PreventionofVenous

ThromboembolisminNonorthopedic
SurgicalPatients

AntithromboticTherapyandPreventionof
Thrombosis,9thed:AmericanCollegeof
ChestPhysiciansEvidenceBasedClinical
PracticeGuidelines

Copyright:AmericanCollegeofChestPhysicians2012

LearningObjectives
Describeaformalmethodologyfortheevidence
baseddevelopmentofclinicalpracticeguidelines
Reviewselectstudiesofvenousthromboembolism
(VTE)preventioninsurgicalpatients,aswellasthe
limitationsofthestudies
SummarizerecommendationsforVTEpreventionin
specificsurgicalpopulations

VTE
Thrombosis:theformationorpresenceofablood
clotwithinabloodvessel
MerriamWebstersMedicalDictionary

Embolism:obstructionorocclusionofavesselby
atransportedclotorvegetation,amassofbacteria,
orothermaterial
StedmansMedicalDictionary

DeepVeinThrombosis(DVT)

PulmonaryEmbolism(PE)

GoldhaberSZ.NEnglJMed.1998;339(2):93104.

PulmonaryAngiography

Bliss et al. N Engl J Med. 2002;347(23):1876-1881.

CTPulmonaryAngiography

GoldhaberSZ.NEnglJMed.1998;339(2):93104.
KearonSF.CMAJ.2003;168:183194.

RiskFactors:VirchowsTriad
Stasis

Immobility
Congestiveheartfailure

Injury

Surgery(especiallymajororthopedicandpelvic)
Trauma

Thrombophilia

Cancer
Oralcontraceptives
Hereditarystates(factorVLeiden,PTmutations)

VTEEpidemiology
Mostcommoncauseofpreventabledeathin
hospitalizedpatients
RiskoffatalperioperativePE~0.8%
InternationalMulticentreTrial.Lancet.1975

150,000to200,000deathsperyear;~1/3in
perioperativepatients
Horlanderetal.ArchInternMed.2003;163:17111717.

AHRQ:VTEpreventionisnumber1priorityto
improvesafetyinhospitals

ManySurgicalPatientsAtRisk
2003NationwideInpatientSample
Adultsurgicalpatients,LOS2days
7.8millionsurgicaldischarges

44%lowrisk
15%moderaterisk
24%highrisk
17%veryhighrisk

4.4millionatriskforVTE
Andersonetal.AmJHematol.2007;82:777782.

MillionWomenStudy
Populationbased,prospectivecohortstudy
947,454middleagedwomeninU.K.enrolledbetween
19962001
Meanfollowup6.2years
239,614underwentsurgery
5,419readmittedforVTEwithin12weeksofinpatientsurgery
270deathsfromfatalPE
Sweetlandetal.BMJ.2009;339:b4583.

VTEConsequences

Legswelling,discomfort(DVT)
Dyspnea,chestpain,hemoptysis,hypoxemia(PE)
ExtendedhospitalLOS
FatalPE(RVfailure)
3monthsofanticoagulanttreatment
Postphlebiticsyndrome
ChronicthromboembolicpulmonaryHTN(~4%)
Pengoetal.NEnglJMed.2004;350:22572264.

VTEPrevention
TargetsoneortwolegsofVirchowstriad:
Mechanicalprophylaxis(stasis)
Elasticcompressionstockings
Intermittentpneumaticcompressiondevices

VTEPrevention
TargetsoneortwolegsofVirchowstriad:
Mechanicalprophylaxis(stasis)
Elasticcompressionstockings
Intermittentpneumaticcompressiondevices

Pharmacologicalprophylaxis(hypercoagulability)

Unfractionatedheparin
Lowmolecularweightheparins
Fondaparinux
Aspirin(?)

GuidelinesDefined
Systematicallydevelopedstatementstoassist
practitionersandpatientdecisionsabout
appropriatehealthcareforspecific
circumstances.
FieldMJ,LohrKN(eds).ClinicalPracticeGuidelines:DirectionsforaNew
Program.InstituteofMedicine,Washington,DC:NationalAcademyPress,
1990.

