DVT/PE Prophylaxis

Committee Members

Ronald S. Adler, MD, PhD (Radiology)
Anne R. Bass, MD (Medicine)
Theodore R. Fields, MD (Medicine)
Steven B. Haas, MD (Orthopedics)
Michelle Horvath, RN (Patient Care and Quality Management)
Richard L. Kahn, MD (Anesthesia)
Jacqueline Kostic, RN (Nursing)
Steven K. Magid, MD (Medicine)
Stephen A. Paget, MD (Medicine)
Eduardo A. Salvati, MD (Orthopedics)
Andrew Sama, MD (Orthopedics)
Nigel E. Sharrock, MD (Anesthesia)
Geoffrey H. Westrich, MD (Orthopedics)

 

1. Introduction
2. Therapeutic Modalities
3. Regional Anesthesia
4. Hip Arthroplasty
5. Knee Arthroplasty
6. Staged Bilateral Arthroplasty
7. Hip Fracture
8. Spine Surgery
9. Knee Arthroscopy
10. Patients on the Medicine Service
11. Committee Follow Up

Introduction

The establishment of the Committee on DVT/PE Prophylaxis was triggered by an increase in the incidence of in-hospital postoperative pulmonary emboli (PE) from approximately 0.3% to 0.97% of inpatient surgeries in the third quarter of 2002 at the Hospital for Special Surgery (HSS). The increase in incidence occurred equally among knee, hip, and spine patients.

Creation of this committee was also motivated by a lack of consensus among the HSS medical and surgical attending staff as to the best approach to prophylaxis of venous thromboembolism (VTE) following orthopedic surgery. The committee was therefore asked to make evidence-based recommendations regarding VTE prophylaxis for patients hospitalized at HSS who are at high risk for VTE.

Support for the committee’s mandate has not been unanimous (although there is universal agreement that every person undergoing major orthopedic surgery should receive some form of prophylaxis). Some physicians have expressed concern that firm guidelines might be misused in a medico-legal setting. Others have argued that rates of VTE are so low at HSS that changes in the system are not necessary. The committee did find that rates of postoperative VTE at HSS are low, and comparable to those in the published literature from other institutions. Nonetheless, the recent increase in PE incidence necessitated an examination of the problem. In addition, surgeons at HSS who perform a small volume of joint arthroplasties, or manage a small number of fracture patients, for example, will benefit from the establishment of guidelines for VTE prophylaxis. There are also a number of "special instances" such as bilateral or staged arthroplasties, or complex spine cases, where the risk of VTE may be high and guidelines will be beneficial. Guidelines can also be helpful medico-legally. For example, these guidelines, supported by the published experience at HSS, allow for the use of aspirin alone as VTE prophylaxis in certain instances where the outside medical literature recommends warfarin or low molecular weight heparin (LMWH).

These guidelines are meant to provide a consistent, and evidence-based approach to the management of VTE prophylaxis at HSS. Guidelines are not meant to supersede clinical judgment, however, and may at times require tailoring to an individual patient. Thus, for example, an elderly patient undergoing joint arthroplasty who is felt to be at unacceptably high risk for bleeding on warfarin or LMWH, might be have to be treated with aspirin (assuming it is not contraindicated).

Therapeutic Modalities

(Note: The dosages below may need to be modified for pediatric patients.)

1. Aspirin (acetylsalicylic acid) irreversibly inactivates cyclooxygenase (COX) through acetylation. Inactivated COX is unable to catalyze the oxygenation of arachidonic acid to prostaglandin G2. Aspirin thereby blocks the formation of thromboxane A2, a mediator of platelet aggregation and vasoconstriction. Because platelets (which lack nuclei) are unable to synthesize new COX, aspirin blocks the function of platelets for the remainder of their lifetime, normally 7 to 10 days. Although platelet function remains impaired for 4 to 7 days after a single dose of aspirin, the prolonged bleeding time generally returns to normal within 24 to 48 hours of aspirin ingestion due to release of uninhibited platelets from the bone marrow.
   
   Aspirin predisposes to gastritis, peptic ulceration, and gastrointestinal bleeding by inhibiting cytoprotective prostaglandins in the stomach, and by inhibiting platelet function. Patients with a history of dyspepsia should receive enteric-coated aspirin. Those with a history of more significant gastrointestinal disease should receive H₂-blockers or proton pump inhibitors in conjunction with aspirin. Patients with a history of recent gastrointestinal bleeding should not receive aspirin.
   
