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Dvt Prophylaxis Orthopedic Surgery Guidelines

Organization Panel Composition Planning And Coordination

Inpatient Management of DVT Prophylaxis

The work of this panel was coordinated with 9 other guideline panels by ASH and the McMaster GRADE Centre . Project oversight was provided initially by a coordination panel, which reported to the ASH Committee on Quality, and then by the coordination panel chair and vice chair . ASH vetted and appointed individuals to the guideline panel. The McMaster GRADE Centre vetted and retained researchers to conduct systematic reviews of evidence and coordinate the guideline-development process, including the use of the GRADE approach. The membership of the panels and the GRADE Centre team is described in Supplement 1.

The panel included surgeons with subspecialty representation, hematologists, internists, and a pharmacist, all of whom had clinical and research expertise on the guideline topic. The panel also included methodologists with expertise in evidence appraisal and guideline development and 2 patient representatives. Both patient representatives participated in question prioritization, and 1 participated in all remaining steps of the development process. The panel chair was a content expert. The vice chair was a urological surgeon with specialized expertise in guideline development.

What Is The Prophylactic Treatment To Prevent Dvt

There are two non-invasive mechanical methods of DVT prevention: intermittent pneumatic compression and anti-embolic stockings . Both methods have proven and effective outcomes for patients with a higher risk of developing diseases, whether used alone or in combination with pharmacologic therapy.

Preventing Hospital-acquired Venous Thromboembolism

Description Of The Health Problem

Deep vein thrombosis and pulmonary embolism are well-recognized, clinically important, and potentially devastating complications that may occur following major surgical procedures, defined as any surgical intervention that carries greater than minimal risk, is performed in the operating room, and requires specialized training. Before the era of the routine use of effective prophylaxis, VTE was a common cause of morbidity and mortality following major surgery. It has been estimated to cause > 50000 deaths per annum in the United States alone. The importance of preventative measures to minimize the risk of VTE following major surgery has been recognized for decades however, even with the use of prophylaxis, surgery accounts for 25% of VTEs observed in communities.

Although most surgical procedures carry some risk for VTE, this risk varies considerably across surgical procures and among individual patients undergoing surgery. Surgical procedures carrying the highest risk of developing postoperative VTE include hip and knee arthroplasty, invasive neurosurgical procures, and major vascular procedures.

Patient factors that carry greater risks for thrombosis include histories of VTE, particularly if unprovoked or associated with cancer, or cancer, even in the absence of previous VTE. Scoring systems that calculate the risk of postoperative VTE for individual patients, such as the Caprini score, have been developed and validated following some surgical procedures.

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Antiplatelet And Anticoagulation Therapy

The decision to stop or continue aspirin use perioperatively involves variables such as the patients cardiovascular risk profile, nature of the surgery, and risk for bleeding. The guideline task force recommended that aspirin use for cardiovascular disease should not be routinely stopped in patients undergoing orthopedic procedures unless contraindicated. In patients with cardiovascular disease, the risk of thrombotic events after acute aspirin withdrawal outweighs the risk of bleeding complications following surgery.

For patients on chronic anticoagulation regimens, the task force recommended discontinuing acenocoumarol for three days, warfarin and fluindione for five days, and phenoprocoumon for seven days prior to elective orthopedic surgery. Stop use of direct acting oral anticoagulants, including apixaban, edoxaban, dabigatran, and rivaroxaban, at least two days prior to elective surgery and possibly longer if creatinine clearance is reduced. Consider bridging chronic anticoagulation in patients with prosthetic heart valves.

Low Molecular Weight Heparin

Venous Thromboembolism Prophylaxis After Total Joint Arthroplasty

LMWH is derived from UFH by chemical or enzymatic depolymerization. Their molecular weight is approximately one-third that of UFH . Compared to UFH, LMWH has a more favourable benefit-to-risk ratio in animal models, with superior pharmacokinetic properties. The inhibitory activity of LMWH against factor Xa is greater than thrombin and exhibits less binding to cells and proteins than UFH. Consequently, LMWH preparations have more predictable pharmacokinetic and pharmacodynamic properties, a longer half-life and a lower risk of non-haemorrhagic side effects than UFH. LMWH is administered subcutaneously via injection, in one or two daily doses without the need of monitoring. The use of LMWH is more convenient than UFH, and thus has replaced UFH for almost any clinical indications.40,42

An uncommon but potentially devastating complication of anticoagulation with LMWH is HIT syndrome, as reported with UFH. The inverse variance-weighted average that determined the absolute risk for HIT with LMWH was 0.2%, compared with 2.6% with UFH.55 The latest ACCP guidelines recommended LMWH as an optimal method for VTE prophylaxis in patients undergoing THR, TKR or hip fracture surgery.31 According to these guidelines, the use of LMWH is recommended in preference to the other agents they have recommended as alternatives for VTE prophylaxis.31 Due to these characteristics, LMWH should be considered the gold standard for VTE prophylaxis in orthopaedic patients.

