GUIDELINES FOR PROPHYLAXIS OF PERI-OPERATIVE VTE 

The European Society of Anaesthesiology (ESA), together with other European societies, has published original and user-friendly guidelines on the prevention of Venous Thromboembolism (VTE) in Anaesthesia and Intensive care in the current issue of the European Journal of Anaesthesiology.

“The American College of Chest Physicians (ACCP) guidelines 2008 and 2012 are still considered by many to be the ‘Holy Bible’, despite conflicting statements, different scope of topics, lack of incorporation of recently published important articles and lack of coverage of several topics of interest to anaesthesiologists”, said  in the Editorial of the EJA February issue.

The guidelines are presented in 12 separate articles (chapters), each edited by members of the VTE Task Force. VTE prophylaxis is discussed in nine clinical settings. The usefulness of controversial treatments is discussed in three additional chapters.

1. CARDIOVASCULAR AND THORACIC SURGERY

Cardiac and vascular surgery

• In the absence of risk factors, ESA suggests considering the risk of VTE as moderate in patients undergoing coronary artery by-pass graft (CABG) and bioprosthetic aortic valve implantation surgery. If the risk of bleeding is to be considered high, ESA suggests the use of mechanical prophylaxis using IPC.
   
• The presence of one or more risk factors [age above 70 years, transfusion of more than four units of RBC concentrate/fresh frozen plasma/cryoprecipitate/fibrinogen concentrate, mechanical ventilation more than 24 h, postoperative complication (e.g. acute kidney injury, infection/sepsis, neurological complication)] should place the cardiac population at high risk for VTE. In this context, ESA suggests the use of pharmacological prophylaxis as soon as satisfactory haemostasis has been achieved, in addition to IPC.
   
• Patients undergoing other valve surgery and those with atrial fibrillation should be considered a specific entity at high risk of VTE, as they will mostly require postoperative therapeutic medical ‘bridging’ prior to long-term anti-coagulation.
   
• In patients undergoing AAA repair, particularly when an open surgical approach is used, the risk of VTE is higher with a high bleeding risk. These patients should be considered as having a moderate risk. Patients with additional risk factors including BMI at least 30 kg m−2, preoperative dyspnoea, chronic steroid usage, ruptured aneurysm, open surgery, operative duration at least 5 h, transfusion of at least 5 U, postoperative mechanical ventilation more than 48 h, postoperative complication (acute kidney injury, infection/sepsis) and re-operation, should be considered as moderate-to-high risk. In this context, ESA suggests the use of pharmacological prophylaxis as soon as satisfactory haemostasis is achieved.

Thoracic surgery

• Based on the current literature, patients undergoing thoracic surgery in the absence of cancer could be considered at low risk of VTE. However, as the vast majority of patients undergoing thoracic surgery have a diagnosis of primary or metastatic cancer, they should be considered at high risk for VTE with an equally high bleeding risk.
• In low-risk patients, ESA suggests the use of mechanical prophylaxis using IPC. In high-risk patients, ESA suggests the use of pharmacological prophylaxis in addition to IPC.

Kindly refer to the full guidelines for here to view all recommendations for Cardiovascular and thoracic surgery: http://bit.ly/2CICLWG

2. NEUROSURGERY

Patients undergoing craniotomy

•  ESA recommends that if IPC is used, it should be applied before the surgical procedure or on admission, used continuously (except when the patient is actually walking) and monitored frequently to optimise compliance.
• In craniotomy patients at particularly high risk of VTE (additional risk factors including malignancy, motor impairment, prolonged operative time), ESA suggests considering the initiation of mechanical thromboprophylaxis with IPC preoperatively with addition of LMWH or LDUH postoperatively when the risk of bleeding is presumed to be decreased.

Patients with non-traumatic intracranial haemorrhage

• ESA suggests thromboprophylaxis with IPC
• ESA suggests the application of IPC on admission, used continuously (except when the patient is actually walking) and monitored frequently to optimise compliance

Spinal surgery

• For patients with no additional risk factors, ESA suggests no active thromboprophylaxis intervention apart from early mobilization.
• For patients undergoing spinal surgery with additional risk factors (limited mobility, active cancer, complex surgical procedure),  recommends starting mechanical thromboprophylaxis with IPC preoperatively and we suggest the addition of LMWH postoperatively when the risk of bleeding is presumed to be decreased.

