Chapter 31. Prevention of Venous Thromboembolism (continued)

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Chapter 31. Prevention of Venous Thromboembolism (continued)

Table 31. 1. Mechanical and pharmacologic preventative measures for VTE

Practice	Type	Description	Comment
Graduated Elastic Stockings (ES)	Mechanical	Fitted hose that extend above the knee	Fitted hose are more efficacious than non-fitted
Intermittent pneumatic compression (IPC)	Mechanical	Devices fitted over lower extremities that sequentially inflate and deflate
Aspirin	Pharmacologic	Usually 325 mg/d
Warfarin	Pharmacologic	5-10 mg started the day of or after surgery; adjust to achieve an INR of 2-3	Monitoring of INR needed
Low-dose unfractionated heparin (LDUH)	Pharmacologic	Generally 5000 U subcutaneous bid or tid, though some studies have adjusted dose to maintain PTT at high end of normal	Contraindicated if active bleeding or history of thrombocytopenia; no need to follow coagulation studies (unless adjusted dose is used)
Low Molecular Weight Heparin (LMWH)	Pharmacologic	Dose depends on type of surgery and VTE risk*	No need to monitor coagulation studies

*LMWH dosing: Enoxaparin 20 mg SC daily (moderate risk surgery) or 40 mg SC daily (can go up to 30 mg SC q12h for high risk general surgery, major trauma or acute spinal cord injury); dalteparin 2500-5000 U SC daily; nadroparin 2500 U SC daily; tinzaparin 3500-4500 U SC daily (may be dosed 75U/kg/d for orthopedic surgery).

Table 31. 2. Summary of DVT risk and prophylactic methods providing significant risk reduction*

Surgery/ Condition	Risk of all DVT in untreated patients	Type of Prophylaxis	Risk Reduction with Prophylaxis	Number of Studies
General Surgery²	25%	ES	44%	3
		LDUH	68%	47
		LMWH	76%	21
		IPC	88%	2
THR²	54%	LMWH	70%	30
THR²	54%	warfarin	59%	13
TKR^2,23	64%	LMWH	52%	13
TKR^2,23	64%	IPC	73%	6
Neuro-surgery^27,28	28%	LMWH	38%	3
Neuro-surgery^27,28	28%	LDUH	72%	1^a
Trauma^2,30	30-60%	LMWH	30% (compared to LDUH)	1
Acute Spinal Cord Injury²	80%	Not established
Ischemic stroke²	55%	LDUH	56%	5
		LMWH	58%	3
		Danaparoid	82%	4
Medical conditions²	16%	LMWH	76%	2^a
		LMWH	39%	2
		LDUH	61%	3^a

*DVT indicates deep venous thrombosis; ES, graduated elastic stockings; IPC, intermittent pneumatic compression; LDUH, low-dose unfractionated heparin; LMWH, low molecular weight heparin; THR, total hip replacement; and TKR, total knee replacement.

^aDVT diagnosed by fibrinogen uptake test (FUT)

Table 31. 3. Recommended VTE prophylaxis for surgical procedures and medical conditions*

Surgery/Condition	Recommended Prophylaxis	Comments
General Surgery—low-risk: minor procedures, <40 years old, no additional risks	None	Early ambulation
General Surgery—moderate risk: minor procedure but with risk factor, nonmajor surgery age 40-60 with no risks, or major surgery <40 years with no risks	LDUH, LMWH, ES, or IPC
General Surgery—high risk: nonmajor surgery over age 60 or over age 40 with risks.	LDUH, LMWH
General Surgery—very high risk: major surgery over age 40 plus prior VTE, cancer or hypercoagulable state	LDUH or LMWH combined with ES or IPC	May consider postdischarge LMWH or perioperative warfarin
Elective Hip Replacement	LMWH or warfarin	May combine with ES or IPC; start LMWH 12 hours before surgery, 12-24 hours after surgery, or 4-6 hours after surgery at half the dose for initial dose. Start warfarin preoperatively or immediately after surgery, target INR 2. 0-3. 0.
Elective Knee Replacement	LMWH or warfarin
Hip Fracture Surgery	LMWH or warfarin
Neurosurgery	IPC, LDUH or LMWH	Start LMWH post-surgery
Trauma	LMWH with ES or IPC	If high risk of bleeding, may use ES and/or IPC alone.
Acute Spinal Cord Injury	LMWH	Continue LMWH during rehabilitation or convert to warfarin (target INR 2. 5)
Ischemic Stroke	LDUH, LMWH, or danaparoid	If contraindication to anticoagulant, use ES or IPC.
Medical Conditions	LDUH or LWMH	If contraindication to anticoagulant, use ES or IPC.

*Adapted with permission from Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Anderson FA, et al. Prevention of venous thromboembolism. Table: Regimens to prevent VTE, pp. 156S-158S. Chest 2001. Sixth ACCP Consensus Conference on Antithrombotic Therapy. ² ES indicates graduated elastic stockings; INR, international normalized ratio; IPC, intermittent pneumatic compression; LDUH, low-dose unfractionated heparin; LMWH, low molecular weight heparin; and VTE, venous thromboembolism.

