It further suggests against placement of an IVC filter for primary VTE prevention, as well as against periodic surveillance with venous compression ultrasound. If DVT is âunlikelyâ, refer for Dâdimer test. For the subset of patients undergoing TURP for whom pharmacological prophylaxis is used, the ASH guideline panel suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). For patients undergoing laparoscopic cholecystectomy, the ASH guideline panel suggests against using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). It was recognized that patients at high risk for major bleeding were excluded from the studies that formed the basis of this recommendation. Pharmacological prophylaxis vs no pharmacological prophylaxis, 16. LMWH may result in little or no difference in symptomatic PEs (RR, 0.20; 95% CI, 0.01-4.03; low certainty in the evidence of effects) compared with UFH following major neurosurgical procedures. This corresponds to 10 fewer (0-14 fewer) symptomatic proximal DVTs per 1000 patients based on a baseline risk of 1.6% from observational data.73 It may reduce symptomatic distal DVTs (RR, 0.57; 95% CI, 0.36-0.90; low certainty in the evidence of effects), which corresponds to 1 fewer (0-1 fewer) symptomatic distal DVT per 1000 patients undergoing major general surgery based on a baseline risk of 1.6% from observational data.73. They determined that there was very low certainty evidence for any net health benefit/harm from using ASA vs anticoagulants. Pharmacological prophylaxis may also reduce the risk of proximal DVTs (RR, 0.51; 95% CI, 0.38-0.69; very low certainty in the evidence of effects), which corresponds to 7 fewer (4-9 fewer) in 1000 higher-risk patients and 3 fewer (2-4 fewer) in 1000 lower-risk patients. Based primarily on the very low baseline risk of VTE following TURP, the panel judged that the balance of effects ultimately favored not using pharmacological prophylaxis. Six studies49,125,278,285,287,290 reported the effect on development of screening-detected proximal DVTs, and 6 studies124,277,283,284,286,289 reported the effect on development of screening-detected distal DVTs. In February 2016, an update to the ninth edition of the antithrombotic guideline from the American College of Chest Physician (ACCP) was published and included updated recommendations on 12 topics in addition to three new topics. In this case, the recommendation was sufficiently supported by the favorable impact on desirable effects for which there was higher quality evidence. Some members of the guideline panel were members of ASH. Five studies assessed the effect of LMWH,68,128,130,135,362 4 studies assessed the effect of UFH,359,361-363 1 study assessed the effect of warfarin,124 and 1 study assessed the effect of heparin-dihydroergotamine.360 Additionally, across the 10 studies, mechanical prophylaxis was used as a cointervention in 6 of the randomized studies68,123,128,130,135,359 and in all 3 of the nonrandomized studies.361-363 Supplement 6 presents the characteristics of all included studies. The panel recognized the very low certainty in comparative evidence, which was based on three small RCTs that did not report symptomatic DVT outcomes. All studies included surgical patients. Pharmacological prophylaxis vs no pharmacological prophylaxis, 21. DVT Treatment Procedures. Taking into consideration the very low certainty in the evidence, the panel judged that LMWH or UFH prophylaxis could be recommended following hip fracture repair. 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. This would be expected to result in 6 more (3 fewer to 20 more) major bleeds per 1000 patients. The panel judged the costs associated with pneumatic compression prophylaxis to be moderate based on very low certainty in the evidence about resource requirements, with no available studies explicitly addressing this question. ASA may lead to a small increased risk for major bleeding (RR, 2.63; 95% CI, 0.64-10.79; low certainty in the evidence of effects). Controlled clinical trial in 632 patients using 125I-fibrinogen uptake test and lung perfusion scans in patients with deep venous thrombosis, Drug prevention of postoperative deep vein thrombosis. We identified 2 systematic reviews of RCTs272,303 addressing this research question. Remark: Patients undergoing an extended node dissection and/or open radical prostatectomy may have a higher VTE risk and may potentially benefit from pharmacological prophylaxis. 