   Patients given aspirin as postoperative VTE prophylaxis should receive 325mg daily for 4-6 weeks, starting the night of surgery.
   
   
2. Warfarin (Coumadin®) acts by inhibiting the synthesis of vitamin K-dependent clotting factors, which include Factors II, VII, IX and X, and the anticoagulant proteins C and S. An anticoagulation effect generally occurs within 24 hours after drug administration, however, peak antithrombotic effects may be delayed 72-96 hours. The duration of action of a single dose of warfarin is 2-5 days, and the response to warfarin may become more pronounced as the effects of daily maintenance doses begin to overlap.
   
   Warfarin is monitored using the International Normalized Ratio (INR) of the prothrombin time. Patients who are malnourished or who have received a recent course of antibiotics (both of which can result in vitamin K deficiency) often require lower than average dosages of warfarin. Postoperative patients, many of whom are not eating a normal diet, and have received perioperative antibiotics, tend to require lower dosages of warfarin than do typical outpatients receiving anticoagulation. In addition, elderly patients exhibit a greater than expected INR response to a given dose of warfarin. All of these issues must be considered when warfarin is prescribed for a patient postoperatively, and they have been factored into the recommendations below.
   
   Postoperative warfarin should be started the night of surgery and given daily thereafter (including postoperative day 1 (POD#1)) aiming for an INR 2-2.5.
   
   
   • The dose of warfarin on the night of surgery should be 5mg.
     
     
   • On POD#1 patients should receive warfarin 5mg unless they: are over age 70, are malnourished, have been on antibiotics preoperatively, or have an INR1.2-1.4, in which case they should receive warfarin 3mg. If the INR is greater than 1.5 on POD#1, then warfarin should be held.
     
     
   • Warfarin dosing starting on POD#2 should be guided by the daily INR.
     
     
   The exception to the above guidelines is for patients previously on chronic warfarin. These patients should resume their previously established dose of warfarin starting the night of surgery. A daily INR should be monitored in case dosage adjustments need to be made.
   
   Warfarin should be held if the INR is >3.0, or if there is active bleeding. Vitamin K₁ 1 mg should be given, via an oral or subcutaneous route, for an INR>6, in the absence of active bleeding. Higher doses of Vitamin K₁ (2.5-5mg) can be used if there is active bleeding. The use of Vitamin K₁ may make patients somewhat refractory to the reinstitution of warfarin. Infusion of fresh frozen plasma is a fast acting treatment, of shorter duration than vitamin K₁, which can also be used in the management of active bleeding.
   
   Aspirin and nonsteroidal anti-inflammatory agents (NSAIDS) should not be given to patients on warfarin. COX-2 inhibitors (such as Celebrex, Vioxx and Bextra) can be given concomitantly with warfarin, if such treatment is necessary.
   
   The duration of warfarin treatment following surgery should be at least 10 days (in the absence of complications). Continuation of treatment for a total of 4-6 weeks should be strongly considered since it will further reduce the incidence of VTE.
   
   Patients treated with warfarin after a documented episode of VTE (proximal DVT or PE) should receive warfarin for 3-6 months, aiming for an INR 2-3.
   
   
3. Low Molecular Weight Heparin (LMWH): Heparin potentiates antithrombin’s inhibition of activated Factor X (Factor Xa) and thrombin. Unlike unfractionated heparin, LMWH does not require monitoring of the aPTT. Enoxaparin (Lovenox) is the LMWH generally used at HSS. Maximum anti-Factor Xa and anti-thrombin activities occur 3-5 hours after subcutaneous injection of enoxaparin. The use of LMWH in conjunction with epidural anesthesia has been associated with epidural and spinal hematomas. See "Regional Anesthesia" below for guidelines on the use of LMWH in patients who have undergone, or will undergo epidural anesthesia.
   
   Enoxaparin 30mg subcutaneously q12h should be started 12-24 hours postoperatively, assuming adequate surgical hemostasis. Enoxaparin cannot be used when an epidural catheter is in place and should not be instituted until 2 hours after removal of an epidural catheter. Enoxaparin should be stopped if there is active bleeding. Platelet counts should be monitored daily for 3 days and then at least weekly, to screen for the development of heparin-associated thrombocytopenia, in the presence of which enoxaparin should be discontinued.
   
