Revision as of 16:58, 30 January 2013 by Vishnu Vardhan Serla(talk | contribs)(/* ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Major Trauma Patients (DO NOT EDIT){{cite journal |author=Gould MK, Garcia DA, Wren SM, et al. |title=Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy an...)
Primary prevention includes the strategies that help to avoid the development of disease. Awareness of Deep venous thrombosis is the best way to prevent this condition.
Primary Prevention
Walking is an effective preventative measure.[1] It prevents backing up of blood in the lower limb vessels. Soleus is a powerful lower limb muscle which assist in walking. Also, in upright posture, it is responsible for pumping venous blood back into the heart from the periphery, and is often called the skeletal-muscle pump, peripheral heart or the sural (tricipital) pump.
Anticoagulants and mechanical measures may also be used. In 2012, the American College of Chest Physicians (ACCP) released their 9th edition of clinical guidelines,[2] which included recommendations on VTE prevention.[3] The recommendations were given strengths with "grades", depending upon the evidence for them.
Strong recommendation, low- or very-low-quality evidence
2A
Weak recommendation, high-quality evidence
2B
Weak recommendation, moderate-quality evidence
2C
Weak recommendation, low- or very-low-quality evidence[5]
Lifestyle Modifications
The most common lifestyle risk factors for venous thromboembolism are:
Obesity,
Inactivity,
Cigarette smoking,
Avoid dehydration,
Maintain normal blood pressure.
Surgery Patients
Surgery patients are at an increased risk of forming a DVT.
I. In patients who have undergone non-orthopedic surgery, depending upon the risk of VTE, risk of major bleeding, and patient preferences, following are potential recommended treatments.
The risk of VTE is increased in pregnancy by about 4-fold[9] due to a more hypercoaguable state, a likely adaptation against fatal postpartum hemorrhage.
There is clinical evidence that suggest, wearing compression socks, on long haul flights, reduces the incidence of thrombosis. A randomised study in 2001 compared two sets of long haul airline passengers, one set wore travel compression hosiery the others did not. The passengers were all scanned and tested to check for the incidence of DVT. The results showed that asymptomatic DVT occurred in 10% of the passengers who did not wear compression socks. The group wearing compression had no DVTs. The authors concluded that wearing elastic compression hosiery reduces the incidence of DVT in long haul airline passengers.[10].
For information on randomized trials which compared the efficacy and safety of antithrombins and anticoagulants in the prevention of deep vein thrombosis, click here
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Nonorthopedic Surgical Patients (DO NOT EDIT)[11]
General surgery, GI surgery, Urological surgery and Gynecologic surgery, Bariatric surgery, Vascular surgery, and Plastic and Reconstructive surgery (DO NOT EDIT)[11]
"1. For general and abdominal-pelvic surgery patients at very low risk for VTE ( < 0.5%; Rogers score, <7; Caprini score, 0), we recommend that no specific pharmaclogic prophylaxis be used other than early ambulation (Level of evidence B)."
"2. For general and abdominal-pelvic surgery patients at high risk for VTE (~6.0%; Caprini score,≥5) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Level of evidence B) or LDUH (Level of evidence B) over no prophylaxis. "
"3. For high-VTE-risk patients undergoing abdominal or pelvic surgery for cancer who are not otherwise at high risk for major bleeding complications, we recommend extended duration pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Level of evidence B)."
