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Chapter 67. Prevention of Venous Thromboembolism (VTE)

Jessica Spellman, MD

  • Venous thromboembolism (VTE) represents a major preventable cause of perioperative morbidity (postphlebitic syndrome) and mortality (fatal pulmonary embolism [PE])
  • Cost-effectiveness of thromboprophylaxis as well as little or no increase in clinically important bleeding with prophylactic doses has been demonstrated

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Risk Factors for VTE
  • Surgery
  • High estrogen states (pregnancy and postpartum, OCPs, HRT, estrogen receptor modulators)
  • Major trauma or lower extremity injury
  • Erythropoiesis-stimulating agents
  • Immobility
  • Myeloproliferative disorders
  • Cancer and cancer therapy
  • Acute medical illness
  • Venous compression
  • Inflammatory bowel disease
  • Prior VTE
  • Nephrotic syndrome
  • Age >60 years
  • Paroxysmal nocturnal hemoglobinuria
  • Obesity
  • Thrombophilia (inherited or acquired)
  • Central venous catheterization

Surgical patients can be generalized into groups based on level of risk for VTE.

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Risk Level for VTE Based on Surgery
Risk levelPatient groupRisk of DVT without prophylaxis (%)
LowMinor surgery in mobile patients<10
ModerateMost general, open gynecologic or urologic surgery patients10–40
High
  • Hip or knee arthroplasty
  • Hip fracture surgery
  • Major trauma
  • Spinal cord injury
40–80
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Thromboembolism Prophylaxis Recommendations for Level of Risk of VTE from the American College of Chest Physicians (ACCP), 2008
Risk levelSuggested thromboprophylaxis options
Low
  • No specific thromboprophylaxis
  • Early and “aggressive” ambulation
Moderate
  • LMWH
  • LDUH bid or tid
  • Fondaparinux
Moderate with high bleeding risk
  • Mechanical thromboprophylaxis
  • Consider anticoagulant thromboprophylaxis when high bleeding risk decreases
High
  • LMWH
  • Fondaparinux
  • Oral vitamin K antagonist (INR 2–3)
High with high bleeding risk
  • Mechanical thromboprophylaxis
  • Consider anticoagulant thromboprophylaxis when high bleeding risk decreases

LMWH, low-molecular-weight heparin; LDUH, low-dose unfractionated heparin.

If additional risk factors are present (see Table of Risk Factors for VTE), consideration should be given to increasing the intensity or duration of prophylaxis.

Table 67-1 Mechanical Thromboprophylaxis Strategies
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Table 67-1 Mechanical Thromboprophylaxis Strategies
  • Early and frequent ambulation
  • Graduated compression stockings (GCS)
  • Intermittent pneumatic compression devices (IPC)
  • Venous foot pump (VFP)

  • Generally less efficacious than anticoagulant thromboprophylaxis
  • Important in high bleeding risk patient groups (if high bleeding risk resolves, consideration should be made for anticoagulant thromboprophylaxis)
  • Useful as adjunct to anticoagulant thromboprophylaxis
  • Devices are nonstandardized and may lack demonstrative evidence of efficacy prior to marketing
  • Patient compliance often poor (recommended to be worn 18 and 20 hours a day)
  • Greater effect shown on calf DVT than proximal DVT, effect on PE and death unknown
  • Should be initiated prior to induction of anesthesia and continued postoperatively

See following table.

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Anticoagulant Thromboprophylaxis
AgentLDUH—low-dose unfractionated heparinLMWH—low-molecular-weight heparin (enoxaparin, dalteparin)
Mechanism of actionBinds antithrombin III, inactivates factor Xa and thrombinSelectively inhibits factor Xa
Notes (including neuraxial block recommendations)Risk of heparin-induced thrombocytopenia (HIT)
  • No contraindication to neuraxial blockade, best to delay dose ...

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