17-EHC021-EF, Prevention of venous thromboembolic disease following primary total knee arthroplasty. A randomised controlled trial, The prevalence of deep venous thrombosis after total hip arthroplasty with hypotensive epidural anesthesia, Prevention of deep venous thrombosis in arthroplastic surgery of the hip by the combination of heparinotherapy and the antithrombosis stocking [in French], The efficacy of pneumatic compression stockings in the prevention of pulmonary embolism after cardiac surgery, Effects of a foot pump on the incidence of deep vein thrombosis after total knee arthroplasty in patients given edoxaban: a randomized controlled study, Intermittent pneumatic leg compression (IPLC) and unfractionated heparin (UFH) in the prevention of post-operative deep vein thrombosis in hip surgery: a randomized clinical trial, Prophylaxis against deep venous thrombosis after total knee arthroplasty. A recent large RCT supports our recommendation that ASA or anticoagulants be used for VTE prophylaxis following total hip or knee arthroplasty. A multicenter trial [published correction appears in, Groote Schuur Hospital Thromboembolus Study Group, Failure of low-dose heparin to prevent significant thromboembolic complications in high-risk surgical patients: interim report of prospective trial, Trial of a single low dose of heparin in the prevention of post-operative deep-vein thrombosis monitored by doppler ultrasound, Minidose heparin in transurethral prostatectomy, The effect of major surgery, low doses of heparin and thromboembolism on plasma antithrombin. The recommendation applies to patients undergoing major surgery who are considered at risk for VTE. 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. We identified 3 studies386-388 in these reviews that fulfilled our inclusion criteria and measured outcomes relevant to this context. However, such comparative studies are not regarded as high priority at this time. Pharmacological prophylaxis may slightly increase the risk of major bleeding (RR, 1.24; 95% CI, 0.87-1.77; low certainty in the evidence of effects). The overall certainty of the estimates of effects was based on the low certainty outcomes and was not based on the lowest certainty of evidence for the critical outcomes. We identified 6 studies in this review that fulfilled our inclusion criteria and measured outcomes relevant to this context.68,123,128,359-361 Our update of the systematic review identified 1 additional study that fulfilled the inclusion criteria.135 We additionally searched for and identified 3 nonrandomized studies that informed this question.362-364 All studies included patients undergoing neurosurgical procedures. This recognition has led to the urgent need for practical guidance regarding prevention, diagnosis, and treatment of VTE. We identified 7 systematic reviews addressing this question.23-26,28,29,31 We identified 19 studies in these reviews that fulfilled our inclusion criteria and measured outcomes relevant to this context.36,60,62,68,70,104-117 Our systematic search of RCTs did not identify any additional study that fulfilled the inclusion criteria. Mechanical prophylaxis combined with pharmacological prophylaxis vs mechanical prophylaxis alone, 6. These studies should include detailed clinical characteristics of the patient populations. IVC filter use may increase mortality slightly (RR, 1.38; 95% CI, 0.81-2.37; very low certainty in the evidence of effects), although the confidence interval was wide and included the possibility of no increase. You We are uncertain about the effect of pharmacological prophylaxis on mortality following major trauma (RR, 0.95; 95% CI, 0.84-1.07; very low certainty in the evidence of effects). Question: Should early vs delayed antithrombotic prophylaxis be used for patients undergoing major surgery? This corresponds to 4 fewer (1-6 fewer) pulmonary embolic events per 1000 patients undergoing major general surgery. In this group, the panel judged the desirable effects of pharmacological prophylaxis as trivial and undesirable effects as small. Diagnosis and treatment of pulmonary embolism and deep vein thrombosis Patients with a score ≤0 were at low risk (≤4.5%) and those with a score ≥1 were at high (≥19%) risk of VTE recurrence over the first 6 months. The panel determined that there was possibly important uncertainty or variability in how much affected individuals might value the main outcomes. These guidelines may not include all appropriate methods of care for the clinical scenarios described. A comparison between unfractionated and low-molecular-weight heparin, Prevention of deep vein thrombosis after elective hip surgery. Overall, the balance of effects did not favor LMWH or UFH, nor did cost-effectiveness or issues surrounding equity, acceptability, and feasibility, at least for inpatient prophylaxis. Our experience in 88 cases [in Italian], Effectiveness and side effects of low-molecular weight heparin-dihydroergotamine in preventing thromboembolism in abdominal surgery [in German], Effect of low molecular weight