Kindly refer to the full guidelines here to view all recommendations in Neurosurgery: http://bit.ly/2m9iCQf

3. PATIENTS WITH PREEXISTING COAGULATION DISORDERS AND AFTER SEVERE PERIOPERATIVE BLEEDING

• For the perioperative management of patients with inherited bleeding disorders, ESA suggests liaison with haematologists to guide treatment.
• ESA suggests that, if factor replacement therapy is required for perioperative haemostasis, excess use should be avoided and factor levels carefully monitored.
• In patients with inherited bleeding disorders undergoing major surgery, ESA suggests mechanical thromboprophylaxis, especially in factor VII deficiency.
• ESA recommends that all patients receiving factor XI concentrate have mechanical thromboprophylactic measures and suggests that they are considered for pharmacological thromboprophylaxis.
• For patients at a high risk of thromboembolism and with a high bleeding risk after surgery, ESA considers that administering a reduced dose of DOAC on the evening after surgery and on the following day (first postoperative day) after surgery is good practice.

Kindly refer to the full guidelines here to view all recommendations in coagulation Disorders: http://bit.ly/2D0k9Py

4. INFERIOR VENA CAVA FILTERS

• There is currently no clear evidence on the efficacy and safety of IVCFs in patients with a contra-indication to pharmacological and mechanical thromboprophylaxis undergoing high thrombotic risk surgery or procedures.
• IVCF-associated complications often seem to outweigh any potential benefit.
• ESA suggests considering temporary IVCF placement in patients at high VTE risk when pharmacological and mechanical thromboprophylaxis are fully contra-indicated.
• ESA suggests considering temporary IVCF placement in patients with documented recent DVT, and with an absolute contra-indication for full anticoagulation and planned non-deferrable major surgery.
• ESA suggests not systematically using IVCFs to prevent pulmonary embolism in the perioperative setting.

Kindly refer to the full guidelines here to view all recommendations in Inferior vena cava filters: http://bit.ly/2m4bHI0

5. MECHANICAL PROPHYLAXIS

• ESA recommended an institution-wide protocol for the prevention of VTE that integrates early ambulation, pharmacological thromboprophylaxis with anticoagulants and mechanical thromboprophylaxis.
• ESA recommended against the routine use of GCS without pharmacological thromboprophylaxis to prevent VTE in patients at intermediate and high risk.
• In patients with contraindications to pharmacological thromboprophylaxis, ESA recommends the use of mechanical prophylaxis with IPC or GCS and suggests the use of IPC over GCS.
• In patients with contraindications to pharmacological thromboprophylaxis who are not at high-risk for VTE, ESA suggests no prophylaxis over GCS alone.
• In patients receiving pharmacological thromboprophylaxis who are not at very high risk for VTE, ESA recommends against the routine use of mechanical thromboprophylaxis with GCS or IPC.
• ESA suggests combined mechanical and pharmacological prophylaxis in selected patients at very high-risk for VTE. ESA suggest the use of IPC rather than GCS in selected high-risk patients in addition to pharmacological thromboprophylaxis.

Kindly refer to the full guidelines here to view all recommendations in Mechanical prophylaxis: http://bit.ly/2F5xVkt

6. SURGERY IN THE ELDERLY

• In elderly patients, EJA suggests identification of co-morbidities increasing the risk for VTE (e.g. congestive heart failure, pulmonary circulation disorder, renal failure, lymphoma, metastatic cancer, obesity, arthritis, post-menopausal oestrogen therapy) and correction if present (e.g. anaemia, coagulopathy).
• EJA suggests against bilateral knee replacement in elderly and frail patients.
• EJA suggests timing and dosing of pharmacological VTE prophylaxis as in the non-aged population.
• In elderly patients with renal failure, low-dose un-fractionated heparin may be used or weight-adjusted dosing of LMWH.
• In the elderly, EJA recommends careful prescription of postoperative VTE prophylaxis and early postoperative mobilisation.
• EJA recommends multi-faceted interventions for VTE prophylaxis in elderly and frail patients, including pneumatic compression devices, LMWH (and/or direct oral anti-coagulants after knee or hip replacement).

