PREVENTION AND TREATMENT OF VENOUS THROMBOEMBOLISM LIFEBLOOD THE Thrombosis CHARITY PREVENTION AND TREATMENT OF VENOUS THROMBOEMBOLISM Nicolaides AN, Fareed J, Kakkar AK, Breddin HK, Goldhaber SZ, Hull R, Kakkar VV, Michiels JJ, Myers K, Samana M, Sasahara A, Kalodiki E.

Definition of risk categories – General surgery The definition of risk categories in general surgical patients using FUT and in hospital pulmonary embolism.* Category Frequency of calf vein thrombosis Frequency of proximal vein thrombosis Frequency of Fatal PE High Risk 40 – 80% 10 – 30% >1% Moderate Risk 10 – 40% 1 – 10% 0.1 – 1% Low Risk <10% <1% <0.1% *Although based on old studies the percentages shown in this table are still used to define the category of risk

Non-orthopaedic patients Risk categories – Non-orthopaedic patients Risk Category General Surgery Gynaecology Obstetrics High Major General Surgery, age>60 Major Gynaecological Surgery, age>60 History of DVT/PE Major General Surgery, age 40-60 & cancer or history of DVT/PE Major Gynaecological Surgery, age 40-60 & cancer or history of DVT/PE Thrombophilia Moderate Major General Surgery, age 40-60 without other risk factors** Major Gynaecological Surgery, age 40-60 Age >35 years Cesarean section Obesity Minor Surgery, age >60 Major Gynaecological Surgery, age<40 on oestrogen therapy Minor Surgery, age 40-60 with history of DVT/PE or on oestrogen therapy Low Major General Suregery, age <40 No other risk factors** Minor Gynaecological Surgery, age <40 without any other risk factors** Age <35 years Without any risk factors Minor Surgery, age 40-60 No other risk factors** Minor Gynaecological Surgery, age 40-60 without any other risk factors**

General surgery and vascular surgery – Moderate risk Moderate risk patients are those > 40 years undergoing major surgery for benign disease LDUH 5000U commenced preoperatively and continued twice or 3 times daily (Grade A) LMWH initiated and dosed according to manufacturers recommendations for moderate risk patients are recommended (Grade A) An alternative method, especially in patients at risk for or with active bleeding, is IPC with GEC compression used continuously until the patient is ambulant (Grade A)

General surgery and vascular surgery – high risk LDUH (5000U commenced 2h before operation and continued post-operatively 3 times a day (Grade A) LMWH initiated and dosed according to the manufacturer’s recommendations (Grade A) Both may be combined with mechanical methods (GEC or IPC) (Grade B) Fondaparinux (one study) is a (Grade B) recommendation

General surgery and vascular surgery Prophylactic subcutaneous LDUH, LMWH, or IPC with GEC are recommended only in patients with additional risk factors (Grade C)

Urological surgery IPC with GEC (Grade B) LDUH giving 5000U commenced 2h before operation and continued 3 times a day in the postoperative period (Grade A) LMWH initiated and dosed according to the manufacturer’s recommendations (Grade C)

Gynaecological surgery LMWH (Grade A) LDUH (5000IU 8 hourly) (Grade A) IPC (throughout hospital stay) (Grade B) LMWH or LDUH combined with IPC or GEC stockings provides optimal prophylaxis (Grade B)

Orthopaedic surgery – Hip replacement LMWH, fondaparinux, oral anticoagulant therapy, IPC or FIT combined with GEC (Grade A). LMWH or fondaparinux are preferred for in-hospital prevention. IPC or FIT combined with GEC stockings are an equivalent alternative to LMWH for those concerned about bleeding. Recombinant hirudin - used in HIT patients (Grade A) LMWH initiated either before or after operation (Grade A) Fondaparinux should be started 6-8 h after surgery Prophylaxis should be continued for 4-6 weeks with LMWH (Grade A) or fondaparinux (Grade C, extrapolation from hip fracture trial).

Orthopaedic surgery – Knee replacement LMWH or warfarin (less effective) (Grade A) Fondaparinux (Grade B) IPC or FIT plus GEC stockings are alternatives but more studies are needed (Grade B)

Orthopaedic surgery – Hip fracture LMWH, fondaparinux, adjusted dose VKA (INR: range 2-3), or LDUH (Grade A) IPC or FIT combined with GEC should be used when there are contraindications for pharmacological prophylaxis (Grade B) If surgery is likely to be delayed, prophylaxis should be initiated with LMWH or IPC or FIT plus GEC as close to the fracture as possible (Grade C)

Orthopaedic/trauma surgery LMWH starting as soon as bleeding risk is acceptable (Grade A) IPC in the presence of contraindications to LMWH (Grade B) and continued until full ambulation

Elective spine surgery IPC initiated before operation (Grade B) LMWH initiated after operation (Grade B) Duration: during hospitalisation (Grade C)

Spinal chord surgery IPC and GEC in combination with LMWH (Grade B) Initiation: IPC and GEC on admission LMWH when bleeding risk is acceptable (Grade C) Duration: LMWH and IPC for three months Continuation with GEC indefinitely (Grade C)

Neurosurgery IPC with or without graduated elastic compression stockings (Grade A) Addition of LMWH is associated with an increase of efficacy (Grade A)

Critical care LDUH or LMWH unless contraindicated (Grade A) For patients with contraindications to pharmacological prophylaxis, GEC stockings + IPC are an alternative (Grade C) In the absence of contraindications, combined mechanical plus pharmacologic prophylaxis (Grade C)

Cancer In surgical patients with cancer, LDUH (5000IU 8-hourly commenced prior to operation) or LMWH (Grade A) For patients at high risk for development of thromboembolic disease in the post-discharge period, prolonged thromboprophylaxis with enoxaparin 40 mg once daily for up to 4 weeks after operation (Grade B) In ambulant non-surgical cancer patients with advanced breast cancer receiving chemotherapy (see above): Use VKA to maintain an INR of between 1.3 and 1.9 (Grade B)

Inferior vena cava filters IVC filters are indicated in patients with PE or proximal DVT who have contraindications to anticoagulation or who have suffered recurrent PE while receiving adequate therapeutic anticoagulation (Grade B) Consider filter placement in patients with major trauma or pelvic fracture (Grade C) Indications for insertion and removal of retrievable IVC filters have not yet been established