   Duration of treatment with enoxaparin should be at least 10 days (assuming no complications). Continuation of treatment for a total of 4-6 weeks should be strongly considered since it will further reduce the incidence of VTE.
   
   Patients with documented VTE (proximal DVT or PE) should receive enoxaparin 1mg/kg subcutaneously q12h (plus warfarin) as long as the INR is less than 2.0 (unless there is active bleeding, in which case an IVC filter should be placed).
   
   
4. Intermittent Pneumatic Compression (IPC): Pneumatic compression devices prevent DVT by producing an increase in lower extremity blood flow by augmentation of venous return. (Newer impulse type pneumatic compression devices are capable of generating more than a 300% increase in peak venous velocity measured at the common femoral vein). Some literature also implicates a secondary thrombolytic effect of such devices. Because IPC is both effective and safe, it is recommended as an adjunctive prophylactic measure in all major orthopedic surgical cases.

   IPC should be applied promptly in the recovery room following surgery and should be used continuously at all times when patients are in bed. All members of the HSS staff should know how to put on compression stockings and all members of the staff (including physicians, physical therapists and nursing staff) are responsible for replacing IPC stockings when patients return to bed.

Regional Anesthesia

The use of hypotensive epidural anesthesia is widespread at HSS and lowers the risk of postoperative VTE. The use of LMWH in conjunction with epidural anesthesia has been associated with the development of epidural hematomas, a potentially catastrophic complication. The following guidelines apply to the use of LMWH in patients who are to undergo, or have undergone epidural anesthesia, and to those who have an epidural catheter in place for the administration of continuous anesthesia postoperatively:

• Patients on epidural PCA should not be administered LMWH.
• Patients receiving LMWH should not have an epidural catheter placed until 24 hours after the last dose.
• LMWH may be administered no sooner than two hours after an epidural catheter is removed.
• When the plan is to administer LMWH on the same day as epidural placement, the first dose should be delayed at least 12 hours after traumatic (bloody) epidural placement.

Hip Arthroplasty

The rate of pulmonary embolism (PE) occurring in hospital following hip arthroplasty (THR) at HSS has been in the 0.2%-1.4% range over the last year (mean 0.7%). In published retrospective and prospective studies of hip arthroplasty performed at HSS over the last decade, the rate of PE has ranged from 0.5% to 1.7% and proximal DVT has been detected in approximately 4% of patients (range 1.7-22%, the high end detected by MRV) [1] [2] [3] [4]. Patients in these studies have been treated using a "risk stratification" approach in which "high risk" patients receive warfarin, and "low risk" patients receive aspirin. All surgeries were performed under hypotensive epidural anesthesia. (Intra-operative heparin administration before femoral preparation, minimization of femoral vein occlusion, and preheating of the femoral stem to shorten cement polymerization time are other techniques used by surgeons at HSS to lower the rate of postoperative VTE.) These rates are comparable to those found in the outside literature in which all patients are treated with either warfarin or LMWH postoperatively[5]. Therefore, "low risk" patients undergoing unilateral hip arthroplasty under hypotensive epidural anesthesia at HSS can be given aspirin, warfarin, or LMWH as VTE prophylaxis postoperatively. "High risk" patients (defined below) should receive warfarin or LMWH. Intermittent pneumatic compression (IPC) is recommended as an adjunctive measure in all patients. Future studies will investigate reliable means of stratifying patients into high and low VTE risk groups, incorporating our growing understanding of the genetics and functional characteristics of thrombophilia and hypofibrinolysis.

Suggestions for VTE prophylaxis following THR:

1. Low risk patients undergoing unilateral THR under epidural anesthesia:
   
   
   • ASA or
   • Warfarin or
   • LMWH
   • IPC as an adjunctive measure.
     
     
2. High risk patients undergoing THR:
   
   
   1. Patients with factors that lead to higher VTE risk, including:
      
      
      • Age over 65 with comorbidity
      • Prolonged immobility
      • Stroke/paralysis
      • Prior DVT
      • Family history of VTE
      • Cancer and its treatment
      • Chronic venous insufficiency
      • Obesity (BMI greater than 30)
      • Cardiac dysfunction
      • Indwelling central venous catheters
      • Nephrotic syndrome
      • Estrogen/SERM
      • Smoking
      • Thrombophilia/Hypofibrinolysis
        
        
      These Patents should recieve:
      
      
      • Warfarin or LMWH
      • IPC as an adjunctive measure
        
        
   2. Patients undergoing bilateral THR:
      
      
      • Warfarin or LMWH
      • IPC as an adjunctive measure.
        