"1. For general and abdominal-pelvic surgery patients at very low risk for VTE ( < 0.5%; Rogers score, <7; Caprini score, 0), we recommend that no specific mechanical prophylaxis be used other than early ambulation.(Level of evidence C) "
"2. For general and abdominal-pelvic surgery patients at low risk for VTE (~1.5%; Rogers score, 7-10; Caprini score, 1-2), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC), over no prophylaxis (Level of evidence C). "
"3. For general and abdominal-pelvic surgery patients at moderate risk for VTE (~3.0%; Rogers score, >10; Caprini score, 3-4) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Level of evidence B), low-dose unfractionated heparin (LDUH) (Level of evidence B) , or mechanical prophylaxis, preferably with IPC (Level of evidence C) , over no prophylaxis. "
"4. For general and abdominal-pelvic surgery patients at moderate risk for VTE (3.0%; Rogers score, > 10; Caprini score, 3-4) who are at high risk for major bleeding complications or those in whom the consequences of bleeding are thought to be particularly severe, we suggest mechanical prophylaxis, preferably with IPC, over no prophylaxis (Level of evidence C) . "
"5. For general and abdominal-pelvic surgery patients at high risk for VTE (~6.0%; Caprini score,≥5) who are not at high risk for major bleeding complications, we suggest that mechanical prophylaxis with elastic stockings (ES) or IPC should be added to pharmacologic prophylaxis (Level of evidence C). "
"6. For high-VTE-risk general and abdominal-pelvic surgery patients who are at high risk for major bleeding complications or those in whom the consequences of bleeding are thought to be particularly severe, we suggest use of mechanical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Level of evidence C). "
"7. For general and abdominal-pelvic surgery patients at high risk for VTE (6%; Caprini score,≥5) in whom both LMWH and unfractionated heparin are contraindicated or unavailable and who are not at high risk for major bleed ing complications, we suggest low-dose aspirin (Level of evidence C) , fondaparinux (Level of evidence C) , or mechanical prophylaxis, preferably with IPC (Level of evidence C) , over no prophylaxis. "
"8. For general and abdominal-pelvic surgery patients, we suggest that an inferior vena cava (IVC) filter should not be used for primary VTE prevention (Level of evidence C). "
"9. For general and abdominal-pelvic surgery patients, we suggest that periodic surveillance with venous compression ultrasound (VCU) should not be performed (Level of evidence C) . "
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Cardiac Surgery Patients (DO NOT EDIT)[11]
"1. For cardiac surgery patients with an uncomplicated postoperative course, we suggest use of mechanical prophylaxis, preferably with optimally applied IPC, over either no prophylaxis (Grade 2C) or pharmacologic prophylaxis (Level of evidence C).
"2. For cardiac surgery patients whose hospital course is prolonged by one or more nonhemorrhagic surgical complications, we suggest adding pharmacologic prophylaxis with LDUH or LMWH to mechanical prophylaxis (Level of evidence C).
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Thoracic Surgery Patients (DO NOT EDIT)[11]
"1. For thoracic surgery patients at high risk for VTE who are not at high risk for perioperative bleeding, we suggest LDUH (Level of evidence B) or LMWH (Level of evidence B)".
"1. For thoracic surgery patients at moderate risk for VTE who are not at high risk for perioperative bleeding, we suggest LDUH (Level of evidence B), LMWH (Level of evidence B), or mechanical prophylaxis with optimally applied IPC (Level of evidence C) over no prophylaxis."
"2. For thoracic surgery patients at high risk for VTE who are not at high risk for perioperative bleeding, we suggest that mechanical prophylaxis with ES or IPC should be added to pharmacologic prophylaxis (Level of evidence C)."
"3. For thoracic surgery patients who are at high risk for major bleeding, we suggest use of mechanical prophylaxis, preferably with optimally applied IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Level of evidence C)."
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Patients undergoing Craniotomy (DO NOT EDIT)[11]
"1. For craniotomy patients, we suggest that mechanical prophylaxis, preferably with IPC, be used over no prophylaxis (Level of evidence B) or pharmacologic prophylaxis (Level of evidence C). "
"2. For craniotomy patients at very high risk for VTE (eg, those undergoing craniotomy for malignant disease), we suggest adding pharmacologic prophylaxis to mechanical prophylaxis once adequate hemostasis is established and the risk of bleeding decreases (Level of evidence C). "
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Spinal Surgery Patients (DO NOT EDIT)[11]
"2. For patients undergoing spinal surgery at high risk for VTE (including those with malignant disease or those undergoing surgery with a combined anterior-posterior approach), we suggest adding pharmacologic prophylaxis to mechanical prophylaxis once adequate hemostasis is established and the risk of bleeding decreases (Level of evidence C)."
