ThromboembolisminOrthopedic
SurgeryPatients
AntithromboticTherapyandPreventionof
Thrombosis,9thed:AmericanCollegeof
ChestPhysiciansEvidenceBasedClinical
PracticeGuidelines
Copyright:AmericanCollegeofChestPhysicians2012
PatientsUndergoingMajorOrthopedicSurgery:TotalHipArthroplasty
(THA),TotalKneeArthroplasty(TKA),HipFractureSurgery(HFS)
VTEisaseriousbutdecreasingcomplicationfollowing
orthopedicsurgery
Thisguidelinefocusesonoptimalprophylaxistoreduce
patientimportantoutcomessuchasPEandsymptomaticDVT
Estimatednonfatal,symptomaticVTEratesaftermajor
orthopedicsurgeryare:
PatientsUndergoingMajorOrthopedicSurgery:TotalHipArthroplasty
(THA),TotalKneeArthroplasty(TKA),HipFractureSurgery(HFS)
PatientsUndergoingMajorOrthopedicSurgery:TotalHipArthroplasty
(THA),TotalKneeArthroplasty(TKA),HipFractureSurgery(HFS)
PatientsUndergoingMajorOrthopedicSurgery:TotalHipArthroplasty
(THA),TotalKneeArthroplasty(TKA),HipFractureSurgery(HFS)
Forpatientsundergoingmajororthopedicsurgery(THA,
TKA,HFS)andreceivingLMWHasthromboprophylaxis,we
recommendstartingeither12ormorehourspreoperatively
orpostoperativelyratherthanwithin4horlesspreoperatively
orpostoperatively(Grade1B).
PatientsUndergoingMajorOrthopedicSurgery:TotalHipArthroplasty
(THA),TotalKneeArthroplasty(TKA),HipFractureSurgery(HFS)
PatientsUndergoingMajorOrthopedicSurgery:TotalHipArthroplasty
(THA),TotalKneeArthroplasty(TKA),HipFractureSurgery(HFS)
Forpatientsundergoingmajororthopedicsurgery,wesuggest
extendingthromboprophylaxisintheoutpatientperiodforup
to35daysfromthedayofsurgeryratherthanforonly10to14
days(Grade2B).
PatientsUndergoingMajorOrthopedicSurgery:TotalHipArthroplasty
(THA),TotalKneeArthroplasty(TKA),HipFractureSurgery(HFS)
PatientsUndergoingMajorOrthopedicSurgery:TotalHipArthroplasty
(THA),TotalKneeArthroplasty(TKA),HipFractureSurgery(HFS)
Inpatientsundergoingmajororthopedicsurgeryandincreased
riskofbleeding,wesuggestusinganIPCDornoprophylaxis
ratherthanpharmacologictreatment(Grade2C).
Remarks:Werecommendtheuseofonlyportable,batterypowereddevices
capableofrecordingandreportingproperweartimeonadailybasisfor
inpatientsandoutpatients.Effortsshouldbemadetoachieve18hofdaily
compliance.Patientswhoplaceahighvalueonavoidingthediscomfortand
inconvenienceofIPCDandalowvalueonavoidingasmallabsoluteincreasein
bleedingwithpharmacologicagentswhenonlyonebleedingriskfactoris
present(inparticularthecontinueduseofantiplateletagents)arelikelyto
choosepharmacologicthromboprophylaxisoverIPCD.
PatientsUndergoingMajorOrthopedicSurgery:TotalHipArthroplasty
(THA),TotalKneeArthroplasty(TKA),HipFractureSurgery(HFS)
Inpatientsundergoingmajororthopedicsurgeryandwho
declineorareuncooperativewithinjectionsoranIPCD,we
recommendusingapixabanordabigatran(alternatively
rivaroxabanoradjusteddoseVKAifapixabanordabigatran
areunavailable)ratherthanalternativeformsofprophylaxis
(allGrade1B).
PatientsUndergoingMajorOrthopedicSurgery:TotalHipArthroplasty
(THA),TotalKneeArthroplasty(TKA),HipFractureSurgery(HFS)
PatientsUndergoingMajorOrthopedicSurgery:TotalHipArthroplasty
(THA),TotalKneeArthroplasty(TKA),HipFractureSurgery(HFS)
Forasymptomaticpatientsfollowingmajororthopedic
surgery,werecommendagainstDoppler(orduplex)
ultrasound(DUS)screeningbeforehospitaldischarge(Grade
1B).
PatientsUndergoingMajorOrthopedicSurgery:TotalHipArthroplasty
(THA),TotalKneeArthroplasty(TKA),HipFractureSurgery(HFS)
PatientsUndergoingKneeArthroscopy
Forpatientsundergoingkneearthroscopywithoutahistoryof
priorVTE,wesuggestnothromboprophylaxisratherthan
prophylaxis(Grade2B).
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.