        
3. Very high risk patients:
   
   
   1. Patients undergoing staged bilateral THR
      
      
      • LMWH during the interval between surgeries.
      • Warfarin or LMWH following the second surgery.
      • IPC as an adjunctive measure.
        
        
   2. Patients with high risk thrombophilia:
      
      Patients with known antiphospholipid antibody syndrome, Protein S or C deficiency, Anti-thrombin III deficiency.
      
      
      • LMWH
      • IPC as an adjunctive measure.
        
        
   3. Patients with a history of pulmonary embolism:
      
      
      • LMWH (Consider IVC filter)
      • IPC as an adjunctive measure.

Knee Arthroplasty

The lowest rates of proximal DVT following TKR are seen in patients treated with either IPC or LMWH 5. In uncomplicated unilateral TKR, the rate of postoperative proximal DVT in patients treated with IPC may be as low as 0% [6] [7]. This modality is not associated with excess bleeding complications, and it can be used with an epidural catheter in place. Therefore, IPC should be the cornerstone of VTE prophylaxis following TKR. Because IPC cannot be continued after discharge from the hospital, however, concomitant pharmacological anticoagulation of some type is recommended in all patients. In addition, the efficacy of IPC is related to its proper use. It is imperative that all involved in the care of patients understand the central role of IPC as it relates specifically to VTE prophylaxis following TKR.

Suggestions for VTE prophylaxis following TKR:

1. Low risk patient undergoing unilateral TKR under epidural anesthesia:
   
   
   • IPC plus ASA or
   • IPC plus warfarin or
   • IPC plus LMWH
     
     
2. High risk patients undergoing TKR:
   
   
   1. Patients with factors that lead to higher VTE risk, including:
      
      
      • Age - over 65 with comorbidity
      • Prolonged immobility
      • Stroke/paralysis
      • Prior DVT
      • Family history of VTE
      • Cancer and its treatment
      • Obesity (BMI greater than 30)
      • Venous insufficiency
      • Cardiac dysfunction
      • Indwelling central venous catheter
      • Nephrotic syndrome
      • Estrogen/SERM
      • Smoking
      • Thrombophilia/Hypofibrinolysis
        
        
      These patients should be given the following:
      
      
      • IPC plus warfarin or
      • IPC plus LMWH
        
        
   2. Patients undergoing bilateral TKR:
      
      
      • IPC plus warfarin or
      • IPC plus LMWH
        
        
3. Very high risk patients:
   
   
   1. Patients undergoing staged bilateral TKR:
      
      
      • IPC plus LMWH during the interval between surgeries.
      • IPC plus either warfarin or LMWH after the second surgery.
        
        
   2. Patients with high risk thrombophilia:
      
      Patients with known antiphospholipid antibody syndrome, Protein S or C deficiency, Anti-thrombin III deficiency.
      
      
      • IPC plus LMWH
        
        
   3. Patients with a history of pulmonary embolism:
      
      
      • IPC plus LMWH (Consider IVC filter)

Staged Bilateral Arthroplasty:

Given that aspirin and warfarin are not therapeutic options during the time between surgeries in patients undergoing staged bilateral arthroplasty (who are at high risk for VTE), LMWH is the treatment of choice during that period. IPC should be used immediately postoperatively. LMWH should then be started 12-24 hours following the first surgery (assuming adequate surgical hemostasis). There should be clear communication between the physician ordering LMWH and the anesthesiologist, so that the patient’s epidural catheter is removed at least two hours prior to institution of LMWH. LMWH should be discontinued 24 hours prior to the second surgery so as to avoid the risk of epidural hematoma (see guidelines under "Regional Anesthesia"). Following the second surgery, patients should receive either warfarin or LMWH, along with IPC.

Hip Fracture:

In the absence of pharmacological prophylaxis, the rate of PE following hip fracture is 4-24%, and fatal PE 3.6-12.9%. These numbers improve dramatically when any form of pharmacological prophylaxis is used.[8] Aspirin is less efficacious than warfarin or LMWH as VTE prophylaxis following hip fracture [5]. In a study of 13,356 hip fracture patients randomized to aspirin or placebo (in addition to usual care, which included heparin in 44% of patients), aspirin did significantly reduce the risk of clinical VTE, and caused a 50% reduction in fatal PE compared to placebo. Other vascular deaths were higher in the aspirin treated group, however, so total mortality was not reduced [9].