Kindly refer to the full guidelines here to view all recommendations in Surgery in the elderly: http://bit.ly/2EfrdqR

7. ASPIRIN

• EJA recommends the use of aspirin as an option for venous thromboembolism (VTE) prevention after total hip arthroplasty, total knee arthroplasty and hip fracture surgery.
• EJA suggests the use of aspirin for VTE prevention after total hip arthroplasty, total knee arthroplasty and hip fracture surgery (high-risk procedures) in patients without high VTE risk.
• EJA suggests the use of aspirin for VTE prevention after low-risk orthopaedic procedures in patients with a high VTE risk or other high-risk orthopaedic procedures in patients without a high VTE risk.
• EJA suggests the use of aspirin for VTE prevention after total hip arthroplasty, total knee arthroplasty and hip fracture surgery in patients with an increased bleeding risk.
• EJA suggests the use of aspirin for VTE prevention after total hip arthroplasty or total knee arthroplasty in a rapid recovery (fast-track) programme.

Kindly refer to the full guidelines here to view all recommendations in Aspirin: http://bit.ly/2CYWvmx

8. SURGERY DURING PREGNANCY AND THE IMMEDIATE POSTPARTUM PERIOD

Nonobstetric surgery during pregnancy

• ESA recommends thromboprophylaxis following surgery during pregnancy or the postpartum period when they imply, as a consequence, bed rest, until full mobility is recovered.
• ESA suggests that thromboprophylaxis should be used in cases of perioperative infection during pregnancy or the postpartum period.

Caesarean section

• Thromboprophylaxis is recommended after caesarean section in all cases, except elective caesarean section in low-risk patients, but there is no clear consensus on the definition of this population.
• The duration of thromboprophylaxis following caesarean section should be at least 6 weeks for high-risk patients, and at least 7 days for the other patients requiring anticoagulation.

Kindly refer to the full guidelines here to view all recommendations in Surgery during pregnancy and the immediate postpartum period: http://bit.ly/2qyuVtL

9. DAY SURGERY AND FAST-TRACK SURGERY

• ESA recommends that all patients undergoing an ambulatory/fast-track protocol should be assessed for the VTE risk of the procedure and for any personal/additional VTE risk.
• For patients undergoing a low-risk procedure, without additional risk according to the Caprini score, ESA recommends general measures of thromboprophylaxis (including early ambulation and optimal hydration) over other specific measures (mechanical or pharmacological).
• For patients undergoing a low-risk procedure with additional risk factors, ESA recommends general measures of thromboprophylaxis (e.g. early ambulation and optimal hydration). ESA suggests assessing pharmacological prophylaxis with LMWH over other drugs. ESA suggests the use of specific mechanical measures [intermittent pneumatic compression (IPC) devices] in patients with an increased bleeding risk.
• For patients undergoing a high-risk procedure without additional risk factors, ESA recommends general measures of thromboprophylaxis (e.g. ambulation and optimal hydration). ESA suggests the administration of pharmacological prophylaxis with LMWH over other drugs. ESA suggests assessing specific mechanical measures (IPC) in patients with an increased bleeding risk.
• For patients undergoing a high-risk procedure with additional risk factors, we recommend general measures of thromboprophylaxis (e.g. early ambulation and optimal hydration) and pharmacological prophylaxis with LMWH over other drugs, or specific mechanical measures (IPC) in patients with an increased bleeding risk.

