Chest
SupplementAntithrombotic and Thrombolytic Therapy, 8th ED: ACCP GuidelinesPrevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Section snippets
Hospital Thromboprophylaxis Policy
1.2.1. For every general hospital, we recommend that a formal, active strategy that addresses the prevention of VTE be developed (Grade 1A).
1.2.2. We recommend that the local thromboprophylaxis strategy be in the form of a written, institution-wide thromboprophylaxis policy (Grade 1C).
1.2.3. We recommend the use of strategies shown to increase thromboprophylaxis adherence, including the use of computer decision support systems (Grade 1A) , preprinted orders (Grade 1B) , and periodic audit and
General Surgery
Studies20, 134, 135 performed > 20 years ago found that the rates of asymptomatic DVT in patients undergoing general surgical procedures without thromboprophylaxis varied between 15% and 30%, while the rates of fatal PE ranged between 0.2% and 0.9%. The risk of VTE in contemporary general surgical patients is uncertain because studies without thromboprophylaxis are no longer performed. Factors that may tend to reduce the risk of VTE in current patients include improvements in general
ORTHOPEDIC SURGERY
Patients undergoing major orthopedic surgery, which includes THR, TKR, and HFS, represent a group that has a particularly high risk for VTE, and routine thromboprophylaxis has been standard of care for > 20 years.1, 284, 285, 286, 287 Randomized clinical trials1, 288 have demonstrated that the rates of venographic DVT and proximal DVT 7 to 14 days following major orthopedic surgery in patients who received no thromboprophylaxis are approximately 40 to 60% and 10 to 30%, respectively (Table 8).
NEUROSURGERY
Patients undergoing major neurosurgery are considered to be at moderately increased risk for postoperative VTE, and warrant the routine use of thromboprophylaxis.1 In several randomized clinical trials, which included a spectrum of neurosurgery patients, the rate of DVT detected by FUT among the control subjects was 22%, and proximal DVT was detected in 5%.480 Intracranial (vs spinal) surgery, malignancy, prolonged procedures, leg weakness, and advanced age have all been shown to increase the
Trauma
Among hospitalized patients, those recovering from major trauma have among the highest risks for VTE.1, 496, 497, 498 Without thromboprophylaxis, patients with multisystem or major trauma have a DVT risk that exceeds 50%, and PE is the third-leading cause of death in those who survive beyond the first day. Factors that are independent predictors of VTE in trauma patients include the following: spinal cord injury (SCI), lower-extremity or pelvic fracture, need for a surgical procedure, insertion
MEDICAL CONDITIONS
Although VTE is most often considered to be associated with recent surgery or trauma, 50 to 70% of symptomatic thromboembolic events and 70 to 80% of fatal PEs occur in nonsurgical patients.1, 573 From the perspective of the general population, hospitalization for an acute medical illness is independently associated with about an eightfold- increased risk for VTE574 and accounts for almost one fourth of all VTE events.6 The risks of VTE and its prevention in stroke patients are discussed in
CANCER PATIENTS
Patients with cancer have at least a sixfold- increased risk of VTE compared to those without cancer,574, 607 and active cancer accounts for almost 20% of all new VTE events occurring in the community.6 Furthermore, VTE is one of the most common and costly complications seen in cancer patients.607, 608, 609, 610 Once VTE develops in a cancer patient, the VTE recurrence rate is high both after and during traditional anticoagulation.609, 610, 611, 612 The development of VTE in cancer patients is
CRITICAL CARE
While the risks of VTE in critically ill patients vary considerably depending primarily on their reason for intensive care, most ICU patients have multiple risk factors for VTE.1, 679, 680 Some of these risk factors predate admission to the ICU, and include recent surgery, trauma, sepsis, malignancy, stroke, advanced age, heart or respiratory failure, previous VTE, and pregnancy. Other thrombotic risk factors may be acquired during the ICU stay, and include immobilization, pharmacologic
LONG-DISTANCE TRAVEL
Prolonged air travel appears to be a risk factor for VTE, although this risk is mild.1, 582, 691, 692, 693, 694, 695, 696, 697, 698 Depending on differences in study design and populations, the magnitude of the reported risk of VTE associated with prolonged travel varies widely, ranging from no increased risk to a fourfold-increased risk.582, 691, 692, 693, 699, 700, 701, 702 The incidence of travel-related VTE is influenced by the type and duration of travel, and by individual risk factors.703
CONLICT OF INTEREST DISCLOSURES
Dr. Geertsdiscloses that he has received grant monies from the Canadian Institutes for Health Research, Sanofi-Aventis, and Pfizer. He has received consultant fees from Bayer, Eisai, GlaxoSmithKline, Lilly, Merck, Pfizer, Roche, and Sanofi-Aventis, along with speakers honoraria from Bayer, Calea, Oryx, Pfizer, and Sanofi-Aventis.
Dr. Bergqvistdiscloses that he has received grant monies from the Swedish Research Council and the Heart and Lung Foundation. He has also served on advisory committees
Acknowledgments
We are grateful to the following for providing very helpful reviews of the manuscript: Dr. Clive Kearon, Dr. Jack Hirsh, Dr. Gordon Guyatt, and Dr. Michael Gould. We thank Dr. David Matchar for providing an economic review of the duration of thromboprophylaxis after orthopedic surgery. Special thanks to Artemis Diamantouros and Tina Papastavros for invaluable assistance with the references.
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