0 to 3.0) (all Grade 1A).

   Underlying values and preferences: The guideline developers have not recommended the use of fondaparinux over LMWH and VKA, or the use of LMWH over VKA, because they place a relatively low value on the prevention of venographic thrombosis and a relatively high value on minimizing bleeding complications.

2. The guideline developers recommend against the use of aspirin, dextran, LDUH, GCS, IPC, or venous foot pump (VFP) as the only method of thromboprophylaxis in these patients (Grade 1A).

Elective Knee Arthroplasty

1. For patients undergoing elective total knee replacement arthroplasty (TKA), the guideline developers recommend routine thromboprophylaxis using LMWH (at the usual high-risk dose), fondaparinux, or adjusted-dose VKA (target INR, 2.5; INR range, 2.0 to 3.0) (all Grade 1A).

   Underlying values and preferences: The guideline developers have not recommended fondaparinux over LMWH and VKA, or LMWH over VKA, because they place a relatively low value on the prevention of venographic thrombosis and a relatively high value on minimizing bleeding complications.

2. The optimal use of IPC is an alternative option to anticoagulant prophylaxis (Grade 1B).
3. The guideline developers recommend against the use of any of the following as sole methods of thromboprophylaxis: aspirin (Grade 1A); LDUH (Grade 1A); or VFP (Grade 1B).

Knee Arthroscopy

1. The guideline developers suggest clinicians do not use routine thromboprophylaxis in these patients, other than early mobilization (Grade 2B).
2. For patients undergoing arthroscopic knee surgery who are at a higher than usual risk, based on preexisting VTE risk factors or following a prolonged complicated procedure, the guideline developers suggest thromboprophylaxis with LMWH (Grade 2B).

Hip Fracture Surgery

1. For patients undergoing hip fracture surgery (HFS), the guideline developers recommend the routine use of fondaparinux (Grade 1A), LMWH at the usual high-risk dose (Grade 1C+), adjusted-dose VKA (target INR, 2.5; INR range, 2.0 to 3.0) (Grade 2B), or LDUH (Grade 1B).
2. The guideline developers recommend against the use of aspirin alone (Grade 1A).
3. If surgery will likely be delayed, the guideline developers recommend that prophylaxis with either LDUH or LMWH be initiated during the time between hospital admission and surgery (Grade 1C+).
4. The guideline developers recommend mechanical prophylaxis if anticoagulant prophylaxis is contraindicated because of a high risk of bleeding (Grade 1C+).

Other Prophylaxis Issues in Major Orthopedic Surgery

1. For major orthopedic surgical procedures, the guideline developers recommend that a decision about the timing of the initiation of pharmacologic prophylaxis be based on the efficacy-to-bleeding tradeoffs for that particular agent (Grade 1A). For LMWH, there are only small differences between starting preoperatively or postoperatively, and both options are acceptable (Grade 1A).
2. The guideline developers recommend against the routine use of Doppler ultrasonography (DUS) screening at the time of hospital discharge in asymptomatic patients following major orthopedic surgery (Grade 1A).
3. The guideline developers recommend that patients undergoing THR, TKA, or HFS receive thromboprophylaxis with LMWH (using a high-risk dose), fondaparinux (2.5 mg daily), or a VKA (target INR, 2.5; INR range, 2.0 to 3.0) for at least 10 days (Grade 1A).
4. The guideline developers recommend that patients undergoing THR or HFS be given extended prophylaxis for up to 28 to 35 days after surgery (Grade 1A). The recommended options for THR include LMWH (Grade 1A), a VKA (Grade 1A), or fondaparinux (Grade 1C+). The recommended options following HFS are fondaparinux (Grade 1A), LMWH (Grade 1C+), or a VKA (Grade 1C+).

Elective Spine Surgery

1. For spinal surgery patients with no additional risk factors, the guideline developers recommend against the routine use of any thromboprophylaxis modality, apart from early and persistent mobilization (Grade 1C).
2. The guideline developers recommend that some form of prophylaxis be used in patients undergoing spinal surgery who exhibit additional risk factors such as advanced age, known malignancy, presence of a neurologic deficit, previous VTE, or an anterior surgical approach (Grade 1B).
3. For patients with additional risk factors, the guideline developers recommend any of the following prophylaxis options: postoperative LDUH alone (Grade 1C+); postoperative LMWH alone (Grade 1B); or perioperative IPC alone (Grade 1B). Other considerations include perioperative GCS alone (Grade 2B), or perioperative IPC combined with GCS (Grade 2C). In patients with multiple risk factors for VTE, the guideline developers recommend combining LDUH or LMWH with GCS and/or IPC (Grade 1C+).