Guidelinesand
PerformanceMeasures
Publicreporting
CardiacsurgeryoutcomesinNewYorkState
Payforperformance
Rewardgoodbehavior
CMS:severalVTEpreventionP4Pmeasures
Registries
Accreditation
Facilitatequalityimprovement

CaseScenario
50yearoldwomanscheduledtoundergoelective
laparoscopiccholecystectomy

PMHnotableformoderateemphysema
NopersonalorfamilyhistoryofVTE
Medications:Spiriva,albuterol
Stoppedsmoking1yearago

Whatshouldwerecommendforperioperative
VTEprophylaxisinthispatient?

BMJ.1999;318:593596.

ConceptualFramework
VTEpharmacoprophylaxisinvolvesatradeoff
betweenpreventingthrombosisandcausingbleeding
Whenmakingtradeoffs,needtocompareabsolute
risksofthrombosisandbleeding
Inordertodetermineabsoluterisks(eg,numberof
symptomaticDVTsprevented),needtoknowthe
following:
Baselineriskincontrol/comparisongroup
Relativeriskforinterventionvscontrol

Whenmakingtradeoffs,alsoneedtoassignvaluesto
eventsbeingcompared

CalculatingAbsoluteEffects
Scenario

Anysurgical
patient

Baseline
Riskof
sVTE
(%)

Baseline
Riskof
Major
Bleeding
(%)

RRVTE RRBleed Number

Number
(UFHvs (UFHvs ofVTEs ofBleeds
no
no
Prevented Caused
Prophy) Prophy) (per1000) (per1000)

0.50

2.0

CalculatingAbsoluteEffects
Scenario

(%)

Baseline
Riskof
Major
Bleeding
(%)

10

10

ModerateVTE/
Highbleed

10

20

HighVTE/
averagebleed

20

10

HighVTE/
highbleed

20

20

ModerateVTE/
AverageBleed

Baseline
Riskof
sVTE

RRVTE
(UFHvs
no
Prophy)

0.50

RRBleed
(UFHvs
no
Prophy)

2.0

Numberof Numberof
VTEs
Bleeds
Prevented
Caused
(per1000) (per1000)

PICOQuestion
Amongpatientsundergoingelectiveabdominal
surgery,shouldLDUHvsnoprophylaxisbeused
forVTEprevention?
Areweconfidentthatthebenefitsofreducing
fatalandnonfatalVTEexceedtheharmsof
increasingfatalandnonfatalmajorbleeding?

EvidenceSynthesis
SystematicReviewforeachPICO!

Literaturesearch
Assessmentforeligibility
Assessmentofstudyquality
Dataabstractionandsynthesis

Expensive,timeconsuming,andlaborintensive
AHRQEvidenceBasedPracticeCenters

AssessmentofBaselineRisk
Idealstudy
Large,populationbased
Prospective(?)
Fewexclusionsorlossesto
followup
Welldefinedendpoints

Moststudies
Singlecenter
Referralcenterbias
Prospective
Employsurveillance
methodstoidentify
Importanttopatients
asymptomaticDVT
Objectivelyconfirmed
Shorttimehorizon
Sufficientlylongtimehorizon
Nodescriptionor
Noprophylaxisorcontrolledfor
adjustmentforprophylaxis
prophylaxis

EstimatingBaselineRisk

AnnSurg.2010;251:344350.

EstimatingBaselineRisk
Retrospective,observationalstudy
Largesample(n=8,216)ofconsecutivelyadmitted
generalsurgicalinpatients
Tertiarycenter
Measuredclinicallysuspected,objectivelyconfirmed
VTEover30days
Riskstratificationaccordingtopatientspecificand
procedurespecificcharacteristics
Prophylaxisnonuniformbutreported

BaselineRiskofVTE

CaseScenario
50yearoldwomanscheduledtoundergoelective
laparoscopiccholecystectomy

PMHnotableformoderateCOPD
NopersonalorfamilyhistoryofVTE
Medications:Spiriva,albuterol
Stoppedsmoking1yearago

Whatshouldwerecommendforperioperative
VTEprophylaxisinthispatient?

BaselineRiskofVTE

BaselineRiskofVTE

Bahl et al. Ann Surg. 2010;251:344-350.

BaselineRiskofVTE

52%
0.1%

10%

37%

Bahletal.AnnSurg.2010;251:344350.