Factors that add to risk for VTE in hip fracture patients, in addition to those listed previously (i.e. age over 65 with comorbidity, stroke/paralysis, prior DVT, family history VTE, cancer and its treatment, obesity (BMI greater than 30), venous insufficiency, cardiac dysfunction, indwelling central venous catheters, nephrotic syndrome, estrogen/SERM, smoking, thrombophilia/hypofibrinolysis) include:

• General anesthesia
• Delayed surgery
• Hip fracture that occurs in the setting of multiple trauma.

Elderly patients with hip fracture represent a particularly debilitated cohort. Many are admitted from nursing facilities, and many suffer from dementia. As a consequence, some physicians consider them poor candidates for anticoagulation.

Unfortunately, these same patients are at high risk for VTE by virtue of their age and comorbidity. Most debilitated elderly patients are discharged to a supervised facility, however, where they can continue to be monitored closely by a physician while receiving either warfarin or LMWH. Patients who are felt to be at high risk for bleeding on warfarin or LMWH can be given aspirin as an alternative if it is not contraindicated. Those patients with hip fracture who cannot receive any form of pharmacological prophylaxis should receive an IVC filter.

Patients with hip fracture in whom surgery is delayed are at very high risk for VTE. They may also be at increased risk for bleeding, however, secondary to recent trauma. If it is known in advance that there will be a greater than 24-hour delay before surgery then patients with hip fracture should be treated with LMWH prior to surgery (assuming there are no contraindications to anticoagulation). Because a fresh fracture site may be prone to bleeding, both the injured limb and the hemoglobin level should be monitored carefully when LMWH is used preoperatively. LMWH should be discontinued 24 hours prior to surgery if it is to be done under epidural anesthesia (see guidelines under "Regional Anesthesia").

Suggestions for VTE prophylaxis in patients with hip fracture:

1. All patients with hip fracture (except as noted below):
   
   
   • Warfarin or LMWH
   • IPC in all patients.
     
     
2. Patients at high risk for bleeding complications on warfarin or LMWH:
   
   
   • ASA (if not contraindicated) and IPC. Doppler on POD#3.If known high risk thrombophilia or a history of pulmonary embolism:
   • ASA (if not contraindicated) plus IVC filter
     
     
3. Patients with high risk thrombophilia:
   
   Patients with known antiphospholipid antibody syndrome, Protein S or C deficiency, Anti-thrombin III deficiency.
   
   
   • LMWH and IPC (Consider IVC filter)
     
     
4. Patients with a history of pulmonary embolism:
   
   
   • LMWH and IPC (Consider IVC filter)
     
     
5. Patients unable to take any form of pharmacological prophylaxis:
   
   
   • IVC filter and IPC
     
     
6. Patients for whom surgery is delayed:
   
   
   • Preoperative LMWH and IPC

Spine Surgery (Modified June 4, 2004)

Patients undergoing complex spine surgery represent a group at high risk for VTE in whom anticoagulation in the early postoperative period is generally contraindicated because of the risk of epidural hematoma. Patients undergoing spine surgery at HSS experience PE at a rate similar to that seen in patients undergoing hip or knee arthroplasty who are receiving prophylaxis. Doppler studies may be insensitive to clot in these patients since they may occur preferentially in the veins of the pelvis. IPC may be relatively ineffective in these patients for the same reason. At present there is insufficient data on which to base recommendations for the optimal management of these patients. Studies are planned at HSS to address this issue. Meanwhile, recommendations for adult spine patients include the following:

• IPC started intraoperatively or immediately postoperatively.
  
• Early mobilization.
  
• Patients still in the hospital on POD#8 who are immobilized or have other risk factors for VTE (age over 65 with comorbidity, stroke/neurological deficit, prior VTE, family history VTE, cancer and its treatment, obesity (BMI greater than 30), venous insufficiency, cardiac dysfunction, indwelling central venous catheters, nephrotic syndrome, estrogen/SERM, smoking, thrombophilia/hypofibrinolysis, anterior/posterior fusion), and in whom there is no contraindication to anticoagulation, should be treated with:
  
  
  • Heparin 5000 units subcutaneously q12h or
  • Enoxaparin 30mg subcutaneously q12h or
  • Enoxaparin 40mg subcutaneously q24hours.
    