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Major Trauma Patients (DO NOT EDIT)[11]
"2. For major trauma patients at high risk for VTE (including those with acute spinal cord injury, traumatic brain injury, and spinal surgery for trauma), we suggest adding mechanical prophylaxis to pharmacologic prophylaxis (Level of evidence C) when not contraindicated by lower extremity injury."
"3. For major trauma patients in whom LMWH and LDUH are contraindicated, we suggest mechanical prophylaxis, preferably with IPC, over no prophylaxis (Level of evidence C) when not contraindicated by lower-extremity injury. We suggest adding pharmacologic prophylaxis with either LMWH or LDUH when the risk of bleeding diminishes or the contraindication to heparin resolves (Level of evidence C)."
"4. For major trauma patients, we suggest that an IVC filter should not be used for primary VTE prevention (Level of evidence C)."
"5. For major trauma patients, we suggest that periodic surveillance with VCU should not be performed (Level of evidence C)."
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Orthopedic Surgery Patients (DO NOT EDIT)[12]
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Patients Undergoing Major Orthopedic Surgery: THA, TKA, HFS (DO NOT EDIT)[12]
"1. In patients undergoing total hip arthro- plasty (THA) or total knee arthroplasty (TKA), we recommend use of one of the following for a minimum of 10 to 14 days rather than no anti-thrombotic prophylaxis: low-molecular-weight heparin (LMWH), fondaparinux, apixaban, dab- igatran, rivaroxaban, low-dose unfractionated heparin (LDUH), adjusted-dose vitamin K antag- onist (VKA), aspirin (all of Level of evidence B), or an inter- mittent pneumatic compression device (IPCD) (Level of evidence C). "
"2. In patients undergoing hip fracture surgery (HFS), we recommend use of one of the following rather than no antithrombotic prophylaxis for a minimum of 10 to 14 days: LMWH, fondaparinux, LDUH, adjusted-dose VKA, aspirin (all Grade 1B) , or an IPCD (Level of evidence C) ."
"3. For patients undergoing major orthopedic surgery (THA, TKA, HFS) and receiving LMWH as thromboprophylaxis, we recommend starting either 12 h or more preoperatively or 12 h or more postoperatively rather than within 4 h or less preoperatively or 4 h or less postoperatively (Level of evidence B)."
"4. In patients undergoing major orthopedic surgery and who decline or are uncooperative with injections or an IPCD, we recommend using apixaban or dabigatran (alternatively rivaroxaban or adjusted-dose VKA if apixaban or dabigatran are unavailable) rather than alternative forms of prophylaxis (all of Level of evidence B).
"5. For asymptomatic patients following major orthopedic surgery, we recommend against Doppler (or duplex) ultrasound (DUS) screening before hospital discharge (Level of evidence B)."
"1. In patients undergoing THA or TKA, irrespective of the concomitant use of an IPCD or length of treatment, we suggest the use of LMWH in preference to the other agents we have recommended as alternatives: fondaparinux,apixaban, dabigatran, rivaroxaban, LDUH (all of Level of evidence B) , adjusted-dose VKA, or aspirin (all of Level of evidence C)."
"2. In patients undergoing HFS, irrespective of the concomitant use of an IPCD or length of treatment, we suggest the use of LMWH in preference to the other agents we have recommended as alternatives: fondaparinux, LDUH (Level of evidence B) , adjusted-dose VKA, or aspirin (all of Level of evidence C)."
"3. For patients undergoing major orthopedic surgery, we suggest extending thromboprophylaxis in the outpatient period for up to 35 days from the day of surgery rather than for only 10 to 14 days (Level of evidence B)."
