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Thromboembolism prevention.

Background

The incidence of objectively confirmed deep venous thrombosis in hospitalized patients is at least 10% in general medical and surgical patients and as high as 60% after major orthopedic surgery. Preventive interventions such as thromboembolism prevention are becoming a focus of national quality improvement measures because of the large potential reduction in morbidity and mortality. The September 2004 publication of reports from the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy highlights these interventions.

Conclusions

Awaiting signs and symptoms of early DVT in the hope of preventing clinically significant thromboembolic events is not useful. Routine screening is neither effective nor cost effective in most cases.

All hospitalized patients, preoperative patients, and victims of trauma should be assessed for overall risk for DVT and its complications--and most should receive some form of thromboembolism prevention.

Abundant clinical trial data indicate little increased risk of clinically important bleeding with prophylactic low-dose unfractionated heparin (LDUH), low-molecular-weight heparins (LMWHs), and vitamin K antagonists; similarly strong data support their advantageous risk-benefit ratio and cost-effectiveness.

Aspirin alone is not recommended as prophylaxis for any patient group.

Inferior vena cava (IVC) filters are not recommended for routine thromboembolism prophylaxis. Filters (both permanent and "removable" varieties) are indicated only in cases of proven proximal DVT with an absolute contraindication to anticoagulation and/or a short-term plan for major surgery. Therapeutic anticoagulation should be started as soon as considered safe following IVC filter placement.

Mechanical prophylaxis with graded compression stockings or intermittent pneumatic compression devices should be used principally in patients at high risk of bleeding or as an adjunct to anticoagulant prophylaxis.

Implementation

Acutely ill medical patients with heart failure, severe respiratory disease, or cancer and/or those who are bed-bound with one or more additional DVT risk factors should receive prophylaxis with LMWH or LDUH.

Moderate-risk and moderately high-risk general surgery patients should receive prophylaxis with LDUH or LMWH; high-risk patients warrant a combination of mechanical and anticoagulant prophylaxis.

Most patients admitted to an intensive care unit should receive thromboembolism prophylaxis. Mechanical prophylaxis is warranted in patients at high risk of bleeding; otherwise LDUH or LMWH is recommended for moderate-risk patients, and LMWH is recommended for high-risk patients.

All trauma patients with one or more risk factors for thromboembolic disease should receive prophylaxis. LMWH is recommended unless there are major contraindications, in which case mechanical prophylaxis may be used until LMWH is considered safe. Thromboembolism prophylaxis should be continued at least until discharge from an inpatient facility; LMWH or adjusted-dose vitamin K antagonist prophylaxis (target international normalized ratio [INR], 2.5) is warranted as long as the patient has major mobility impairment. Doppler ultrasound screening for DVT is indicated in patients who have received no preventive therapy or suboptimal prevention.

Patients who require surgery for hip fracture should receive anticoagulant prophylaxis with fondaparinux, LMWH, LDUH, or adjusted-dose vitamin K antagonist (target INR 2.5).

In patients who have elective total hip or knee replacement, fondaparinux, LMWH, or vitamin K antagonist prophylaxis is recommended similarly. Thromboembolism prophylaxis should be continued for a minimum of 10 days in orthopedic patients following hip fracture or hip or knee replacement.

Patients undergoing major gynecologic or open urologic procedures should receive prophylaxis with LDUH administered b.i.d. or t.i.d.

Burn patients with any additional risk factors for thromboembolism should be given prophylaxis with LDUH or LMWH as soon as the physician considers it safe.

Thromboembolism prophylaxis other than early mobilization is not recommended for patients undergoing routine laparoscopic procedures. In patients with risk factors, prophylaxis should be implemented as in other general surgery patients.

In all patients undergoing spinal or other neuroaxial anesthesia, anticoagulant prophylaxis should be used with particular caution.

Neither LMWH nor fixed-dose warfarin is recommended for routine prophylaxis against thrombosis of long-term indwelling central venous catheters in cancer patients.

Long-distance travelers with additional risk factors for thromboembolism should avoid constrictive clothing and stretch their calves regularly; long-distance travel is defined as more than 6 hours. If active prophylaxis is considered due to perceived further risk, a single dose of LMWH prior to departure or fitted below-knee graded compression stockings may be used.

Reference

Geerts W.H. et al.: Prevention of venous thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126 (Suppl. 3):338S-400S.

BY WILLIAM E. GOLDEN, M.D., AND ROBERT H. HOPKINS, M.D.

DR. GOLDEN is a professor of medicine and public health and DR. HOPKINS the associate director of the medicine/pediatrics residency program at the University of Arkansas. Write to Dr. Hopkins and Dr. Golden at our editorial offices or imnews@elsevier.com.
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Title Annotation:THE EFFECTIVE PHYSICIAN
Author:Golden, William E.; Hopkins, Robert H.
Publication:Internal Medicine News
Date:Apr 1, 2005
Words:769
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