Deep vein thrombosis prevention: Difference between revisions
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACCP guidelines classification scheme#Grading Scheme Classification|Grade 2]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACCP guidelines classification scheme#Grading Scheme Classification|Grade 2]] | ||
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 [[ACCP guidelines classification scheme#Level of Evidence|Level of evidence B]]) , adjusted-dose VKA, or aspirin (all of [[ACCP guidelines classification scheme#Level of Evidence|Level of evidence C]]). | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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( | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 ([[ACCP guidelines classification scheme#Level of Evidence|Level of evidence B]]) , adjusted-dose VKA, or aspirin (all of [[ACCP guidelines classification scheme#Level of Evidence|Level of evidence C]]). | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 ( | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 ([[ACCP guidelines classification scheme#Level of Evidence|Level of evidence B]]). | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' In patients undergoing major orthopedic surgery, we suggest using dual prophylaxis with an antithrombotic agent and an IPCD during the hospital stay ( | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' In patients undergoing major orthopedic surgery, we suggest using dual prophylaxis with an antithrombotic agent and an IPCD during the hospital stay ([[ACCP guidelines classification scheme#Level of Evidence|Level of evidence C]]). | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' In patients undergoing major orthopedic surgery and increased risk of bleeding, we suggest using an IPCD or no prophylaxis rather than pharmacologic treatment ( | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' In patients undergoing major orthopedic surgery and increased risk of bleeding, we suggest using an IPCD or no prophylaxis rather than pharmacologic treatment ([[ACCP guidelines classification scheme#Level of Evidence|Level of evidence C]]). | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' In patients undergoing major orthopedic surgery, we suggest against using inferior vena cava (IVC) fi lter placement for primary prevention over no thromboprophylaxis in patients with an increased bleeding risk or contraindications to both pharmacologic and mechanical thromboprophylaxis ( | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' In patients undergoing major orthopedic surgery, we suggest against using inferior vena cava (IVC) fi lter placement for primary prevention over no thromboprophylaxis in patients with an increased bleeding risk or contraindications to both pharmacologic and mechanical thromboprophylaxis ([[ACCP guidelines classification scheme#Level of Evidence|Level of evidence C]]) . | ||
|} | |} | ||
Revision as of 12:04, 10 October 2012
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] ; Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet
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Deep Vein Thrombosis Microchapters |
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Diagnosis |
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Treatment |
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Special Scenario |
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Trials |
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Case Studies |
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Deep vein thrombosis prevention On the Web |
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Risk calculators and risk factors for Deep vein thrombosis prevention |
Overview
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.
| Grade | Description of 2012 ACCP grade[4] |
|---|---|
| 1A | Strong recommendation, high-quality evidence |
| 1B | Strong recommendation, moderate-quality evidence |
| 1C | 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.
- Early ambulation (walking).
- Mechanical prophylaxis (intermittent pneumatic compression [IPC] or graduated compression stockings [GCS]).
- Drugs (low-molecular-weight heparin [LMWH], low-dose-unfractionated heparin [LDUH])[6]
II) In major orthopedic surgery patients—those undergoing total hip replacement, total knee replacement, and hip fracture surgery—additional drug options, such as fondaparinux and aspirin, are recommended (1B), though LMWH is preferred (2B or 2C).[7] IPC is an option (1C).[7][8]
Pregnancy
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.
Travelers
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].
ACCP Guidelines- Recommendations for Prevention of VTE in Nonorthopedic Surgical Patients (DO NOT EDIT)
General surgery, GI surgery, Urological surgery and Gynecologic surgery, Bariatric surgery, Vascular surgery, and Plastic and Reconstructive surgery
| Grade 1 |
| "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)." |
| "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 recommend pharmacologic prophylaxis with LMWH (Level of evidence B) or LDUH (Level of evidence B) over no prophylaxis. " |
| "6. 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)." |
| Grade 2 |
| "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). " |
| "7. 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). " |
| "8. 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. " |
| "9. 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). " |
| "10. 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 Guidelines- Recommendations for Prevention of VTE in Cardiac Surgery Patients (DO NOT EDIT)
| Grade 2 |
| "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 Guidelines- Recommendations for Prevention of VTE in Thoracic Surgery Patients (DO NOT EDIT)
| Grade 1 |
| "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)". |
| Grade 2 |
| "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 Guidelines- Recommendations for Prevention of VTE in Patients undergoing Craniotomy (DO NOT EDIT)
| Grade 2 |
| "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 Guidelines- Recommendations for Prevention of VTE in Spinal Surgery Patients (DO NOT EDIT)
| Grade 2 |
| "1. For patients undergoing spinal surgery, we suggest mechanical prophylaxis, preferably with IPC, over no prophylaxis (Level of evidence C), unfractionated heparin (Level of evidence C), or LMWH (Level of evidence C)." |
| "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 Guidelines- Recommendations for Prevention of VTE in Major Trauma Patients (DO NOT EDIT)
| Grade 2 |
| "1. For major trauma patients, we suggest use of LDUH (Level of evidence C), LMWH (Level of evidence C), or mechanical prophylaxis, preferably with IPC (Level of evidence C), over no prophylaxis." |
| "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 Guidelines- Recommendations for Prevention of VTE in Orthopedic Surgery Patients (DO NOT EDIT)
ACCP Guidelines- Recommendations for Prevention of VTE in Patients Undergoing Major Orthopedic Surgery: THA, TKA, HFS (DO NOT EDIT)
| Grade 1 |
| "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)." |
| "9. 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). |
| "11. For asymptomatic patients following major orthopedic surgery, we recommend against Doppler (or duplex) ultrasound (DUS) screening before hospital discharge (Level of evidence B)." |
| Grade 2 |
| "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) fi lter 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) . |
Related Chapters
References
- ↑ Perry, Anne Griffen (2010). Clinical Nursing Skills and Techniques. St. Louis, MO: Mosby. p. 243. ISBN 978-0-323-05289-4.
- ↑ "Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. American College of Chest Physicians. 141 (suppl 2). 2012.
- ↑ 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. PMID 22315261.
- ↑ 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
- ↑ Guyatt GH, Norris SL, Schulman S; et al. (2012). "Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (suppl 2): 53S–70S. doi:10.1378/chest.11-2288. PMID 22315256.
- ↑ 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. PMID 22315263.
- ↑ 7.0 7.1 Falck-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. PMID 22315265.
- ↑ 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. PMID 18843686.
- ↑ Marik PE, Plante LA (2008). "Venous thromboembolic disease and pregnancy". N Engl J Med. 359 (19): 2025–33. doi:10.1056/NEJMra0707993. PMID 18987370.
- ↑ 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.
- ↑ 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 (2 Suppl): e227S–77S. doi:10.1378/chest.11-2297. PMID 22315263. Unknown parameter
|month=ignored (help) - ↑ Falck-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. PMID 22315265. Unknown parameter
|month=ignored (help)