ProphylaxisReceived
Risk
Category

%ReceivingProphylaxis
Pharm

Mechanica
l

Both

Neither

0.55

0.08

0.37

Low

0.02

0.66

0.13

0.19

Moderate

0.05

0.55

0.21

0.2

High

0.05

0.52

0.27

0.16

All

0.05

0.55

0.23

0.18

Verylow

VTE
Patient Population
Risk Risk categories from Patients undergoing general surgery,
AT7
including gastrointestinal, urological,
Estimated risk (%)
vascular, breast and thyroid
procedures
Proximal
PE
Caprini
Observed Adjusted risk
DVT
score
risk of sVTE of sVTE (%)
(%)
Very
0.4
0.2
0
0
0
low
Low
2-4
1-2
1-2
0.7
1.7
Mod
4-8
2-4
3-4
1.0
2.6
High
>10
4-10
5
1.9
5.7

EstimatedBaselineRisk
Capriniscore=4
Unadjustedrisk=1.0%
Crudeadjustedrisk=2.6%
Observed,unadjustedriskinobservationalstudy
of2,274dischargesfollowinglapcholein
California,19921996was0.9%
WhiteRHetal.ThrombHaemost.2003;90:446455.

CalculatingAbsoluteEffects
Scenario

Moderate
VTErisk
patient

Baseline
Riskof
sVTE
(%)

Baseline
Riskof
Major
Bleeding
(%)

2.6

1.2

RRVTE RRBleed Number

Number
(UFHvs (UFHvs ofVTEs ofBleeds
no
no
Prevented Caused
Prophy) Prophy) (per1000) (per1000)

AssessmentofSafety/Effectiveness
Idealstudy
Large,multicenterRCT
Blindingofpatients,treating
physicians,adjudicators
Welldefinedendpoints
Importanttopatients
Objectivelyconfirmed

Fewexclusionsorlossesto
followup
Sufficientlylongtimehorizon

Moststudies
Small,singlecenter
Referralcenterbias
Incompleteblinding
Surrogateoutcome,
asymptomaticDVT
Largepercentexcluded
fromefficacyevaluation
Shorttimehorizon

EffectivenessofLDUH:IMT

IMTDesign
Unblinded,randomized,controlledtrial
Patients:adultsage>40yearsundergoingmajor
electivesurgery(GA,>30min,LOS7days)at28
centersinEurope,AustraliaandSouthAfrica
Intervention:UFH5,000unitstidfor7days,1stdose2
hourspreop
Comparator:noprophylaxis
Outcomes:fatalPE,fatalbleed,nonfatalPE,nonfatal
bleed,clinicalDVT,DVTbyFUT

IMTOutcomes
PE:clinicallysuspectedwithconfirmatoryevidence
recorded(chestradioraphandECG)
FatalPE:confirmedbyautopsy
DVT:
Clinicallysuspectedandconfirmedbyvenography
Continuoussurveillancebyfibrinogenuptaketest(10centers)

Excessiveoperativebleeding(surgeonsjudgment)
Woundhematoma,transfusion,fallinHgb

IMTResults:VTE
Outcome

LDUH
N=2045

NoProphylaxis
N=2076

RR

Deathanycause

80

100

0.81(0.61to1.1)

FatalPE

16

0.13(0.02to0.55)

DeathwithPE

0.51(0.13to2.0)

SuspectedDVT

39

81

0.49(0.33to0.71)

ConfirmedDVT

11

32

0.35(0.18to0.69)

DVTbyFUT

48/625

164/667

0.31(0.23to0.42)

ProximalDVT

5/625

49/667

0.11(0.04to0.27)

IMTResults:Bleeding
Outcome

LDUH
N=2045

NoProphylaxis
N=2076

RR

0.81(0.21to3.0)

Excessiveintraop

182

126

1.47(1.18to1.82)

Woundhematoma

158

117

1.37(1.09to1.73)

202/731

202/744

1.02(0.86to1.20)

Fatalbleed

Transfusion

CollinsMetaanalysis

N Engl J Med. 1988;318:1162-1173.