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Limitations Of These Guidelines

The panel recognized that many studies of pharmacological and mechanical prophylaxis for VTE prevention following major surgery date back decades, thereby raising questions about the applicability of this evidence. This includes largely outdated means to assess for VTEs postoperatively. Surgical practice has changed considerably over the decades, aimed at improving the patient experience. In most circumstances, these innovations would be expected to reduce the overall risk of postoperative VTEs. Examples of such innovations include use of minimally invasive surgical procedures, early and increased postoperative patient mobilization, and use of regional anesthesia however, it is uncertain whether such changes in surgical practice impact the relative effectiveness of various thromboembolic interventions. Therefore, for the purpose of this guideline, this type of evidence informing the relative effectiveness of these interventions was included when obtained in the setting of RCTs. For determining baseline risk of VTEs and major bleeding, we used data, where available, from contemporary large cohort studies that were deemed representative of contemporary patients.

What About Moving Back To Shorter Durations Of Prophylaxis

What does this mean for our orthopedic surgery patients? On the one hand, these patients are at increased risk for VTE, and risk persists for weeks after surgery, which is why extended-duration prophylaxis is guideline recommended. On the other hand, the average risk of VTE after major orthopedic surgery may be decreasing over time and is similar to or may be lower than the risk of bleeding with pharmacologic thromboprophylaxis. Further, shortened duration prophylaxis for lower-VTE-risk patients having fast-track orthopedic procedures may prove, with further study, to be effective. The key to optimizing prophylaxis in this patient group is better risk stratification, as discussed below.

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Description Of The Target Populations

The primary target population of this guideline is patients hospitalized for major surgical procedures that carry a risk for postoperative VTE. This guideline also addresses patients hospitalized following major trauma most, but not all, subsequently required major surgical procedures. The panel recognized that there are 2 major modalities applied for the prevention of VTE in the postoperative period: pharmacological antithrombotic prophylaxis and mechanical prophylaxis. For evaluation of the pharmacological methods for the prevention of VTE, the panel weighed the benefits and risks of the various options for individual surgical procedures or domains, such as hip or knee arthroplasty, general surgery, or urological or neurosurgical procedures.

For mechanical interventions, such as graduated or mechanical compression devices or IVC filters, the effectiveness of these interventions was assessed across all surgical domains. Likewise, other questions, such as the duration of pharmacological prophylaxis and timing of the initiation of pharmacological prophylaxis, were also assessed across all surgical domains.

The target populations included patients who underwent surgery for cancer or noncancer-related procedures. Patients hospitalized for major trauma were included whether they underwent surgery or not.

What Is The Protocol For Dvt

Developing VTE Prophylaxis Consensus in Orthopedics

To treat acute DVT, anticoagulation should include one of the following treatments: 1) apixaban 10 mg twice a day for 7 days, followed by 5 mg twice a day 2) dabigatran 150 mg twice a day after a 5- to 10-day LMWH lead-in

Dvt: How Much Aspirin Should You Take?

This question can only be answered in the absence of a specific answer because it is largely dependent on the persons underlying health condition and the severity of the DVT. Most experts, on the other hand, recommend starting with a low dose and gradually increasing it as needed. Taking aspirin on a regular basis can help to prevent further blood clots from forming and could even lower the risk of death from DVT.

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Effectiveness Of Thromboprophylaxis After Knee Arthroscopy Or Lower Leg Casting

The Thrombosis Prophylaxis After Knee Arthroscopy and Thrombosis Prophylaxis During Plaster Cast Lower Leg Immobilization randomized controlled trials assessed the effectiveness and safety of LMWH versus placebo given for 8 days after knee arthroscopy or for the full period of immobilization after lower leg casting . Results showed that VTE prophylaxis with LMWH was ineffective after knee arthroscopy or lower leg casting. In the POT-KAST trial, 0.7% randomized to LMWH versus 0.4% randomized to placebo developed VTE , with very low rates of major bleeding . In the POT-CAST trial, 1.4% randomized to LMWH versus 1.8% randomized to placebo developed VTE , with no episodes of major bleeding in either group. Overall rates of VTE were low in all groups, consistent with the observational data presented above however, it should be noted that patients with a history of VTE were excluded from participation in the 2 trials.

