Aggressive Anticoagulation after TJA: An Evaluation of the ACCP Guidelines for Thromboprophylaxis

Abstract

Thromboembolic disease is common after orthopaedic surgery. In an effort to minimize the risk of pulmonary embolism and deep vein thrombosis (DVT), anticoagulation administration has become a common practice. Both the American College of Chest Physicians (ACCP) and the American Association of Orthopaedic Surgeons (AAOS) have published guidelines recommending antithrombotic protocols. The ACCP guidelines are excessive and do not adequately evaluate the complications resulting from aggressive anticoagulation. These complications include, but are not limited to, major and minor bleeding events, thrombocytopenia, subsequent periprosthetic infection, and complications with spinal or epidural anesthesia. The AAOS guidelines generated by a group of orthopedic surgeons evaluate the efficacy of various agents in preventing pulmonary embolus and not distal DVT. They differ from the AACP guidelines in some aspects. The AAOS guidelines accept the use of aspirin combined with mechanical compression devices, and low-dose warfarin therapy. We believe that the AAOS guidelines for thromboprophylaxis take into account all risks associated with anticoagulation therapy and may prove to be a safer option for our patients.

Aspirin: An Alternative for Pulmonary Embolism Prophylaxis After Arthroplasty?

“…It also has a narrow therapeutic index and undergoes hepatic metabolism, making its onset, duration, and offset of action unpredictable. Excessive and therapeutic anticoagulation are associated with increased rates of minor and major bleeding, prolonged wound drainage, and periprosthetic joint infection [30,31]. Sachs et al [37] found twice as many wound problems (including superficial and deep infections and wound necrosis) in patients receiving warfarin postoperatively when compared to a control group not receiving any form of thromboprophylaxis after TKA.…”

The Use of Warfarin for DVT Prophylaxis Following Hip and Knee Arthroplasty: How Often Are Patients Within Their Target INR Range?

“…Patients must be discharged with a projected dose of warfarin and have their INR levels monitored closely as outpatients. While several studies have explored potential complications with the administration of warfarin (19, 21-23), to our knowledge none have followed the percentage of time that patients are actually within their targeted INR range during their post-operative course. Knowing the percentage of time that patients are actually within the recommended INR for therapeutic efficacy may further clarify the role of warfarin in the prevention of post-TJA complications and readmissions.…”

Timing of Symptomatic Pulmonary Embolism with Warfarin Following Arthroplasty

“…These include the intraoperative administration of heparin, the minimization of operative time, the use of regional anesthesia, the use of lower extremity sequential compression devices, the early mobilization of patients, and the use of pharmacologic anticoagulants [2][3][4]. Despite the success of these measures in reducing the incidence of postoperative VTE to approximately 1%, VTE prophylaxis is not without risk [3,5]. Specifically, studies have shown that the administration of aggressive anticoagulation agents such as low molecular weight heparin (LMWH) or warfarin may dramatically increase the risk of major and minor bleeding complications, including hematoma formation and prolonged wound drainage [3,5,6].…”

“…Despite the success of these measures in reducing the incidence of postoperative VTE to approximately 1%, VTE prophylaxis is not without risk [3,5]. Specifically, studies have shown that the administration of aggressive anticoagulation agents such as low molecular weight heparin (LMWH) or warfarin may dramatically increase the risk of major and minor bleeding complications, including hematoma formation and prolonged wound drainage [3,5,6]. The latter is not without consequence since it may lead to possible re-operation in the case of hematoma formation as well as an increased risk of infection in cases of prolonged wound drainage [7].…”