Isolated Lower Extremity Injuries

The guideline developers suggest that clinicians not use thromboprophylaxis routinely in patients with isolated lower extremity injuries (Grade 2A).

Neurosurgery

1. The guideline developers recommend that thromboprophylaxis be routinely used in patients undergoing major neurosurgery (Grade 1A).
2. The guideline developers recommend the use of IPC with or without GCS in patients undergoing intracranial neurosurgery (Grade 1A).
3. Acceptable alternatives to the above options are prophylaxis with LDUH (Grade 2B) or postoperative LMWH (Grade 2A).
4. The guideline developers suggest the combination of mechanical prophylaxis (i.e., GCS and/or IPC) and pharmacologic prophylaxis (i.e., LDUH or LMWH) in high-risk neurosurgery patients (Grade 2B).

Trauma, Spinal Cord Injury, Burns

Trauma

1. The guideline developers recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis, if possible (Grade 1A).
2. In the absence of a major contraindication, the guideline developers recommend that clinicians use LMWH prophylaxis starting as soon as it is considered safe to do so (Grade 1A).
3. The guideline developers recommend that mechanical prophylaxis with IPC, or possibly with GCS alone, be used if LMWH prophylaxis is delayed or if it is currently contraindicated due to active bleeding or a high risk for hemorrhage (Grade 1B).
4. The guideline developers recommend DUS screening in patients who are at high risk for VTE (e.g., the presence of a spinal cord injury [SCI], lower extremity or pelvic fracture, major head injury, or an indwelling femoral venous line), and who have received suboptimal prophylaxis or no prophylaxis (Grade 1C).
5. The guideline developers recommend against the use of inferior vena cava filters (IVCFs) as primary prophylaxis in trauma patients (Grade 1C).
6. The guideline developers recommend the continuation of thromboprophylaxis until hospital discharge, including the period of inpatient rehabilitation (Grade 1C+). The guideline developers suggest continuing prophylaxis after hospital discharge with LMWH or a VKA (target INR, 2.5; INR range, 2.0 to 3.0) in patients with major impaired mobility (Grade 2C).

Acute SCI

1. The guideline developers recommend that thromboprophylaxis be provided for all patients with acute SCIs (Grade 1A).
2. The guideline developers recommend against the use of LDUH, GCS, or IPC as single prophylaxis modalities (Grade 1A).
3. In patients with acute SCI, the guideline developers recommend prophylaxis with LMWH, to be commenced once primary hemostasis is evident (Grade 1B). The guideline developers suggest the combined use of IPC and either LDUH (Grade 2B) or LWMH (Grade 2C) as alternatives to LMWH.
4. The guideline developers recommend the use of IPC and/or GCS when anticoagulant prophylaxis is contraindicated early after injury (Grade 1C+).
5. The guideline developers recommend against the use of an IVCF as primary prophylaxis against pulmonary embolism (PE) (Grade 1C).
6. During the rehabilitation phase following acute SCI, the guideline developers recommend the continuation of LMWH prophylaxis or conversion to an oral VKA (INR target, 2.5; INR range, 2.0 to 3.0) (Grade 1C).

Burns

1. The guideline developers recommend that burn patients with additional risk factors for VTE, including one or more of the following: advanced age, morbid obesity, extensive or lower extremity burns, concomitant lower extremity trauma, use of a femoral venous catheter, and/or prolonged immobility, receive thromboprophylaxis, if possible (Grade 1C+).
2. If there are no contraindications, the guideline developers recommend the use of either LDUH or LMWH, starting as soon as is considered safe to do so (Grade 1C+).

Medical Conditions

1. In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, including active cancer, previous VTE, sepsis, acute neurologic disease, or inflammatory bowel disease, the guideline developers recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A).
2. In medical patients with risk factors for VTE, and in whom there is a contraindication to anticoagulant prophylaxis, the guideline developers recommend the use of mechanical prophylaxis with GCS or IPC (Grade 1C+).