CollinsMetaanalysis
69studiesofLDUHprophylaxis

Generalsurgery(45)
Urology(7)
Electiveorthopedic(12)
Trauma(7)

Abouthalfopenlabel
MostmeasuredsurrogateoutcomeforVTE
Manyusedsuboptimaltest(FUT)
Bleedingoutcome:excessiveintraoperativebleedingorneed
fromtransfusion

Results:Metaanalysis
Outcome

Studies
Withat
Least1
Event

Baseline
Riskin
Control
Groups

PooledOR
(REM)

Deathfromanycause

32

3.5%

0.82(0.69to0.99)

FatalPE

20

0.8%

0.53(0.31to0.91)

NonfatalPE

32

2.1%

0.59(0.41to0.84)

Fatalbleeding

0.1%

1.14(0.41to3.15)

Nonfatalbleeding

44

3.8%

1.57(1.32to1.87)

SensitivityAnalysis
Frequency
Q8h72+/5
Q12h63+/5

CalculatingAbsoluteEffects
Scenario

Moderate
VTERisk
Patient

Baseline
Riskof
sVTE
(%)

2.6

Baseline RRVTE
RR
Number Number
Riskof (UFHvs Bleed
ofVTEs ofBleeds
Major
no
(UFHvs Prevented Caused
Bleeding Prophy)
no
(per1000) (per1000)
(%)
Prophy)

1.2

0.59

1.57

11

EvidenceSynthesis:
Tradeoffsbetweendesirableand
undesirableoutcomes

Summary of Findings
Absolute Risks
Effect
Importanc
No
Relative
e
LDUH
Absolute
Prophylaxis
(95% CI)
Nonfatal symptomatic VTE, inferred from no-fatal PE (clinical
diagnosis)
1.7%
7 fewer per 1000
11 fewer per
OR 0.59
2.6%
118/8216
1000
CRITICAL
(1.4%)
(0.41 to 0.84)
23 fewer per
5.7%
1000
Non-fatal major bleeding, inferred from excessive intraoperative
bleeding or need for transfusion (clinical diagnosis)
1.2%
7 more per 1000
OR 1.57
388/6524
12 more per
CRITICAL
2.2%
(5.9%)
(1.32 to 1.87)
1000

Summary of Findings
Absolute Risks
Effect
No
Relative
LDUH
Absolute
Prophylaxis
(95% CI)
Fatal PE (autopsy)
1 fewer per
0.3%
1000
OR 0.53
19/6809
2 fewer per
0.5%
(0.3%)
1000
(0.31 to 0.91)
5 fewer per
1.1%
1000
Fatal bleeding (autopsy)
0 more per
0.09%
OR 1.14
1000
7/6703 (0.1%)
(0.41 to 3.15) 0 more per
0.17%
1000

Importance

CRITICAL

CRITICAL

GRADE:QualityofEvidence
Limitations

Inconsistency

Indirectness

Imprecision

Other

Threatsto
validity,riskof
bias:
concealmentof
allocation
sequence,
blinding,losses
tofollowup,
selective
reporting,early
stopping

Unexplained
heterogeneityin
resultsacross
studies

Indirect
evidencefrom
different
population,
intervention,
comparatoror
outcome

Confidence
intervalaround
effectincludes
bothnoeffect
andeither
important
benefitor
importantharm
(orboth)

Potentialfor
publicationbias

OR
Indirect
comparison:
Usestudiesof
AvsBandB
vsCto
compareAvsC

No. of
Studies
Fatal PE
20

Design

Quality Assessment
Inconsiste Indirectnes Imprecisio
Limitations
ncy
s
n

randomise no serious
d trials limitations

+/-

Quality

no serious no serious Moderate

indirectnes imprecisio to High
s
n

Fatal bleeding
7
randomise no serious no serious no serious serious
Moderate
d trials limitations inconsiste indirectnes
ncy
s
No-fatal symptomatic VTE, inferred from nonfatal PE
32
randomise serious
mild
no serious no serious Moderate
d trials
indirectnes imprecisio
s
n
Nonfatal major bleeding, inferred from excessive intraoperative bleeding or
need for transfusion
44
randomise serious no serious no serious no serious Moderate
d trials
inconsiste indirectnes imprecisio
ncy
s
n

Guyatt et al. BMJ. 2008;336:1049-1051.