"4. In patients undergoing major orthopedic surgery, we suggest using dual prophylaxis with an antithrombotic agent and an IPCD during the hospital stay (Level of evidence C)."
"5. In patients undergoing major orthopedic surgery and increased risk of bleeding, we suggest using an IPCD or no prophylaxis rather than pharmacologic treatment (Level of evidence C)."
"6. In patients undergoing major orthopedic surgery, we suggest against using inferior vena cava (IVC) filter placement for primary prevention over no thromboprophylaxis in patients with an increased bleeding risk or contraindications to both pharmacologic and mechanical thromboprophylaxis (Level of evidence C) ."
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Isolated Lower-Leg Injuries Distal to the Knee (DO NOT EDIT)[12]
"1. We suggest no prophylaxis rather than pharmacologic thromboprophylaxis in patients with isolated lower-leg injuries requiring leg immobilization (Level of evidence C)."
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in patients undergoing Knee Arthroscopy (DO NOT EDIT)[12]
"1. For patients undergoing knee arthroscopy without a history of prior VTE, we suggest no thromboprophylaxis rather than prophylaxis (Level of evidence B)."
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Nonsurgical Patients (DO NOT EDIT)[13]
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Hospitalized Acutely Ill Medical Patients (DO NOT EDIT)[13]
"1. For acutely ill hospitalized medical patients at increased risk of thrombosis, we recommend anticoagulant thromboprophylaxis with low molecular-weight heparin [LMWH], low-dose unfractionated heparin (LDUH) bid, LDUH did, or fondaparinux (Grade 1B)."
"2. For acutely ill hospitalized medical patients at low risk of thrombosis, we recommend against the use of pharmacologic prophylaxis or mechanical prophylaxis (Grade 1B)."
"3. For acutely ill hospitalized medical patients who are bleeding or at high risk for bleeding, we recommend against anticoagulant thromboprophylaxis (Grade 1B)."
"1. For acutely ill hospitalized medical patients at increased risk of thrombosis who are bleeding or at high risk for major bleeding, we suggest the optimal use of mechanical thromboprophylaxis with graduated compression stockings (GCS) (Grade 2C) or intermittent pneumatic compression (IPC) (Grade 2C), rather than no mechanical thromboprophylaxis. When bleeding risk decreases, and if VTE risk persists, we suggest that pharmacologic thromboprophylaxis be substituted for mechanical thromboprophylaxis (Grade 2B)."
"2. In acutely ill hospitalized medical patients who receive an initial course of thromboprophylaxis, we suggest against extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay (Grade 2B)."
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Critically Ill Patients (DO NOT EDIT)[13]
"1. In critically ill patients, we suggest against routine ultrasound screening for DVT (Level of evidence C)."
"2. For critically ill patients, we suggest using LMWH or LDUH thromboprophylaxis over no prophylaxis (Level of evidence C)."
"3. For critically ill patients who are bleeding, or are at high risk for major bleeding, we suggest mechanical thromboprophylaxis with GCS (Level of evidence C) or IPC (Level of evidence C) until the bleeding risk decreases, rather than no mechanical thromboprophylaxis. When bleeding risk decreases, we suggest that pharmacologic thromboprophylaxis be substituted for mechanical thromboprophylaxis (Level of evidence C)."
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Patients With Cancer in the Outpatient Setting (DO NOT EDIT)[13]
"1. In outpatients with cancer who have no additional risk factors for VTE, we recommend against the prophylactic use of vitamin K antagonists (Level of evidence B)."
"1. In outpatients with cancer who have no additional risk factors for VTE, we suggest against routine prophylaxis with LMWH or LDUH (Level of evidence B)."
"2. In outpatients with solid tumors who have additional risk factors for VTE and who are at low risk of bleeding, we suggest prophylactic dose LMWH or LDUH over no prophylaxis (Level of evidence B)."