Cancer Patients

1. The guideline developers recommend that cancer patients undergoing surgical procedures receive prophylaxis that is appropriate for their current risk state (Grade 1A). Refer to the recommendations in the relevant surgical subsections.
2. The guideline developers recommend that hospitalized cancer patients who are bedridden with an acute medical illness receive prophylaxis that is appropriate for their current risk state (Grade 1A). Refer to the recommendations in the section dealing with medical patients.
3. The guideline developers suggest that clinicians not routinely use prophylaxis to try to prevent thrombosis related to long-term indwelling central venous catheters (CVCs) in cancer patients (Grade 2B). Specifically, the guideline developers suggest that clinicians not use LMWH (Grade 2B), and the guideline developers recommend against the use of fixed-dose warfarin (Grade 1B) for this indication.

Critical Care

1. The guideline developers recommend that, on admission to a critical care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).
2. For patients who are at high risk for bleeding, the guideline developers recommend mechanical prophylaxis with GCS and/or IPC until the bleeding risk decreases (Grade 1C+).
3. For intensive care unit (ICU) patients who are at moderate risk for VTE (e.g., medically ill or postoperative patients), the guideline developers recommend using LDUH or LMWH prophylaxis (Grade 1A).
4. For patients who are at higher risk, such as that following major trauma or orthopedic surgery, the guideline developers recommend LMWH prophylaxis (Grade 1A).

Long Distance Travel

1. The guideline developers recommend the following general measures for long-distance travelers (i.e., flights of >6 hours duration): avoidance of constrictive clothing around the lower extremities or waist, avoidance of dehydration, and frequent calf muscle stretching (Grade 1C).
2. For long-distance travelers with additional risk factors for VTE, the guideline developers recommend the general strategies listed above. If active prophylaxis is considered, because of the perceived increased risk of venous thrombosis, the guideline developers suggest the use of properly fitted, below-knee GCS providing 15 to 30 mm Hg of pressure at the ankle (Grade 2B), or a single prophylactic dose of LMWH injected prior to departure (Grade 2B).
3. The guideline developers recommend against the use of aspirin for VTE prevention associated with travel (Grade 1B).

Definitions

*These situations include RCTs with both lack of blinding and subjective outcomes, where the risk of bias in measurement of outcomes is high, or RCTs with large loss to follow-up.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2001 Jan (revised 2004 Sep)

American College of Chest Physicians - Medical Specialty Society

Funding was provided through an unrestricted educational grant by AstraZeneca LP, Aventis Pharmaceuticals, GlaxoSmithKline, Bristol-Myer Squibb/Sanofi-Synthelabo Partnership, and Organon Sanofi-Synthelabo LLC.

American College of Chest Physicians Consensus Panel on Antithrombotic and Thrombolytic Therapy

Primary Authors: William H. Geerts, MD, FCCP; Graham F. Pineo, MD; John A. Heit, MD; David Bergqvist, MD, PhD; Michael R. Lassen, MD; Clifford W. Colwell, MD; Joel G. Ray, MD, MSc

Committee Co-Chairs: Jack Hirsh, MD, FCCP (Chair); Gregory W. Albers, MD; Gordon H. Guyatt, MD, MSc; Holger J. Schünemann, MD, MSc, PhD, FCCP