• Anticoagulation should be continued until the patient is discharged home.
  
• Patients undergoing staged spine procedures, whose second surgery is scheduled after POD#10, should receive anticoagulation starting on POD#8 (assuming there are no contraindications). Anticoagulation treatment should be stopped 24 hours prior to the second surgery.
  
• Treatment of clinically established DVT or PE during the first week after spine surgery will have to be defined on a case by case basis, but might include placement of an IVC filter. Time from surgery, and extent of surgery should be considered in determining whether pharmacological anticoagulation can be safely given in this setting.

Knee Arthroscopy (formulated March 26, 2004)

The prevalence of deep vein thrombosis (DVT) following knee arthroscopy is approximately 8%. Ninety-nine percent of these clots are distal [10] [11] [12] [13] [14]. Clinically evident postoperative pulmonary embolism (PE) following knee arthroscopy is rare, but does occur. Because of the relatively low rate of postoperative VTE, prophylaxis cannot be mandated in all cases. Studies suggest, however, that there are surgical and clinical risk factors that can be used to identify patients at higher than average risk for postoperative VTE following knee arthroscopy [10] [11] [12] [13] [14].

The term "knee arthroscopy" encompasses a wide variety of surgical procedures ranging from simple knee "washout", or meniscectomy, to ligament repairs and other procedures involving bone drilling. These differences in surgical invasiveness, as well as differences in tourniquet use/duration, type of anesthesia, and duration of postoperative immobility, are important "surgical" risk factors to consider, in addition to clinical "patient" risk factors, in assessing the likelihood of postoperative VTE.

There is a paucity of data on effective VTE prophylaxis for patients undergoing knee arthroscopy. Two studies suggest that postoperative low molecular weight heparin (LMWH) reduces the risk of postoperative DVT by 78-90%[15] [16] Warfarin has not been studied as VTE prophylaxis following arthroscopy, and is impractical for short-term use in the outpatient setting. There are no studies of aspirin for VTE prophylaxis following knee arthroscopy. Aspirin can, however, be efficacious in reducing the risk of VTE following other orthopedic procedures.[5] [9]

Suggestions for VTE prophylaxis in patients undergoing knee arthroscopy:

1. Very High Risk Patients:
   
   
   • History of DVT or PE
   • Antiphospholipid syndrome
   • Protein S, C, antithrombin III deficiency
   • These patients should be given Lovenox 30mg q12 for 7-10 days.
     • Start 12 hours postoperatively. (Can start 6 hours postoperatively following simple meniscectomy or "washout" procedures)
       
       
2. Moderate Risk Patients:
   
   Patients with several risk factors, including:
   
   
   • Ligament surgery, bone drilling
   • Tourniquet time >60min
   • Postoperative immobility
   • Age >65 with comorbidity
   • Stroke/paralysis
   • Family history of VTE
   • Cancer and its treatment
   • Obesity
   • Venous insufficiency
   • Cardiac dysfunction
   • Indwelling central venous catheters
   • Nephrotic syndrome
   • Pregnancy
   • Estrogen/SERM
   • Smoker
   • Thrombophilia/Hypofibrinolysis
   
   These patients should be given the following:
   
   
   • Consider Lovenox 30mg q12h for 7-10 days. (Start 12 hours postoperatively, or start 6 hours postoperatively following simple meniscectomy or "washout" procedures.)
   • Some physicians may choose to use aspirin in lower risk patients.

Patients on the Medicine Service:

Patients on the medicine service should receive VTE prophylaxis if risk factors are present, including:

• Age - over 65 with comorbidity
• Prolonged immobility
• Stroke/paralysis
• Prior VTE
• Family history of VTE
• Cancer and its treatment
• Obesity (BMI greater than 30)
• Venous insufficiency
• Cardiac dysfunction
• Indwelling central venous catheters
• Nephrotic syndrome
• Pregnancy
• Estrogen/SERM
• Smoking
• Thrombophilia/Hypofibrinolysis

These patients should be given the following:

• Heparin 5000 units subcutaneously q12h or
• Enoxaparin 30mg subcutaneously q12h or
• Enoxaparin 40mg subcutaneously q24hours.

