THROMBOPROPHYLAXIS: NON-ORTHOPEDIC SURGERY

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1 THROMBOPROPHYLAXIS: NON-ORTHOPEDIC SURGERY OBJECTIVE: To outline a practical approach for the prevention of venous thromboembolism (VTE) in patients undergoing non-orthopedic surgery. BACKGROUND: VTE is a common and yet generally preventable cause of post-operative morbidity and mortality. The use of elastic compression stockings (ECS), intermittent pneumatic compression (IPC), low-dose unfractionated heparin (LDH), and low molecular weight heparin (LMWH), combined with early ambulation, have all been shown to reduce post-operative VTE to varying degrees in patients undergoing surgery. THROMBOPROPHYLAXIS APPROACHES IN NON-ORTHOPEDIC SURGERY: Thromboprophylaxis decisions rely on a consideration of the balance in the risks of VTE and bleeding which are affected by procedure-specific and patient-specific factors. Two general approaches to thromboprophylaxis in patients undergoing non-orthopedic surgery exist. A. Group-based: This approach provides standard thromboprophylaxis to all patients who belong to a large group (e.g. abdominal-pelvic surgery, spine surgery, etc) unless there is a specific patient contraindication. This simple and effective approach has been adopted by The Canadian Patient Safety Institute and is shown in the Table 1 below. [see also: B. Individualized: This strategy is based on individual patient risk assessment using a formal risk assessment model such as the Caprini score. This approach has been adopted by the 2012 American College of Chest Physicians (ACCP) guidelines. In general, the estimated VTE risk and thromboprophylaxis recommendations using this approach are similar to the group-based approach. The risk of bleeding, which has not been validated in a formal model for surgical patients, also depends on patient-related and procedure-related factors. In general, patients at moderate and high VTE risk with a usual low bleeding risk should receive anticoagulant thromboprophylaxis. When such patients have a high bleeding risk, they should receive mechanical thromboprophylaxis with IPC or ECS Thrombosis Canada Page 1 of 5

2 TABLE 1: THROMBOPROPHYLAXIS RECOMMENDATIONS BASED ON SURGICAL GROUP 1 PATIENT GROUP RECOMMENDED THROMBOPROPHYLAXIS OPTIONS 2,3 INITIATION DURATION 4 High bleeding risk 5 Heparin-induced thrombocytopenia (HIT) (current or previous) Burn patients Cardiovascular surgery General surgery Gynecology Properly-fitted, bilateral, calf-length ECS used continuously (except for bathing) Bilateral IPC devices used continuously (except for bathing and when patient actually walking) Suggest specialist referral No heparin or LMWH Fondaparinux 2.5 mg SC once daily Use Burn Patient order set, if available LMWH Use Cardiac Surgery or Vascular Surgery order set, if available Use General Surgery order set, if available For very high-risk patients, ECS or IPC started preop and used continuously along with LMWH For patients at high risk of bleeding, properly-fitted, bilateral calf-length ECS or IPC until LMWH can be started Use Gynecology order set, if available For very high-risk patients, ECS or IPC started preop and used continuously along with LMWH For patients at high risk of bleeding, properly-fitted, bilateral calf-length ECS or IPC until LMWH can be started ASAP after emergency admission Just prior to surgery for elective surgical procedures As soon as the diagnosis of HIT is considered When there is evidence of primary hemostasis When there is evidence of primary hemostasis 0-2 hour preop (if no epidural or liver resection surgery) or the evening of day of surgery or next AM if there are bleeding concerns 0-2 hour preop or the evening of day of surgery or next AM if there are bleeding concerns Until bleeding risk allows the use of anticoagulant prophylaxis Discharge and platelet count >120x10 9 /L For selected, high risk cancer patients continue LMWH for up to 30 days For selected, high risk cancer patients continue LMWH for up to 30 days 2016 Thrombosis Canada Page 2 of 5

