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.
BACKGROUND
VTE is a common cause of preventable death in surgical patients.


METHODS
We developed recommendations for thromboprophylaxis in nonorthopedic surgical patients by using systematic methods as described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.


RESULTS
We describe several alternatives for stratifying the risk of VTE in general and abdominal-pelvic surgical patients. When the risk for VTE is very low (< 0.5%), we recommend that no specific pharmacologic (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation. For patients at low risk for VTE (∼1.5%), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC), over no prophylaxis (Grade 2C). For patients at moderate risk for VTE (∼3%) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated heparin (Grade 2B), or mechanical prophylaxis with IPC (Grade 2C) over no prophylaxis. For patients at high risk for VTE (∼6%) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or low-dose unfractionated heparin (Grade 1B) over no prophylaxis. In these patients, we suggest adding mechanical prophylaxis with elastic stockings or IPC to pharmacologic prophylaxis (Grade 2C). For patients at high risk for VTE undergoing abdominal or pelvic surgery for cancer, we recommend extended-duration, postoperative, pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B). For patients at moderate to high risk for VTE who are at high risk for major bleeding complications or those in whom the consequences of bleeding are believed to be particularly severe, we suggest use of mechanical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Grade 2C). For patients in all risk groups, we suggest that an inferior vena cava filter not be used for primary VTE prevention (Grade 2C) and that surveillance with venous compression ultrasonography should not be performed (Grade 2C). We developed similar recommendations for other nonorthopedic surgical populations.


CONCLUSIONS
Optimal thromboprophylaxis in nonorthopedic surgical patients will consider the risks of VTE and bleeding complications as well as the values and preferences of individual patients.
Keck School of Medicine, University of Southern California, Los Angeles, CA. Electronic address: michael.k.gould@kp.org.
Michael K
MK
Gould
University of New Mexico School of Medicine, Albuquerque, NM.
David A
DA
Garcia
Stanford School of Medicine, Stanford, CA.
Sherry M
SM
Wren
Surgical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
Paul J
PJ
Karanicolas
University of Granada Medical School, Granada, Spain.
Juan I
JI
Arcelus
College of Medicine, Mayo Clinic, Rochester, MN.
John A
JA
Heit
Department of Anaesthesiology and Intensive Care, Hotel-Dieu University Hospital, Paris, France.
Charles M
CM
Samama
D003131:Combined Modality Therapy; D019317:Evidence-Based Medicine; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000097:blood / Q000627:therapeutic use*; D006470:Hemorrhage / Q000097:blood / Q000139:chemically induced; D006493:Heparin / Q000009:adverse effects / Q000627:therapeutic use; D006495:Heparin, Low-Molecular-Weight / Q000009:adverse effects / Q000627:therapeutic use; D048228:Intermittent Pneumatic Compression Devices; D011183:Postoperative Complications / Q000097:blood / Q000517:prevention & control*; D011655:Pulmonary Embolism / Q000097:blood / Q000188:drug therapy / Q000517:prevention & control; D012307:Risk Factors; D012955:Societies, Medical; D053828:Stockings, Compression; D013514:Surgical Procedures, Operative; D014481:United States; D054556:Venous Thromboembolism / Q000097:blood / Q000188:drug therapy / Q000517:prevention & control*
D005343:Fibrinolytic Agents; D006495:Heparin, Low-Molecular-Weight; D006493:Heparin