GRADE:StrengthofRecommendation

BMJ.2008;336:10491051.

Recommendation
Forgeneralsurgicalpatientsatmoderateriskfor
venousthromboembolismwhoarenotathighrisk
forperioperativebleeding,wesuggestlowdose
unfractionatedheparin(Grade2B)overno
prophylaxis.

Recommendation
Forgeneralsurgicalpatientsathighriskfor
venousthromboembolismwhoarenotathighrisk
forperioperativebleeding,werecommenduseof
lowdoseunfractionatedheparin(Grade1B)over
noprophylaxis.

MajorChallenges
Multiplesourcesofheterogeneity
Indirectness
Whenshouldoneapplyindirectevidencefromstudies
performedinamixed(surgical)ordifferentpatient
population?

Surrogateoutcome:asymptomaticDVT
Poorlystandardizedoutcome:majorbleeding
LimitedinformationaboutbaselineriskofVTEin
absenceofprophylaxis

BiasesIntroducedbySurveillancefor
AsymptomaticDVT
Downward:identificationandtreatmentof
asymptomaticDVTpreventsunknownnumberof
eventsthatwouldhavebecomesymptomatic
Upward:morelikelytolabelafinding(eg,leg
swelling)asasymptomaticifeventisdetectedby
surveillance
Difficulttoestimatetheratioofasymptomaticto
symptomaticevents

AdditionalChallenges
Numerouscomparisons
LDUH,LMWH,fondaparinux,lowdoseASA,highdoseASA,
ESandIPCvsnoprophy
Mechanicalvspharmacologic
Addmechanicaltopharmacologic
16uniqueevidenceprofilesandstillcounting!

Numeroussurgicalpopulations

Abdomenandpelvis(vascular,bariatric)
Neurosurgery(craniotomy,spine)
Trauma(TBI,SCI,othermajortrauma)
Cardiac,thoracic,other

PatientsUndergoingGeneral,GI,Urologic,Gynecologic,Bariatric,
Vascular,Plastic,orReconstructiveSurgery

Forgeneralandabdominalpelvicsurgerypatientsatverylow
riskforVTE(<0.5%;Rogersscore,<7;Capriniscore,0),we
recommendthatnospecificpharmacologic(Grade1B)or
mechanical(Grade2C)prophylaxisbeusedotherthanearly
ambulation.

PatientsUndergoingGeneral,GI,Urologic,Gynecologic,Bariatric,
Vascular,Plastic,orReconstructiveSurgery

Forgeneralandabdominalpelvicsurgerypatientsatlowrisk
forVTE(~1.5%;Rogersscore,710;Capriniscore,12),we
suggestmechanicalprophylaxis,preferablywithintermittent
pneumaticcompression(IPC),overnoprophylaxis(Grade2C).

PatientsUndergoingGeneral,GI,Urologic,Gynecologic,Bariatric,
Vascular,Plastic,orReconstructiveSurgery

Forgeneralandabdominalpelvicsurgerypatientsatmoderate
riskforVTE(~3.0%;Rogersscore,>10;Capriniscore,34)
whoarenotathighriskformajorbleedingcomplications,we
suggestLMWH(Grade2B),LDUH(Grade2B),ormechanical
prophylaxis,preferablywithIPC(Grade2C),overno
prophylaxis.

Remarks:Threeofthesevenauthorsfavoredastrong(Grade1B)
recommendationinfavorofLMWHorLDUHovernoprophylaxis
inthisgroup.

PatientsUndergoingGeneral,GI,Urologic,Gynecologic,Bariatric,
Vascular,Plastic,orReconstructiveSurgery

Forgeneralandabdominalpelvicsurgerypatientsatmoderate
riskforVTE(3.0%;Rogersscore,>10;Capriniscore,34)
whoareathighriskformajorbleedingcomplicationsorthose
inwhomtheconsequencesofbleedingarethoughttobe
particularlysevere,wesuggestmechanicalprophylaxis,
preferablywithIPC,overnoprophylaxis(Grade2C).