Committee Follow Up:

The risk of VTE is elevated for up to 12 weeks following orthopedic surgery. Our current system of data collection documents only those PE that occur in the hospital or that randomly come to the attention of the patient care department. In future, a system should be implemented to better capture clinical VTE events occurring in patients during the three months following their discharge from HSS.

When pulmonary embolism occurs in a patient after discharge from the hospital, the event should be reported to the Patient Care Quality Management Department by calling (212) 774-2917. We hope to simplify reporting by establishing an electronic link to that department through the HSS website.

The Committee on DVT/PE Prophylaxis will continue to meet periodically to monitor the rate of VTE at HSS, and to review newly available literature on VTE prophylaxis. The committee will recommend changes in policy when and if new data warrants it.

Finally, because guidelines are only useful if they are followed, a program of ongoing education directed toward physicians (attending and resident staff), nurses and patients is recommended in order to implement the recommendations made above.

 

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[1] Huo, Salvati, Sharrock, et al. Intraoperative Heparin Thromboembolic Prophylaxis in Primary Total Hip Arthroplasty. Clin Ortho Rel Research 274:35-46, 1992.

[2] Westrich, Farrell, Bono et al. The Incidence of Venous Thromboembolism After Total Hip Arthroplasty. J Arthroplasty 14:456-463, 1999.

[3] DiGiovanni, Restrepo, Della Valle et al. The Safety and Efficacy of Intraoperative Heparin in Total Hip Arthroplasty. Clin Ortho Rel Research 379:178-185, 2000.

[4] Ryan, Westrich, Potter, et al. Effect of Mechanical Compression on the Prevalence of Proximal Deep Venous Thrombosis as Assessed by Magnetic Resonance Venography. J Bone Joint Surg 84-A:1998-2004, 2002.

[5] Geerts, Heit, Clagett et al. Prevention of Venous Thromboembolism. CHEST 119:132S-175S, 2001.

[6] Haas, Insall, Scuderi et al. Pneumatic Sequential-Compression Boots Compared with Aspirin Prophylaxis of Deep-Vein Thrombosis after Total Knee Arthroplasty. J Bone Joint Surg 72-A:27-31, 1990.

[7] Westrich, Sculco. Prophylaxis against DVT after TKR: Pneumatic Plantar Compression and Aspirin Compared with Asprin Alone. J Bone Joint Surg 78-A:826-834, 1996.

[8] Todd, Freeman, Camilleri-Ferrante et al. Differences in Mortality after Fracture of Hip: the East Anglian Audit. BMJ 31:904-908, 1995.

[9] Pulmonary Embolism Prevention (PEP) Trial Collaborative Group. Prevention of Pulmonary Embolism and Deep vein Thrombosis with Low Dose Aspirin: Pulmonary Embolism Prevention (PEP) Trial. Lancet 355:1295-1302, 2000.

[10] Williams JS et al. Incidence of Deep Vein Thrombosis After Arthroscopic Knee Surgery: A Prospective Study. Arthroscopy (1995) 11:701-705.

[11] Durica S: Abstract presented at Thrombosis and Haemostasis meeting in Milan 1997. Unpublished. Cited in Muntz, JE. The Risk of Venous Thromboembolism in Non-Large-Joint Surgeries. Orthopedics (2003) 26:s237-s242.

[12] Demers C et al. Incidence of Venographically Proved Deep Vein Thrombosis After Knee Arthroscopy. Arch Intern Med (1998) 158:47-50.

[13] Jaureguito JW et al. The Incidence of Deep Venous Thrombosis After Arthroscopic Knee Surgery. Am J Sports Med (1999) 27:707-710.

[14] Delis KT et al. Incidence, Natural History and Risk Factors of Deep Vein Thrombosis in Elective Knee Arthroscopy. Thromb Haemost (2001) 86:817-821.

[15] Wirth T, et al. Prevention of Venous Thromboembolism After Knee Arthroscopy With Low-Molecular weight Heparin (Reviparin): results of a Randomized Controlled Trial. Arthroscopy (2001) 17:393-399.

[16] Michot M et al. Prevention of Deep-Vein Thrombosis in Ambulatory Arthroscopic Knee Surgery: A Randomized Trial of Prophylaxis With Low-Molecular Weight Heparin. Arthroscopy (2002) 18:257-263.

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posted 6/7/2004

Originally published July 2003.