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Chapter 31. Prevention of Venous Thromboembolism (continued)

Table 31. 1. Mechanical and pharmacologic preventative measures for VTE
PracticeTypeDescriptionComment
Graduated Elastic Stockings (ES)MechanicalFitted hose that extend above the kneeFitted hose are more efficacious than non-fitted
Intermittent pneumatic compression (IPC)MechanicalDevices fitted over lower extremities that sequentially inflate and deflate 
AspirinPharmacologicUsually 325 mg/d 
WarfarinPharmacologic5-10 mg started the day of or after surgery; adjust to achieve an INR of 2-3Monitoring of INR needed
Low-dose unfractionated heparin (LDUH)PharmacologicGenerally 5000 U subcutaneous bid or tid, though some studies have adjusted dose to maintain PTT at high end of normalContraindicated if active bleeding or history of thrombocytopenia; no need to follow coagulation studies (unless adjusted dose is used)
Low Molecular Weight Heparin (LMWH)PharmacologicDose depends on type of surgery and VTE risk*No need to monitor coagulation studies

*LMWH dosing: Enoxaparin 20 mg SC daily (moderate risk surgery) or 40 mg SC daily (can go up to 30 mg SC q12h for high risk general surgery, major trauma or acute spinal cord injury); dalteparin 2500-5000 U SC daily; nadroparin 2500 U SC daily; tinzaparin 3500-4500 U SC daily (may be dosed 75U/kg/d for orthopedic surgery).

Table 31. 2. Summary of DVT risk and prophylactic methods providing significant risk reduction*

Surgery/ ConditionRisk of all DVT in untreated patientsType of ProphylaxisRisk Reduction with ProphylaxisNumber of Studies
General Surgery225%ES44%3
LDUH68%47
LMWH76%21
IPC88%2
THR254%LMWH70%30
warfarin59%13
TKR2,2364%LMWH52%13
IPC73%6
Neuro-surgery27,2828%LMWH38%3
LDUH72%1a
Trauma2,3030-60%LMWH30% (compared to LDUH)1
Acute Spinal Cord Injury280%Not established  
Ischemic stroke255%LDUH56%5
LMWH58%3
Danaparoid82%4
Medical conditions216%LMWH76%2a
39%2
LDUH61%3a

*DVT indicates deep venous thrombosis; ES, graduated elastic stockings; IPC, intermittent pneumatic compression; LDUH, low-dose unfractionated heparin; LMWH, low molecular weight heparin; THR, total hip replacement; and TKR, total knee replacement.

aDVT diagnosed by fibrinogen uptake test (FUT)

Table 31. 3. Recommended VTE prophylaxis for surgical procedures and medical conditions*

Surgery/ConditionRecommended ProphylaxisComments
General Surgery—low-risk: minor procedures, <40 years old, no additional risksNoneEarly ambulation
General Surgery—moderate risk: minor procedure but with risk factor, nonmajor surgery age 40-60 with no risks, or major surgery <40 years with no risksLDUH, LMWH, ES, or IPC 
General Surgery—high risk: nonmajor surgery over age 60 or over age 40 with risks.LDUH, LMWH 
General Surgery—very high risk: major surgery over age 40 plus prior VTE, cancer or hypercoagulable stateLDUH or LMWH combined with ES or IPCMay consider postdischarge LMWH or perioperative warfarin
Elective Hip ReplacementLMWH or warfarinMay combine with ES or IPC; start LMWH 12 hours before surgery, 12-24 hours after surgery, or 4-6 hours after surgery at half the dose for initial dose. Start warfarin preoperatively or immediately after surgery, target INR 2. 0-3. 0.
Elective Knee ReplacementLMWH or warfarin 
Hip Fracture SurgeryLMWH or warfarin 
NeurosurgeryIPC, LDUH or LMWHStart LMWH post-surgery
TraumaLMWH with ES or IPCIf high risk of bleeding, may use ES and/or IPC alone.
Acute Spinal Cord InjuryLMWHContinue LMWH during rehabilitation or convert to warfarin (target INR 2. 5)
Ischemic StrokeLDUH, LMWH, or danaparoidIf contraindication to anticoagulant, use ES or IPC.
Medical ConditionsLDUH or LWMH

*Adapted with permission from Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Anderson FA, et al. Prevention of venous thromboembolism. Table: Regimens to prevent VTE, pp. 156S-158S. Chest 2001. Sixth ACCP Consensus Conference on Antithrombotic Therapy. 2 ES indicates graduated elastic stockings; INR, international normalized ratio; IPC, intermittent pneumatic compression; LDUH, low-dose unfractionated heparin; LMWH, low molecular weight heparin; and VTE, venous thromboembolism.

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Current as of July 2001
Internet Citation: Chapter 31. Prevention of Venous Thromboembolism (continued). July 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/evidence-based-reports/services/quality/er43/ptsafety/chapter31b.html