PatientsUndergoingGeneral,GI,Urologic,Gynecologic,Bariatric,
Vascular,Plastic,orReconstructiveSurgery

Forgeneralandabdominalpelvicsurgerypatientsathighrisk
forVTE(~6.0%;Capriniscore,5)whoarenotathighrisk
formajorbleedingcomplications,werecommend
pharmacologicprophylaxiswithLMWH(Grade1B)orLDUH
(Grade1B)overnoprophylaxis.Wesuggestthatmechanical
prophylaxiswithelasticstockingsorIPCshouldbeaddedto
pharmacologicprophylaxis(Grade2C).

PatientsUndergoingGeneral,GI,Urologic,Gynecologic,Bariatric,
Vascular,Plastic,orReconstructiveSurgery

For high-VTE-risk patients undergoing abdominal or pelvic

surgery for cancer who are not otherwise at high risk for major
bleeding complications, we recommend extended-duration
pharmacologic prophylaxis (4 weeks) with LMWH
over limited-duration prophylaxis (Grade 1B).
Remarks: Patients who place a high value on minimizing out-ofpocket health-care costs might prefer limited-duration over
extended-duration prophylaxis in settings where the cost of
extended-duration prophylaxis is borne by the patient.

PatientsUndergoingGeneral,GI,Urologic,Gynecologic,Bariatric,
Vascular,Plastic,orReconstructiveSurgery

ForhighVTEriskgeneralandabdominalpelvicsurgery
patientswhoareathighriskformajorbleedingcomplications
orthoseinwhomtheconsequencesofbleedingarethoughtto
beparticularlysevere,wesuggestuseofmechanical
prophylaxis,preferablywithIPC,overnoprophylaxisuntilthe
riskofbleedingdiminishesandpharmacologicprophylaxis
maybeinitiated(Grade2C).

PatientsUndergoingGeneral,GI,Urologic,Gynecologic,Bariatric,Vascular,
Plastic,orReconstructiveSurgery

Forgeneralandabdominalpelvicsurgerypatientsathighrisk
forVTE(6%;Capriniscore,5)inwhombothLMWHand
unfractionatedheparinarecontraindicatedorunavailableand
whoarenotathighriskformajorbleedingcomplications,we
suggestlowdoseaspirin(Grade2C),fondaparinux(Grade2C),
ormechanicalprophylaxis,preferablywithIPC(Grade2C),
overnoprophylaxis.

PatientsUndergoingGeneral,GI,Urologic,Gynecologic,Bariatric,
Vascular,Plastic,orReconstructiveSurgery

Forgeneralandabdominalpelvicsurgerypatients,wesuggest
thataninferiorvenacava(IVC)filtershouldnotbeusedfor
primaryVTEprevention(Grade2C).

PatientsUndergoingGeneral,GI,Urologic,Gynecologic,Bariatric,
Vascular,Plastic,orReconstructiveSurgery

Forgeneralandabdominalpelvicsurgerypatients,wesuggest
thatperiodicsurveillancewithvenouscompressionultrasound
(VCU)shouldnotbeperformed(Grade2C).

PatientsUndergoingCardiacSurgery
Forcardiacsurgerypatientswithanuncomplicated
postoperativecourse,wesuggestuseofmechanical
prophylaxis,preferablywithoptimallyappliedIPC,overeither
noprophylaxis(Grade2C)orpharmacologicprophylaxis
(Grade2C).

PatientsUndergoingCardiacSurgery
For cardiac surgery patients whose hospital course is prolonged
by one or more nonhemorrhagic surgical complications, we
suggest adding pharmacologic prophylaxis with LDUH
or LMWH to mechanical prophylaxis (Grade 2C).

PatientsUndergoingThoracicSurgery
For thoracic surgery patients at moderate risk for VTE who
are not at high risk for perioperative bleeding, we suggest
LDUH (Grade 2B), LMWH (Grade 2B), or mechanical
prophylaxis with optimally applied IPC (Grade 2C) over no
prophylaxis.
Remarks: Three of the seven authors favored a strong (Grade 1B)
recommendation in favor of LMWH or LDUH over no prophylaxis
in this group.