A subsequent secondary analysis of the POT-CAST trial identified that while BMI > 30 kg/m2, family history of VTE, Achilles tendon rupture, and surgical treatment of traumatic leg injury increased VTE risk, thromboprophylaxis remained ineffective in these high-risk subgroups.

Epidemiology And Trends Over Time In Vte Occurrence After Major Orthopedic Surgery

An important aspect of the epidemiology of VTE after major orthopedic surgery, reported more than 20 years ago, is that most cases occurred after hospital discharge. White and colleagues showed in 1998 that patients undergoing THA and TKA remained at risk of VTE for weeks after surgery. Using the California discharge database, the median time to VTE was 17 days in 19 586 patients undergoing THA and 7 days in 24 059 patients undergoing TKA, and many of these events occurred after hospital discharge. Of note, mean length of stay in that study for both THA and TKA was ~7 days but is much shorter now. These data provided the impetus for numerous clinical trials evaluating postdischarge, extended-duration thromboprophylaxis, compared with prophylaxis restricted to the duration of hospital stay. Results of these trials have informed guideline panels to recommend extended duration prophylaxis after major orthopedic surgery., ,

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What Are Others Saying And What Is New In These Ash Guidelines

These ASH guidelines stand out by their scope, which includes general issues relevant to any surgical procedure and those related to surgical subspecialties. They make consistent use of high-quality systematic reviews and provide a formal EtD framework for every recommendation, thereby enhancing transparency about the judgments that were made.

Mechanical methods of perioperative VTE prophylaxis have been addressed by a number of guidelines., The 2012 ACCP guidelines did not provide a detailed comparison of the effectiveness of graduated compression stockings and pneumatic compression stockings, but they generally favor pneumatic compression stockings on the basis of indirect evidence, from the Clots in Legs or Stockings after Stroke trial for patients with stroke, that elastic stockings increased the risk of skin complications without reducing the risk of VTEs. Other guidelines presented by SIGN, NICE, the American Academy of Orthopedic Surgeons , the Neurocritical Society, and the International Union of Angiology discuss the use of pneumatic compression and graduated compression stockings in various surgical settings but generally consider these modalities together as mechanical devices and do not offer a direct comparison of their effectiveness or safety other than noting that graduated compression stockings cannot be used for patients with certain lower extremity pathologies.

When Do You Start Dvt Prophylaxis After Hip Surgery

PRACTICE PATTERNS IN PROPHYLAXIS OF DEEP VEIN THROMBOSIS AMONG US ...

According to evidence-based guidelines, patients undergoing total hip or total knee arthroplasty should receive anticoagulant prophylaxis for at least 14 days after surgery and for up to 35 days after surgery.

Bimonthly ELIQUIS dosed for DVT protection, which can lead to pulmonary embolism. Hip replacement surgery should be performed at a dose of 2.5 mg twice daily for a period of 35 days. The dose should be taken after knee replacement surgery in the hours after it is administered. Coadministration with other P-GP and CYP3A4 inhibitors is not recommended. The recommended dose adjustment for patients with end-stage renal disease on diabetic nephritis is not recommended for those receiving treatment for DVT, PE, or prevention of recurrent DVT and PE after initial therapy. Adjust ELIQUIS dose for patients taking medications that combine P-GP and CYP3A4 inhibitors. Because of the combination of P-GP and CYP3A4 inhibitors , the risk of stroke and otherthrombotic events increases.

In patients with nonvalvular atrial fibrillation , eliqus has been shown to reduce stroke and systemic embolism risk. This medication is used to prevent deep vein thrombosis in patients who have recently had hip or knee replacement surgery. Refrain from making any undue assumptions about a patients neurological condition because they may show signs of neurological impairment.

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Accp Recommendations For Major Orthopedic Surgery And Knee Arthroscopy

In 2012, the American College of Chest Physicians issued recommendations for VTE prevention in orthopedic surgery patients, based on the ninth edition of its evidence-based clinical practice guidelines for antithrombotic therapy and prevention of thrombosis.

Recommendations for patients undergoing major orthopedic surgery included the following :

In patients undergoing knee arthroscopy who do not have a prior history of VTE, no thromboprophylaxis was recommended.

The 2016 updates for the 10th edition of the ACCP guidelines did not contain significant changes with regard to VTE prophylaxis in orthopedic surgery.