References

1. US Bureau of the Census. Statistical Abstract of the United States: 2000. 120th edition. Washington, DC. 2000.

2. Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Anderson FA, et al. Prevention of venous thromboembolism. Chest 2001;119:132S-175S.

3. Caprini JA, Arcelus JI, Hoffman K, Mattern T, Laubach M, Size GP, et al. Prevention of venous thromboembolism in North America: results of a survey among general surgeons. J Vasc Surg 1994;20:751-758.

4. Janku GV, Paiement GD, Green HD. Prevention of venous thromboembolism in orthopaedics in the United States. Clin Ortho & Related Research 1996:313-321.

5. Bratzler DW, Raskob GE, Murray CK, Bumpus LJ, Piatt DS. Underuse of venous thromboembolism prophylaxis for general surgery patients: physician practices in the community hospital setting. Arch Intern Med 1998;158:1909-1912.

6. Stratton MA, Anderson FA, Bussey HI, Caprini J. Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians Consensus Guidelines for Surgical Patients. Arch Intern Med 2000;160:334-340.

7. Clagett GP, Anderson FAJ, Levine MN, Wheeler HB. Prevention of venous thromboembolism. Chest 1995;108S:312S-334S.

8. Keane MG, P IE, Goldhaber SZ. Utilization of venous thromboembolism prophylaxis in the medial intensive care unit. Chest 1994;106:13-14.

9. Goldhaber SZ, Dunn K, MacDougall RC. New onset of venous thromboembolism among hospitalized patients at Brigham and Women's Hospital is caused more often by prophylaxis failure than by withholding treatment. Chest 2000;118:1680-1684.

10. Heijboer H, Cogo A, Buller HR. Detection of deep vein thrombosis with impedance plethysmography and real-time compression ultrasonography in hospitalized patients. Arch Intern Med 1992;152:1901-1903.

11. Lensing AW, Hirsh J. 1251-fibrinogen leg scanning: reassessment of its role for the diagnosis of venous thrombosis in post-operative patients. Thromb Heamost 1993;69:2-7.

12. Eskandari MK, Sugimoto H, Richardson T. Is color-flow duplex a good diagnostic test for detection of isolated calf vein thrombosis in high-risk patients? Angiology 2000;51:705-710.

13. Perrier A, Miron MJ, Desmarais S, de Moerloose P. Using clinical evaluation and lung scan to rule out suspected pulmonary embolism. Arch Intern Med 2000;160:512-516.

14. Meignan M, Rosso J, Gauthier H, Brunengo F. Systematic lung scans reveal a high frequency of silent pulmonary embolism in patients with proximal deep venous thrombosis. Arch Intern Med 2000;160:159-164.

15. Palmer AJ, Schramm W, Kirchhof B, Bergemann R. Low molecular weight heparin and unfractionated heparin for prevention of thrombo-embolism in general surgery: a meta-analysis of randomised clinical trials. Haemostasis 1997;27:65-74.

16. Koch A, Bouges S, Ziegler S, Dinkel H, Daures JP, Victor N. Low molecular weight heparin and unfractionated heparin in thrombosis prophylaxis after major surgical intervention: update of previous meta-analyses. Br J Surg 1997;84:750-759.

17. Vanek VW. Meta-analysis of effectiveness of intermittent pneumatic compression devices with a comparison of thigh-high to knee-high sleeves. American Surgeon 1998;64:1050-1058.

18. Wells PS, Lensing AW, Hirsh J. Graduated compression stockings in the prevention of postoperative venous thromboembolism. A meta-analysis. Arch Intern Med 1994;154:67-72.

19. Agu O, Hamilton G, Baker D. Graduated compression stockings in the prevention of venous thromboembolism. Br J Surg 1999;86:992-1004.

20. Amarigiri SV, Lees TA. Elastic compression stockings for prevention of deep vein thrombosis. In: The Cochrane Library, Issue1, 2001.

21. Freedman KB, Brookenthal KR, Fitzgerald RH, Jr. , Williams S, Lonner JH. A meta-analysis of thromboembolic prophylaxis following elective total hip arthroplasty. J Bone Joint Surg 2000;82-A:929-938.

22. Pulmonary Embolism Prevention (PEP) Trial Collaborative Group. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000;355:1295-1302.

23. Westrich GH, Haas SB, Mosca P, Peterson M. Meta-analysis of thromboembolic prophylaxis after total knee arthroplasty. J Bone Joint Surg 2000;82-B:795-800.

24. Heit JA, Berkowitz SD, Bona R, Cabanas V, Corson JD, Elliott CG, et al. Efficacy and safety of low molecular weight heparin compared to warfarin for the prevention of VTE after total knee replacement surgery: a double-blind, dose-ranging study. Thromb Haemost 1997;77:32-38.