heparin (Certoparin) versus unfractionated heparin on cancer survival following breast and pelvic cancer surgery: A prospective randomized double-blind trial, Antithrombotic defense during the postoperative period. A randomized, controlled clinical study [in German], Venous thrombosis after abdominal surgery. You'll also have a physical exam so that your doctor can check for areas of swelling, tenderness or discoloration on your skin. The certainty was categorized into 4 levels ranging from very low to high.5,6,14. The purpose of these guidelines is to provide evidence-based recommendations about the prevention of VTE for patients undergoing major surgical procedures. A placebo-controlled study, Deep vein thrombosis in elderly Hong Kong Chinese with hip fractures detected with compression ultrasound and Doppler imaging: incidence and effect of low molecular weight heparin, Prevention of thromboembolism in hip-fracture patients. In addition to synthesizing evidence systematically, the McMaster GRADE Centre supported the guideline-development process, including determining methods, preparing agendas and meeting materials, and facilitating panel discussions. Potential harms included reduced mobility, and pneumatic compression prophylaxis may be uncomfortable. Our systematic search for RCTs identified 3249,122,125,131,274,276-302 additional studies that fulfilled the inclusion criteria, including patients undergoing major general surgery. For patients at high risk for VTE, addition of mechanical prophylaxis to pharmacological prophylaxis is suggested when not contraindicated by lower extremity injury. Studies evaluated included patients with cancer and without cancer. If the Dâdimer level is normal, DVT can be excluded; if the Dâdimer level is increased, refer for compression ultrasound. We identified 1 systematic review that addressed this question.236 We identified 12 trials in this review that fulfilled our inclusion criteria and measured outcomes relevant to this context.242-253 Our systematic search of RCTs did not identify any additional study that fulfilled the inclusion criteria. Question: Should LMWH vs UFH prophylaxis be used for patients undergoing major gynecological surgery? Prophylaxis with LMWH vs UFH probably does not reduce mortality following major general surgery (RR, 1.03; 95% CI, 0.89-1.18; moderate certainty in the evidence of effects). Based on overall very low certainty in the evidence, the panel judged that the desirable effects of pharmacological prophylaxis were outweighed by the undesirable effects, specifically the increased risk of bleeding in this setting. ASH staff supported panel appointments and coordinated meetings but had no role in choosing the guideline questions or determining the recommendations. Eur Heart J 2019;Aug 31:[Epub ahead of print]. Cost-effectiveness probably favors extended-duration prophylaxis. There was possibly important uncertainty or variability in how much affected individuals valued the main outcomes. 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). For patients considered at very high risk of postoperative VTE and at low bleeding risk, high-quality comparative studies of LMWH vs UFH using clinically important outcome measures would be of value. For patients undergoing radical prostatectomy in whom pharmacological prophylaxis is used, the ASH guideline panel suggests using either LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects, (⊕◯◯◯). Further research into pharmacological prophylaxis following laparoscopic cholecystectomy was not regarded as high priority given the low baseline incidence of VTE complications in this patient population. A widely used high-quality guideline is the 2012 Guideline of the American College of Chest Physicians (ACCP), which places a strong emphasis on patients’ VTE risk scores.398 In the guideline recommendations for VTE prevention in nonorthopedic surgical patients, patient-oriented VTE risk calculators, such as the Caprini score10 and Rogers score,399 were adopted. We rated the overall certainty in the evidence of effects as low based on the lowest certainty in the evidence for the critical outcomes, downgrading for very serious imprecision. The panel also advises periodic monitoring of the platelet count for patients receiving LMWH and, in particular, UFH, as postoperative prophylaxis in consideration of the risk of heparin-induced thrombocytopenia. The panel determined that there was probably important uncertainty or variability in how much affected individuals value the main outcomes. During deliberations, panel members with a current direct financial interest in a commercial entity with any product that could be affected by the guidelines participated in discussions about the evidence and