Preventing Deep Vein Thrombosis After Hip Replacement Surgery

Deep vein thrombosis is a blood clot that forms in a vein, usually in the leg. A DVT can cause pain, swelling, and redness in the affected area. It can also lead to serious complications, such as pulmonary embolism , which is when the clot breaks loose and travels to the lungs. DVT is a serious condition that can be prevented with prophylactic measures. The most common DVT prophylaxis for hip replacement is mechanical compression, which is the use of compression devices, such as graduated compression stockings or intermittent pneumatic compression devices, to reduce the risk of DVT.

Oral anticoagulants, such as XARELTO, have a higher risk of thrombotic events when taken in excess of the recommended time. Epidural or spinal hematomas have occurred in patients who have received neuraxial anesthesia or have had spinal punctures. There is no evidence that children under the age of one have elevated serum creatinine levels above 97.5% in clinical studies. It is also approved for the treatment of venous thromboembolism and the reduction in the risk of recurrent VTE in pediatric patients who have never had any prior experience of venous thromboembolism. XARELTO was approved by the FDA in July 2012. This medication is also used in children with congenital heart disease who have undergone the Fontan procedure.

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International Consensus Meeting On Venous Thromboembolism Prevention In Orthopedic Surgery

Cite as: Cozowics C, Memtsoudis S. International consensus meeting on venous thromboembolism prevention in orthopedic surgery. ASRA Pain Medicine News 2022 47. https://doi.org/10.52211/asra110122.044

Venous thromboembolism involves deep venous thrombosis and pulmonary embolism and is a significant complication of orthopedic surgery.1,2 Primary prevention, initiated during hospitalization, is key to mitigating and managing the significant related disease burden.2

The International Consensus Meeting convened a multidisciplinary task force of nearly 600 renowned experts from 68 countries to evaluate the issue of perioperative thrombosis in orthopedic surgery and to specifically inform best clinical practices with evidence-based guideline recommendations to prevent and manage perioperative VTE. The experts reviewed nearly 100 important patient healthcare questions using systematic, quantitative, and qualitative analyses and followed a consensus process using the Delphi method to develop recommendations that comprehensively address the broad spectrum of perioperative VTE implications. It was the most comprehensive project on preventing perioperative VTE to date.

Oral Options For Vte Prophylaxis After Orthopedic Surgery

DVT Prophylaxis

Jessica L. Johnson, PharmD, BCPSClinical Assistant Professor of PharmacyXavier University of Louisiana

Treavor T. Riley, PharmD, BCPSClinical Pharmacy ManagerJackson, Mississippi

US Pharm. 2012 37:HS-8-HS-11.

Venous thromboembolism occurs when a blood clot, or thrombus, occludes venous blood flow. VTE comprises deep venous thrombosis , in which the thrombus forms in the distal vein of the leg or arm, and pulmonary embolism , which involves the lung. While DVT may be asymptomatic, it also can cause pain and swelling in the limb. Further, the thrombus may dislodge, travel to the lungs, and block the pulmonary vasculature, causing a potentially fatal PE. Other adverse consequences of VTE include costs associated with investigating symptomatic patients, costs and risks associated with VTE treatment, increased risk of future VTE, and the possibility of postthrombotic syndrome .1-3

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Timing Of Antithrombotic Prophylaxis

Question: Should extended antithrombotic prophylaxis vs short-term antithrombotic prophylaxis be used for patients undergoing major surgery?

For patients undergoing major surgery, the ASH guideline panel suggests using extended antithrombotic prophylaxis over short-term antithrombotic prophylaxis . Remark: Extended prophylaxis was generally considered as beyond 3 weeks , and short-term prophylaxis was considered as up to 2 weeks .

Summary of the evidence

We identified 9 systematic reviews addressing this research question. We identified 14 studies in these reviews that fulfilled our inclusion criteria and measured outcomes relevant to this context. Our systematic search of RCTs identified 6 additional studies not included in previous systematic reviews that fulfilled the inclusion criteria.

Seventeen studies reported the effect of extended vs short-term duration of pharmacological thromboprophylaxis on the development of mortality,,, 17 studies reported the effect on the development of PEs,, 18 studies reported the effect on the development of proximal DVTs,, 14 studies reported the effect on the development of distal DVTs,,,, 16 studies reported the effect on the risk of major bleeding,, and 6 studies reported the effect on the risk of reoperation. In general, these studies compared shorter courses of pharmacological prophylaxis with extended courses of pharmacological prophylaxis and then followed patients for a common period for VTE and bleeding complications.

Benefits

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