PatientsUndergoingThoracicSurgery
ForthoracicsurgerypatientsathighriskforVTEwhoarenot
athighriskforperioperativebleeding,wesuggestLDUH
(Grade1B)orLMWH(Grade1B)overnoprophylaxis.In
addition,wesuggestthatmechanicalprophylaxiswithESor
IPCshouldbeaddedtopharmacologicprophylaxis(Grade2C).

PatientsUndergoingThoracicSurgery
For thoracic surgery patients who are at high risk for major
bleeding, we suggest use of mechanical prophylaxis, preferably
with optimally applied IPC, over no prophylaxis until the risk
of bleeding diminishes and pharmacologic prophylaxis may be
initiated (Grade 2C).

PatientsUndergoingCraniotomy
For craniotomy patients, we suggest that mechanical
prophylaxis, preferably with IPC, be used over no prophylaxis
(Grade 2C) or pharmacologic prophylaxis (Grade 2C).

PatientsUndergoingCraniotomy
ForcraniotomypatientsatveryhighriskforVTE(eg,those
undergoingcraniotomyformalignantdisease),wesuggest
addingpharmacologicprophylaxistomechanicalprophylaxis
onceadequatehemostasisisestablishedandtheriskof
bleedingdecreases(Grade2C).

PatientsUndergoingSpinalSurgery
Forpatientsundergoingspinalsurgery,wesuggestmechanical
prophylaxis,preferablywithIPC,overnoprophylaxis(Grade
2C),unfractionatedheparin(Grade2C),orLMWH(Grade
2C).

PatientsUndergoingSpinalSurgery
For patients undergoing spinal surgery at high risk for VTE
(including those with malignant disease or those undergoing
surgery with a combined anterior-posterior approach), we
suggest adding pharmacologic prophylaxis to mechanical
prophylaxis once adequate hemostasis is established and the
risk of bleeding decreases (Grade 2C).

Major Trauma
For major trauma patients, we suggest use of LDUH (Grade
2C), LMWH (Grade 2C), or mechanical prophylaxis, preferably
with IPC (Grade 2C), over no prophylaxis.

Major Trauma
For major trauma patients in whom LMWH and LDUH are
contraindicated, we suggest mechanical prophylaxis, preferably
with IPC, over no prophylaxis (Grade 2C) when not
contraindicated by lower-extremity injury. We suggest adding
pharmacologic prophylaxis with either LMWH or LDUH when
the risk of bleeding diminishes or the contraindication to
heparin resolves (Grade 2C).

Major Trauma
For major trauma patients, we suggest that an IVC filter
should not be used for primary VTE prevention (Grade 2C).

PatientsWithMajorTrauma:TraumaticBrainInjury,AcuteSpinalInjury,
andTraumaticSpineInjury

FormajortraumapatientsathighriskforVTE(including
thosewithacutespinalcordinjury,traumaticbraininjury,
andspinalsurgeryfortrauma),wesuggestaddingmechanical
prophylaxistopharmacologicprophylaxis(Grade2C)whennot
contraindicatedbylowerextremityinjury.

PatientsWithMajorTrauma:TraumaticBrainInjury,AcuteSpinalInjury,
andTraumaticSpineInjury

For major trauma patients, we suggest that periodic

surveillance with VCU should not be performed (Grade 2C).

EndorsingOrganizations
Thisguidelinehasreceivedtheendorsementofthe
followingorganizations:
AmericanAssociationforClinicalChemistry
AmericanCollegeofClinicalPharmacy
AmericanSocietyofHealthSystemPharmacists
AmericanSocietyofHematology
InternationalSocietyofThrombosisandHemostasis

AcknowledgementofSupport
TheACCPappreciatesthesupportofthefollowingorganizations
forsomepartoftheguidelinedevelopmentprocess:
BayerScheringPharmaAG
NationalHeart,Lung,andBloodInstitute(GrantNo.R13HL104758)
Witheducationalgrantsfrom

BristolMyersSquibbandPfizer,Inc.
CanyonPharmaceuticals,and
sanofiaventisU.S.
Althoughtheseorganizationssupportedsomeportionofthedevelopment
oftheguidelines,theydidnotparticipateinanymannerwiththescope,
panelselection,evidencereview,development,manuscriptwriting,
recommendationdraftingorgrading,voting,orreview.Supportersdidnot
seetheguidelinesuntiltheywerepublished.