25. Hull RD, Brant RF, Pineo GF, Stein PD. Preoperative vs postoperative initiation of low-molecular-weight heparin prophylaxis against venous thromboembolism in patients undergoing elective hip replacement. Arch Intern Med 1999;159:137-141.

26. Hull RD, Pineo GF, Francis C, Bergqvist D, Fellenius C, Soderberg K, et al. Low-molecular-weight heparin prophylaxis using dalteparin extended out-of-hospital placebo in hip arthroplasty patients. Arch Intern Med 2000;160:2208-2215.

27. Iorio A, Agnelli G. Low-molecular-weight and unfractionated heparin for prevention of venous thromboembolism in neurosurgery: a meta-analysis. Arch Intern Med 2000;160:2327-2332.

28. Cerrato D, Ariano C, Fiacchino F. Deep vein thrombosis and low-dose heparin prophylaxis in neurosurgical patients. J Neurosurg 1978;49:378-381.

29. Velmahos GC, Kern J, Chan LS, Oder D, Murray JA, Shekelle P. Prevention of venous thromboembolism after injury: an evidence-based report-part I: analysis of risk factors and evaluation of the role of vena caval filters. J Trauma 2000;49:132-138.

30. Geerts WH, Jay RM, Code KI. A comparison of low dose heparin with low molecular weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med 1996;335:701-707.

31. Geerts WH, Code KI, Jay RM, Chen E. A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994;331:1601-1606.

32. Green D, Rossi EC, Yao JS. Deep vein thrombosis in spinal cord injury: effect of prophylaxis with calf compression, aspirin and dipyridamole. Paraplegia 1982;20:227-234.

33. Green D, Lee MY, Lim AC. Prevention of thromboembolism after spinal cord injury using low molecular weight heparin. Ann Intern Med 1990;113:571-574.

34. Green D, Chen D, Chmiel JS. Prevention of thromboembolism in spinal cord injury: role of low molecular weight heparin. Arch Phys Med Rehabil 1994;75:290-292.

35. Mismetti P, Laporte-Simitsidis S, Tardy B, Cucherat M, Buchmuller A, Juillard-Delsart D, et al. Prevention of venous thromboembolism in internal medicine with unfractionated or low-molecular-weight heparins: a meta-analysis of randomised clinical trials. Thromb Haemost 2000;83:14-19.

36. Samama MM, Cohen AT, Darmon JY, Desjardins L, Eldor A, Janbon C, et al. A comparison of enoxaparin with placebo for the prevention of VTE in acutely ill medical patients. N Engl J Med 1999;341:793-800.

37. Bern MM, Lokich JJ, Wallach SR. Very low doses of warfarin can prevent thrombosis in central venous catheters: a randomized prospective trial. Ann Intern Med 1990;112:423-428.

38. Norwwod SH, McAuley CE, Berne JD, Vallina VL, Kerns DB, Grahm TW, et al. A potentially expanded role for enoxaparin in preventing venous thromboembolism in high risk blunt trauma patients. J Am Coll Surg 2001;192:161-167.

39. Bergqvist D, Lindgren B, Matzsch T. Comparison of the cost of preventing postoperative deep vein thrombosis with either unfractionated or low molecular weight heparin. Br J Surg 1996;83:1548-1552.

40. Etchells E, McLeod RS, Geerts W, Barton P, Detsky AS. Economic analysis of low-dose heparin vs the low-molecular-weight heparin enoxaparin for prevention of venous thromboembolism after colorectal surgery. Arch Intern Med 1999;159:1221-1228.

41. Anderson DR, O'Brien BJ, Levine MN, Roberts R, Wells PS, Hirsh J. Efficacy and cost of low-molecular-weight heparin compared with standard heparin for the prevention of deep vein thrombosis after total hip arthroplasty. Ann Intern Med 1993;119:1105-1112.

42. Hull RD, Raskob GE, Pineo GF, Feldstein W. Subcutaneous low-molecular-weight heparin vs warfarin for prophylaxis of deep vein thrombosis after hip or knee implantation: an economic perspective. Arch Intern Med 1997;157:293-303.

43. Menzin J, Colditz GA, Regan MM, Richner RE, Oster G. Cost-effectiveness of enoxaparin vs low-dose warfarin in the prevention of deep-vein thrombosis after total hip replacement surgery. Arch Intern Med 1995;155:757-764.

44. Wade WE. Cost-effectiveness analysis of deep vein thrombosis prophylaxis in internal medicine patients. Thrombrosis Research 1999;94:65-68.

45. Peterson GM, Drake CI, Jupe DM, Vial JH, Wilkinson S. Educational campaign to improve the prevention of postoperative venous thromboembolism. J Clin Pharm Therapeutics 1999;24:279-287.

46. Durieux P, Nizard R, Ravaud P, Mounier N, Lepage E. A clinical decision support system for prevention of venous thromboembolism. JAMA 2000;283:2816-2821.

47. Levi D, Kupfter Y, Seneviratne C, Tessler S. Computerized order entry sets and intensive education improve the rate of prophylaxis for deep vein thrombophlebitis. Chest 1998;114S:280S.

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