"3. In outpatients with cancer and indwelling central venous catheters, we suggest against routine prophylaxis with LMWH or LDUH (Level of evidence B) and suggest against the prophylactic use of vitamin K antagonists (Level of evidence C)."
ACCP 2012 Guidelines- Recommendations for Prevention of VTE in Chronically Immobilized Outpatients (DO NOT EDIT)[13]
"1. In chronically immobilized persons residing at home or at a nursing home, we suggest against the routine use of thromboprophylaxis (Level of evidence C)".
ACCP 2012 Guidelines- Recommendations for Thromboprophylaxis during Long-Distance Travel (DO NOT EDIT)[13]
"1. For long-distance travelers at increased risk of VTE (including previous VTE, recent surgery or trauma, active malignancy, pregnancy, estrogen use, advanced age, limited mobility, severe obesity, or known thrombophilic disorder), we suggest frequent ambulation, calf muscle exercise, or sitting in an aisle seat if feasible (Level of evidence C). "
"2. For long-distance travelers at increased risk of VTE (including previous VTE, recent surgery or trauma, active malignancy, pregnancy, estrogen use, advanced age, limited mobility, severe obesity, or known thrombophilic disorder), we suggest use of properly fitted, below-knee GCS providing 15 to 30 mmHg of pressure at the ankle during travel (Level of evidence C). For all other long-distance travelers, we suggest against the use of GCS (Level of evidence C). "
"3. For long-distance travelers, we suggest against the use of aspirin or anticoagulants to prevent VTE (Level of evidence C). "
ACCP 2012 Guidelines- Recommendations for Thromboprophylaxis to Prevent VTE in Asymptomatic Persons With Thrombophilia (DO NOT EDIT)[13]
"1. In persons with asymptomatic thrombophilia (ie, without a previous history of VTE), we recommend against the long-term daily use of mechanical or pharmacologic thromboprophylaxis to prevent VTE (Level of evidence C). "
↑Kahn SR, Lim W, Dunn AS; et al. (2012). "Prevention of VTE in Nonsurgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (suppl 2): e195S–e226S. doi:10.1378/chest.11-2296. PMID22315261.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
↑For more detailed text descriptions of the grades, including benefits vs. the risks and burdens, the methodologic strength of supporting evidence, and implications, see Table 4 of Guyatt et al., p. 62S
↑Gould MK, Garcia DA, Wren SM; et al. (2012). "Prevention of VTE in Nonorthopedic Surgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (suppl 2): e227S–e277S. doi:10.1378/chest.11-2297. PMID22315263.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
↑ 7.07.1Falck-Ytter Y, Francis CW, Johanson NA; et al. (2012). "Prevention of VTE in Orthopedic Surgery Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (suppl 2): e278S–e325S. doi:10.1378/chest.11-2404. PMID22315265.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
↑Kakkos SK, Caprini JA, Geroulakos G; et al. (2008). Kakkos, Stavros K, ed. "Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients". Cochrane Database Syst Rev (4): CD005258. doi:10.1002/14651858.CD005258.pub2. PMID18843686.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
↑Scurr JH, Machin SJ, Bailey-King S, Mackie IJ, McDonald S, Smith PD. Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights: a randomised trial. Lancet 2001;12(9267):1485-9. PMID 11377600.
↑ 11.011.111.211.311.411.511.6Gould MK, Garcia DA, Wren SM; et al. (2012). "Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e227S–77S. doi:10.1378/chest.11-2297. PMID22315263. Unknown parameter |month= ignored (help)CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
↑ 12.012.112.212.3Falck-Ytter Y, Francis CW, Johanson NA; et al. (2012). "Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e278S–325S. doi:10.1378/chest.11-2404. PMID22315265. Unknown parameter |month= ignored (help)CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
↑ 13.013.113.213.313.413.513.6Kahn SR, Lim W, Dunn AS; et al. (2012). "Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e195S–226S. doi:10.1378/chest.11-2296. PMID22315261. Unknown parameter |month= ignored (help)CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)