Participants: Giancarlo Agnelli, MD; Amin Al-Ahmad, MD; Pierre Amarenco, MD; Jack E. Ansell, MD; Shannon M. Bates, MD; Richard C. Becker, MD; Peter B. Berger, MD; David Bergqvist, MD, PhD, FRCS; Rebecca J. Beyth, MD, MSc; Stewart Brower, MLIS; Harry R. Buller, MD; Henry I. Bussey, PharmD, FCCP; Christopher P. Cannon, MD, FACC; Elizabeth A. Chalmers, MB, ChB, MD, MRCP(UK). FRCPath; Anthony K.C. Chan, MD; G. Patrick Clagett, MD; Barry Coller, MD; Clifford W. Colwell, MD; Deborah Cook, MD, MSc; James E. Dalen, MD, MPH, FCCP; J. Donald Easton, MD; Michael Ezekowitz, MD; Garret A. Fitzgerald, MD; William H. Geerts, MD, FCCP; Jeffrey S. Ginsberg, MD, FCCP; Alan S. Go, MD; Shaun D. Goodman, MD, FACC; Ian A. Greer, MD, FRCP, FRCOG; Andreas Greinacher, MD; Jeremy Grimshaw, MD, PhD; Cindy Grines, MD; Jonathan L. Halperin, MD; Robert A. Harrington, MD; John Heffner, MD, MPH; John A. Heit, MD; Judith S. Hochman, MD, FACC; Dieter Horstkotte, MD, FESC; Russell D. Hull, MBBS, MSc, FCCP; Elaine Hylek, MD; Thomas M. Hyers, MD, FCCP; Mark R. Jackson, MD; Alan Jacobson, MD; Roman Jaeschke, MD, MSc; Ajay Kakkar BSc, PhD; Clive Kearon, MD, PhD, FCCP; Matthew Kraay; Michael R. Lassen, MD; Mark N. Levine, MD, MSc; Alessandro Liberati, MD; Gregory YH Lip, MD, FESC, FACC; Warren J. Manning, MD; M. Patricia Massicotte, MD, MSc, FRCPC, MSc; Thomas W. Meade, MD; Venu Menon, MD, FACC; Alan D. Michelson, MD; Nancy Miller, RN; Paul Monagle, MBBS, MSc, MD, FRACP, FRCPA, FCCP; Heather Munger, MLS; Christopher M. O'Connor, MD; Martin O'Donnell, MD; E. Magnus Ohman, MD, FCCP; Carlo Patrono, MD; Stephen G. Pauker, MD; Graham F. Pineo, MD; Leon Poller, MD; Jeffrey J. Popma, MD; Martin H. Prins, MD; Robert Raschke, MD, MS; Gary Raskob, PhD; Joel G. Ray, MD, MSc; Gerald Roth, MD; Ralph L. Sacco, MD; Deeb N. Salem, MD, FCCP; Meyer M. Samama, MD; Andrew Schafer; Sam Schulman, MD, PhD; Daniel Singer, MD; Michael Sobel, MD; Paul D. Stein, MD, FCCP; Marco Tangelder, MD; Victor F. Tapson, MD, FCCP; Philip Teal, MD; Raymond Verhaeghe, MD; David A. Vorchheimer, MD; Theodore E. Warkentin, MD; Jeffrey Weitz, MD; Robert G. Wilcox, MD

Dr. Geerts has received research funding from AstraZeneca, Aventis Pharma, and Pharmacia and has participated on advisory boards and/or research steering committees for AstraZeneca, Aventis Pharma, Eli Lilly, Pharmacia, and Sanofi-Synthelabo-Organon;

Dr. Pineo has received research funding from Aventis, Emisphere Technologies, Leo Pharma, and Pharmacia and has participated on advisory boards and/or research steering committees for AstraZeneca, Aventis, Bristol-Myers Squibb, GlaxoSmithKline, Pfizer-Pharmacia, and Sanofi-Synthelabo-Organon;

Dr. Heit has received research funding from AstraZeneca, Aventis, and Corvas and has participated on advisory boards and/or research steering committees for AstraZeneca, Aventis, and Pharmacia;

Dr. Bergqvist has participated on advisory boards and/or research steering committees for AstraZeneca, Aventis, Boehringer Ingelheim, Pharmacia/Pfizer, and Sanofi-Synthelabo;

Dr. Lassen has received research funding from Sanofi-Synthelabo and has participated on advisory boards and/or research steering committees for AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Leo Pharma, Mitsubishi Pharma, Vivolution Inc, Wyeth, and Yamanautchi;

Dr. Colwell has received research funding from Amgen, AstraZeneca, Baxter, and Sanofi-Synthelabo and has participated on advisory boards and/or research steering committees for AstraZeneca, Aventis, Pharmacia, and Sanofi-Synthelabo; and Dr. Ray has no potential conflicts.

This is the current release of the guideline.

This guideline updates a previous version: Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Anderson FA Jr, Wheeler HB. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S.

This summary was completed by ECRI on July 12, 2001. The information was verified by the guideline developer on September 27, 2001. This summary was updated by ECRI on December 28, 2004. The updated information was verified by the guideline developer on January 12, 2005. This summary was updated by ECRI Institute on June 22, 2007 following the U.S. Food and Drug Administration (FDA) advisory on heparin sodium injection. This summary was updated by ECRI Institute on March 14, 2008 following the updated FDA advisory on heparin sodium injection.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.