clinical context but were recused from making judgments or voting about individual domains (eg, magnitude of desirable consequences) and the direction and strength of relevant recommendations.4,18-20 The Evidence-to-Decision (EtD) framework for each recommendation describes which individuals were recused from making judgments about each recommendation. The panel rated the magnitude of the desirable and undesirable effects of using LMWH over UFH as trivial. We identified 1 systematic review254 that addressed, in part, this question. For new reviews, risk of bias was assessed at the health outcome level using the Cochrane Collaboration’s risk of bias tool for randomized trials or nonrandomized studies. The panel was particularly interested in seeing future high-quality studies of early vs late pharmacological prophylaxis studies in high-risk bleeding patients, examining the benefits and risks of later intervention (days following surgery) once the bleeding risk had greatly subsided. Question: Should LMWH prophylaxis vs UFH prophylaxis be used for patients undergoing hip fracture repair? There were no concerns about the feasibility of implementation. For patients undergoing major surgery, the ASH guideline panel suggests using pharmacological prophylaxis or mechanical prophylaxis (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯). As science advances and new evidence becomes available, recommendations may become outdated. Because of the paucity of studies related to TURP, data across all major general, urological, and gynecological surgical procedures were pooled, and TURP-specific baseline risk estimates were applied, where available. However, higher priority would be comparative studies of different antithrombotic regimens for the prevention of VTEs in these patients requiring repair of hip fracture. 122, National Institute for Health and Care Excellence, Venous Thromboembolism in Over 16s: Reducing the Risk of Hospital-Acquired Deep Vein Thrombosis or Pulmonary Embolism. There may also be no difference in symptomatic PEs (RR, 0.56; 95% CI, 0.17-1.86; low certainty in the evidence of effects). We are very uncertain whether pharmacological prophylaxis results in little or no difference in reoperation (RR, 0.93; 95% CI, 0.35-2.50; very low certainty in the evidence of effects); this corresponds to 1 fewer (8 fewer to 18 more) reoperation per 1000 patients. The International Consensus Statement on Prevention and Treatment of Venous Thromboembolism published by the European Venous Forum, in cooperation with several other organizations, offers guidelines for general, vascular, bariatric, and plastic surgical patients.403 Major vascular surgery was considered with other “major surgery,” and patients were judged to generally be at moderate risk in the absence of specific high-risk characteristics, such as age older than 60 years or prior VTE. Patients undergoing open radical prostatectomy with lymph node dissection were considered at higher risk for VTEs and bleeding. Surgical procedures carrying the highest risk of developing postoperative VTE include hip and knee arthroplasty, invasive neurosurgical procures, and major vascular procedures.9, 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. We rated the overall certainty in the evidence of effects as very low based on the lowest certainty in the evidence for the critical outcomes, downgrading for study limitations and very serious imprecision. The panel assessed that this recommendation probably would have no impact on health equity and would be acceptable to stakeholders. The analysis indicated no subgroup effect with regard to desirable and undesirable effects comparing ASA with anticoagulant prophylaxis. When pharmacological prophylaxis is used, the panel suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). The EtD framework is available online at https://guidelines.gradepro.org/profile/D32EF371-AE1E-1ACF-82CD-E11528E7B8E0. • Patients with established deep vein thrombosis (DVT). Depending on baseline risk,73 this corresponds to 4 fewer (1-6 fewer) deaths per 1000 patients with a baseline risk of 0.8% and 6 fewer (2-9 fewer) deaths per 1000 patients with a baseline risk of 1.1% receiving extended pharmacological prophylaxis. A double-blind multicenter trial, Prevention of fatal postoperative pulmonary embolism by low doses of heparin. Please refer to our, Statistics, epidemiology and research design, View AHRQ Publication No. In formulating this recommendation, the panel formally acknowledges its prior conditional recommendation against pharmacological prophylaxis (Recommendation 19) for patients undergoing neurosurgical procedures. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. 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