Kindly refer to the full guidelines here to view all recommendations in Day surgery and fast-track surgery: http://bit.ly/2CPLSWs

10. CHRONIC TREATMENTS WITH ANTIPLATELET AGENTS

• In patients receiving APA chronically, ESA recommends thromboprophylaxis in cases of moderate/high VTE risk, whilst assessing the risk of perioperative bleeding.
• In patients receiving APA chronically, if the risk of VTE outweighs the risk of bleeding, ESA suggests pharmacological (anticoagulant) prophylaxis (LMWH, direct oral anticoagulants, fondaparinux depending on the indication).
• In patients treated with dual antiplatelet therapy (recent coronary stent implantation) undergoing a procedure associated with a high risk of VTE, ESA suggests resuming APA shortly after the procedure, prioritising over pharmacological VTE prevention.
• If an anticoagulant is associated with an APA, ESA suggests the administration of the lowest approved dose.
• If the risk of bleeding of a combination of an APA and an anticoagulant outweighs the risk of VTE, ESA suggests considering intermittent pneumatic compression over anticoagulant prophylaxis, without discontinuing the APA.

Kindly refer to the full guidelines here to view all recommendations in Chronic treatments with antiplatelet agents: http://bit.ly/2CzAWrM

11. INTENSIVE CARE

• In critically ill patients, ESA recommends against the routine use of compression DUS screening of DVT.
• ESA recommends an institution-wide protocol for the prevention of VTE that includes the use of mechanical thromboprophylaxis that is IPC.
• For critically ill patients, ESA recommends using thromboprophylaxis with LMWH or LDUH and recommends LMWH over LDUH.
• For VTE prophylaxis in critically ill patients with severe renal insufficiency, ESA suggests the use of LDUH, dalteparin or reduced doses of enoxaparin. Monitoring of anti-Xa activity may be considered when LMWH is used in these patients.
• The use of pharmacological prophylaxis in patients with severe liver dysfunction should be carefully balanced against the risk of bleeding. If a treatment is administered, the use of LDUH or LMWH is suggested.
• ESA suggests no prophylaxis or the use of IPC in patients with a platelet count less than 50 000 mm⁻³ and a high risk of bleeding.

Kindly refer to the full guidelines here to view all recommendations in Intensive care: http://bit.ly/2m0QfCI

12. SURGERY IN THE OBESE PATIENT

Bariatric surgery

• Laparoscopic bariatric procedures for obese patients have a lower risk of VTE than open procedures.
• ESA suggests using only anticoagulants or IPC for obese patients with a low risk of VTE during and after bariatric procedures.
• ESA recommends using anticoagulants and IPC together for obese patients with a high risk of VTE (age >55 years, BMI >55 kg m⁻², history of VTE, venous disease, sleep apnoea, hypercoagulability or pulmonary hypertension) during and after bariatric procedures.
• ESA recommends the use of LMWH over LDUH.
• ESA suggests a dose of LMWH (3000 to 4000 anti-Xa IU 12 h⁻¹ subcutaneously) depending on BMI as acceptable for obese patients with a lower risk of VTE.
• ESA suggests the use of a higher dose of LMWH (4000 to 6000 anti-Xa IU 12 h⁻¹ subcutaneously) as acceptable for obese patients with a higher risk of VTE.
• ESA recommends extended prophylaxis for patients with a high risk of VTE during the postdischarge period for 10 to 15 days.

Nonbariatric surgery

ESA suggests that in surgery with an indication for VTE prophylaxis, a higher prophylactic dose of LMWH (3000 to 4000 anti-Xa IU 12 h⁻¹ subcutaneously) should be considered for obese patients with a BMI more than 40 kg m⁻² undergoing nonbariatric surgery.
 

Kindly refer to the full guidelines here to view all recommendations in Surgery in the obese patient: http://bit.ly/2CMEzhl

About ESA: The European Society of Anaesthesiology (ESA) resulted from the amalgamation of the former European Society of Anaesthesiologists (ESA), the European Academy of Anaesthesiology (EAA) and the Confederation of European National Societies of Anaesthesiologists (CENSA) and holds the most prominent position in the community of anaesthesiologists in Europe and elsewhere. The aims of the Society are: to promote exchange of information between European anaesthesiologists; to disseminate information in regard to anaesthesiology; to raise the standards of the speciality by fostering and encouraging education, research, scientific progress and exchange of information; to promote and protect the interest of its members; to promote improvements in safety and quality of care of patients who are under the care of anaesthesiologists inside and outside the operating room by facilitating and harmonising the activities of national and international societies of anaesthesiologists in Europe.