3 PATIENT GROUP RECOMMENDED THROMBOPROPHYLAXIS OPTIONS 2,3 INITIATION DURATION 4 Neurosurgery Spinal cord injury Trauma Urology Use Neurosurgery order set, if available Select one of the following options: For patients at high risk of bleeding IPC or properly-fitted, bilateral calf-length ECS LMWH Start with IPC or bilateral calf-length ECS and switch to LMWH when risk of bleeding decreases Use Spinal Cord Injury order set, if available For patients at high risk of bleeding, IPC or properly-fitted, bilateral calf-length ECS until LMWH can be started Use Trauma order set, if available For patients at high risk of bleeding, IPC or properly-fitted, bilateral calf-length ECS until LMWH can be started Use Urology order set, if available For patients at high risk of bleeding, IPC or properly fitted, bilateral, calf-length ECS until LMWH can be started For IPC or ECS, start just prior to surgery for elective procedure and ASAP after admission for major neurotrauma or nontraumatic intracranial hemorrhage For LMWH, no sooner than the day after surgery ASAP after admission For LMWH, once hemostasis is evident ASAP after admission For LMWH, once hemostasis is evident 0-2 hour preop or the evening of day of surgery or next AM if there are bleeding concerns from hospital including rehab from hospital including rehab Abbreviations: ASAP = as soon as possible; ECS = elastic compression stockings; LMWH = low molecular weight heparin Footnotes to the Table: 1. Modified from the Canadian Patient Safety Institute, Venous Thromboembolism Prevention Getting Started Kit. Not every patient group is included here use the recommendations for the group on the list that is most similar to the group of interest consistent with local policy. 2. For all patients in whom it is possible and appropriate, early and frequent mobilization and ambulation are essential. 3. Although the recommended options apply to most patients in each risk group, individual patient factors may suggest an alternate approach. 4. The duration of thromboprophylaxis is not based on mobility status alone. 5. Absolute contraindications to anticoagulant thromboprophylaxis are: active, clinically-important bleeding, platelets < /L, major bleeding disorder. Relative contraindications to anticoagulant thromboprophylaxis are: recent intracranial hemorrhage, recent perispinal bleeding, and recent high bleeding risk surgery Thrombosis Canada Page 3 of 5

4 ANTICOAGULANT DOSING: LMWH usual doses: dalteparin 5,000 U SC once daily enoxaparin 40 mg SC once daily tinzaparin 4,500 U SC once daily LMWH for weight <40 kg (reduce to next lower pre-filled syringe dose): dalteparin 2,500 U SC once daily enoxaparin 30 mg SC once daily tinzaparin 2,500 U SC once daily (~75 U/kg) LMWH for weight >100 kg (double the usual dose): dalteparin 5,000 U SC BID enoxaparin 40 mg SC BID tinzaparin 4,500 U SC BID (~75 U/kg) LMWH with severe renal dysfunction (CrCl <30 ml/min): enoxaparin 30 mg SC once daily no dosage reduction for dalteparin or tinzaparin Low dose heparin is usually given as 5,000 U SC BID or TID (in higher risk patients). SPECIAL CONSIDERATIONS: It is suggested that every institution have a written policy for thromboprophylaxis and, where possible, that thromboprophylaxis be embedded into routinely used electronic or paper order sets. Start of thromboprophylaxis: For most elective non-orthopedic surgery patients in whom thromboprophylaxis is recommended, anticoagulant prophylaxis should start 0-2 hours preoperatively or 0-12 hours after the start of surgery. Duration of thromboprophylaxis: Although the optimal duration of thromboprophylaxis is not known for any non-orthopedic surgery group, patients with a moderate or high risk for VTE, thromboprophylaxis should be given at least until discharge from hospital. Extended-duration thromboprophylaxis (up to 30 days) may be considered in patients having major abdominal-pelvic cancer surgery. Direct oral anticoagulants: The use of direct oral anticoagulants (e.g. apixaban, dabigatran, edoxaban, rivaroxaban) has not been evaluated in the non-orthopedic surgical setting for thromboprophylaxis. Pediatrics: Evidence for the need for, safety and efficacy of thromboprophylaxis in neonates and children is lacking. However, there may be high-risk cohorts where thromboprophylaxis may be considered. Consultation with a pediatrician or hematologist with expertise in pediatric thrombosis is recommended Thrombosis Canada Page 4 of 5

5 OTHER RELEVANT THROMBOSIS CANADA CLINICAL GUIDES: Thromboprophylaxis: Orthopedic Surgery Unfractionated Heparin and Low-molecular-weight Heparin REFERENCES: Canadian Patient Safety Institute. Venous Thromboembolism Prevention. Getting Started Kit [ ] Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon 2005;51(2-3): Gould MK, et al. 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 2012;141(2 Suppl):e227S-277S. Date of Version: 2016Dec07 Please note that the information contained herein is not to be interpreted as an alternative to medical advice from your doctor or other professional healthcare provider. If you have any specific questions about any medical matter, you should consult your doctor or other professional healthcare providers, and as such you should never delay seeking medical advice, disregard medical advice or discontinue medical treatment because of the information contained herein Thrombosis Canada Page 5 of 5