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===General surgery, GI surgery, Urological surgery and Gynecologic surgery, Bariatric surgery, Vascular surgery, and Plastic and Reconstructive surgery===
===General surgery, GI surgery, Urological surgery and Gynecologic surgery, Bariatric surgery, Vascular surgery, and Plastic and Reconstructive surgery===
<ref name="pmid22315263">{{cite journal |author=Gould MK, Garcia DA, Wren SM, ''et al.'' |title=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 |journal=Chest |volume=141 |issue=2 Suppl |pages=e227S–77S |year=2012 |month=February |pmid=22315263 |doi=10.1378/chest.11-2297 |url=}}</ref>
<ref name="pmid22315263">{{cite journal |author=Gould MK, Garcia DA, Wren SM, ''et al.'' |title=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 |journal=Chest |volume=141 |issue=2 Suppl |pages=e227S–77S |year=2012 |month=February |pmid=22315263 |doi=10.1378/chest.11-2297 |url=}}</ref>
{{cquote|
'''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 (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation.


{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACCP guidelines classification scheme#Grading Scheme Classification|Grade 1]]
|-
| bgcolor="LightGreen"| <nowiki>"</nowiki>'''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 (Grade 1B).<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"| <nowiki>"</nowiki>'''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 (Grade 1B) or LDUH (Grade 1B) over no prophylaxis. <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"| <nowiki>"</nowiki>'''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 (Grade 1B).<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACCP guidelines classification scheme#Grading Scheme Classification|Grade 2]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation.


 
|-
'''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 (Grade 1B) or LDUH (Grade 1B) over no prophylaxis. We suggest that mechanical prophylaxis with elastic stockings (ES) or IPC should be added to pharmacologic prophylaxis (Grade 2C).
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 (Grade 2C) .
 
|-
 
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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) (Grade 2B ), low-dose unfractionated heparin (LDUH) (Grade 2B) , or mechanical prophylaxis, preferably with IPC (Grade 2C) , 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 (Grade 1B).
|-
 
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 (Grade 2C) .
 
|-
'''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 (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation.
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 (Grade 1B) or LDUH (Grade 1B) over no prophylaxis. We suggest that mechanical prophylaxis with elastic stockings (ES) or IPC should be added to pharmacologic prophylaxis (Grade 2C).
'''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 (Grade 2C) .
|-
 
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 (Grade 2C).
 
|-
'''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) (Grade 2B ), low-dose unfractionated heparin (LDUH) (Grade 2B) , or mechanical prophylaxis, preferably with IPC (Grade 2C) , over no prophylaxis.
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 (Grade 2C) , fondaparinux (Grade 2C) , or mechanical prophylaxis, preferably with IPC (Grade 2C) , over no prophylaxis.
 
|-
 
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 (Grade 2C).
'''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 (Grade 2C) .
|-
 
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''10.''' For general and abdominal-pelvic surgery patients, we suggest that periodic surveillance with venous compression ultrasound (VCU) should not be performed (Grade 2C) .
 
|}
'''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 (Grade 1B) or LDUH (Grade 1B) over no prophylaxis. We suggest that mechanical prophylaxis with elastic stockings (ES) or IPC should be added to pharmacologic prophylaxis (Grade 2C).
 
'''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 (Grade 2C).
 
 
'''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 (Grade 2C) , fondaparinux (Grade 2C) , or mechanical prophylaxis, preferably with IPC (Grade 2C) , 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 (Grade 2C).
 
 
'''10.''' For general and abdominal-pelvic surgery patients, we suggest that periodic surveillance with venous compression ultrasound (VCU) should not be performed (Grade 2C) .


==Related Chapters==
==Related Chapters==

Revision as of 03:05, 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

Deep Vein Thrombosis Microchapters

Home

Patient Information

Overview

Classification

Pathophysiology

Causes

Differentiating Deep vein thrombosis from other Diseases

Epidemiology and Demographics

Risk Factors

Triggers

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Approach

Assessment of Clinical Probability and Risk Scores

Assessment of Probability of Subsequent VTE and Risk Scores

History and Symptoms

Physical Examination

Laboratory Findings

Ultrasound

Venography

CT

MRI

Other Imaging Findings

Treatment

Treatment Approach

Medical Therapy

IVC Filter

Invasive Therapy

Surgery

Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Special Scenario

Upper extremity DVT

Recurrence

Pregnancy

Trials

Landmark Trials

Case Studies

Case #1

Deep vein thrombosis prevention On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

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US National Guidelines Clearinghouse

NICE Guidance

FDA on Deep vein thrombosis prevention

CDC on Deep vein thrombosis prevention

Deep vein thrombosis prevention in the news

Blogs on Deep vein thrombosis prevention

Directions to Hospitals Treating Deep vein thrombosis

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:

  1. Obesity,
  2. Inactivity,
  3. Cigarette smoking,
  4. Avoid dehydration,
  5. 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.

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

Main article: Economy class syndrome

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].

Deep vein thrombosis guidelines for patients undergoing surgery

ACCP Guidelines - Recommendations for Prevention of VTE in Nonorthopedic Surgical Patients

General surgery, GI surgery, Urological surgery and Gynecologic surgery, Bariatric surgery, Vascular surgery, and Plastic and Reconstructive surgery

[11]

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 (Grade 1B)."
"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 (Grade 1B) or LDUH (Grade 1B) 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 (Grade 1B)."
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 pharmaclogic (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation.
"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 (Grade 2C) .
"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) (Grade 2B ), low-dose unfractionated heparin (LDUH) (Grade 2B) , or mechanical prophylaxis, preferably with IPC (Grade 2C) , 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 (Grade 2C) .
"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 (Grade 1B) or LDUH (Grade 1B) over no prophylaxis. We suggest that mechanical prophylaxis with elastic stockings (ES) or IPC should be added to pharmacologic prophylaxis (Grade 2C).
"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 (Grade 2C).
"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 (Grade 2C) , fondaparinux (Grade 2C) , or mechanical prophylaxis, preferably with IPC (Grade 2C) , 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 (Grade 2C).
"10. For general and abdominal-pelvic surgery patients, we suggest that periodic surveillance with venous compression ultrasound (VCU) should not be performed (Grade 2C) .

Related Chapters

Economy class syndrome

References

  1. ↑ Perry, Anne Griffen (2010). Clinical Nursing Skills and Techniques. St. Louis, MO: Mosby. p. 243. ISBN 978-0-323-05289-4.
  2. ↑ "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.
  3. ↑ 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.
  4. ↑ 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
  5. ↑ 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.
  6. ↑ 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. ↑ 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.
  8. ↑ 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.
  9. ↑ Marik PE, Plante LA (2008). "Venous thromboembolic disease and pregnancy". N Engl J Med. 359 (19): 2025–33. doi:10.1056/NEJMra0707993. PMID 18987370.
  10. ↑ 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. ↑ 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)

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