American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients

Abstract

Background:Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality.Objective:These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery.Methods:ASH formed a multidisciplinary guideline panel balanced to minimize bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic reviews. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment.Results:The panel agreed on 30 recommendations, including for major surgery in general (n = 8), orthopedic surgery (n = 7), major general surgery (n = 3), major neurosurgical procedures (n = 2), urological surgery (n = 4), cardiac surgery and major vascular surgery (n = 2), major trauma (n = 2), and major gynecological surgery (n = 2).Conclusions:For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH). For major general surgery, the panel suggested pharmacological prophylaxis over no prophylaxis, using LMWH or unfractionated heparin. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. For major trauma surgery or major gynecological surgery, the panel suggested pharmacological prophylaxis over no prophylaxis.

What’s new in VTE risk and prevention in orthopedic surgery

“…Results of these trials have informed guideline panels to recommend extended duration prophylaxis (up to 28-35 days) after major orthopedic surgery. 5,11,12 Recent studies have suggested that overall rates of VTE after major orthopedic surgery are falling. A study from a national database from England and Wales of 10-year trends (2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014) in medical complications in 540 623 patients undergoing THA found that despite a population with increasing levels of comorbidity, the 90-day mortality rate decreased from 0.60% to 0.15%, the 30-day DVT rate decreased from 1.15% to 0.28%, and the 30-day PE rate decreased from 0.77% to 0.40%.…”

Cancer‐associated venous thromboembolism: Treatment and prevention with rivaroxaban

“…In some clinical circumstances, DOACs are used in VTE prophylaxis in patients without cancer . Studies specific to VTE prevention in patients with cancer were warranted, given the benefits observed with LMWH for the prevention of CAT in ambulatory patients receiving systemic anticancer therapy in the SAVE‐ONCO (Evaluation of AVE5026 in the Prevention of VTE in Cancer Patients Undergoing Chemotherapy) and PROTECHT (PROphylaxis of ThromboEmbolism during CHemoTherapy) trials .…”

Profilaxia do tromboembolismo venoso nas cirurgias do tornozelo e do pé

“…48,49 Still, none of these drugs were approved for use in proximal femur and hip fractures. 4,7,50 Despite the approval of the use of DAOAs in major orthopedic surgeries, current data refer only to rivaroxaban for VTE prophylaxis in surgeries below the level of the knee. In a randomized study with 3,604 patients treated with 40 mg of subcutaneous enoxaparin or 10 mg of oral rivaroxaban, both administered once a day, rivaroxaban was more effective in preventing VTE than enoxaparin (RR: 0.25; 95%CI: 0.09 to 0.75), with no increased risk of bleeding.…”

“…3 Most data on VTE prevention in orthopedics relates to major orthopedic surgeries, such as knee and hip arthroplasties. [4][5][6] The main guidelines on the subject refer to objective recommendations for surgical prophylaxis, 1,4,7 including clear definitions on the type of drug and the duration of the treatment.…”

“…9 The most recent reccomendation of the American Society of Hematology does not mention ankle and foot injuries at all. 7 The present review aims to present data on the incidence of VTE in ankle and foot surgeries, to identify the main risk factors in these scenarios, and to discuss the tools for the prediction of the risk and the alternatives for thromboprophylaxis.…”