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Starting Prophylaxis for Venous Thromboembolism Postoperatively

Starting Prophylaxis for Venous Thromboembolism Postoperatively Abstract A large proportion of hospitalized patients who are at high risk for venous thrombo-embolism (VTE) do not receive prophylaxis. Reluctance to use VTE prophylaxis in surgical patients may be due to fear of perioperative bleeding when anticoagulants are given preoperatively. We preformed a literature review to determine (1) whether prophylaxis for VTE is effective when it is started postoperatively and (2) the relative efficacy of preoperatively and postoperatively initiated prophylaxis. Studies were included in the review (1) if they were randomized trials with "blind" assessment of appropriate VTE outcomes, and (2) if prophylaxis was started postoperatively. Randomized, controlled trials establish that pharmacologic and nonpharmacologic methods of prophylaxis that are effective when started preoperatively are also effective when they are started postoperatively, with relative risks for VTE of 0.16 to 0.49. Low rates of VTE in noncontrolled randomized trials that included postoperatively intitiated prophylactic regimens support this finding. The relative efficacy of preoperatively and postoperatively initiated VTE prophylaxis could not be determined definitively, as direct comparisons of the same regimens have not been performed. Indirect comparisons suggest that any loss of efficacy resulting from deferring VTE prophylaxis until after surgery is unlikely to be marked. Randomized trials are required to resolve this question. This comparison may be of greatest clinical importance when twice-daily, low-molecular-weight heparin is used to prevent VTE after major orthopedic surgery. (Arch Intern Med. 1995;155:366-372) References 1. Clagett GP, Anderson FA, Levine MN, Salzman EW, Wheeler HB. Prevention of venous throm-boembolism. Chest . 1992;102:391 S-407S.Crossref 2. Flanc C, Kakkar VV, Clarke MB. The detection of venous thrombosis of the legs using 125-I fibrinogen. Br J Surg . 1968;55:742-747.Crossref 3. Pinto DJ. Controlled trial of an anticoagulant (war-farin sodium) in the prevention of venous thrombosis following hip surgery. Br J Surg . 1970: 57:349-352.Crossref 4. Browse NL, Clemenson G, Croft DN. Fibrinogen-detectable thrombosis in the legs and pulmonary embolism. BMJ . 1974;1:603-604.Crossref 5. Gallus AS, Salzman EW, Hirsh J. Prevention of venous thromboembolism . In: Colman RW, Hirsh J, Marder VJ, Salzman EW, eds. Hemostasis and Thrombosis: Basic Principles and Clinical Practice . Philadelphia, Pa: JB Lippincott Co; 1993: 1331-1345. 6. Collins R, Scrimgeour A, Yusuf S, Phil D, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. N Engl J Med . 1988; 318:1162-1173.Crossref 7. Nurmohamed MT, Rosendaal FR, Buller HR, et al. Low-molecular-weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis. Lancet . 1992;340:152-156.Crossref 8. Laverick MD, Croal SA, Mollan RAB. Orthopaedic surgeons and thromboprophylaxis. BMJ . 1991: 303:549-550.Crossref 9. Paiement GD, Wessinger SJ, Harris WH. Survey of prophylaxis against venous thromboembolism in adults undergoing hip surgery. Clin Orthop Rel Res . 1987;223:188-193. 10. Conti S, Daschbach M. Venous thromboembolism prophylaxis. Arch Surg . 1982;117:1036-1040.Crossref 11. O'Reilly R, Aggeler PM. Studies on coumarin anticoagulant drugs: initiation of warfarin therapy without a loading dose. Circulation . 1968:38: 169-177.Crossref 12. Hirsh J. Oral anticoagulant drugs. N Engl J Med . 1991;324:1865-1875.Crossref 13. Leizorovicz A, Haugh MC. Chapuis F-R, Samama MM, Boissel JP. Low molecular weight heparin in prevention of perioperative thrombosis. BMJ . 1992;305:913-920.Crossref 14. Thomas DG, Gart JJ. A table of exact confidence limits for differences and ratios of two proportions and their odds ratio. J Am Stat Assoc . 1977;72:73-76.Crossref 15. Turpie AGG, Gallus AS, Beattie WS, Hirsh J. Prevention of venous thrombosis in patients with intracranial disease by intermittent pneumatic compression of the calf. Neurology . 1977;27:435-438.Crossref 16. Hull RD, Raskob GE, Gent M, et al. Effectiveness of intermittent pneumatic leg compression for preventing deep vein thrombosis after total hip replacement. JAMA . 1990;263:2313-2317.Crossref 17. Wilson NV, Das SK, Kakkar VV, et al. Thrombo-embolic prophylaxis in total knee replacement: evaluation of the A-V impulse system. J Bone Joint Surg Br . 1992;74:50-52. 18. Lynch AF, Biurne RB, Rorabeck CH, et al. Deepvein thrombosis and continuous passive motion after total knee arthroplasty. J Bone J Surg Am . 1988;70:11-14. 19. Soreff J, Johnsson H, Diener L, Goransson L. Acetylsalicylic acid in a trial to diminish thromboembolic complications after elective hip surgery. Acta Orthop Scand . 1975;46:246-255.Crossref 20. Belch JJF, Meek DR, Lowe GDO, et al. Subcutaneous ancrod in prevention of deep vein thrombosis after hip replacement surgery. Thromb Res . 1982;25:23-31.Crossref 21. Turpie AGG, Levine MN, Hirsh J, et al. A randomized controlled trial of a low molecular weight heparin (enoxaparin) to prevent deep vein thrombosis in patients undergoing elective hip surgery. N Engl J Med . 1986;315:925-929.Crossref 22. Leclerc JR, Geerts WH, Desjardins L, et al. Prevention of deep vein thrombosis after major knee surgery: a randomized, double-blind trial comparing a low molecular weight heparin fragment (enoxaparin) to placebo. Thromb Hae-most . 1992;67:417-423. 23. Bailey JP, Kruger MP, Solano FX, Zajko AB, Rubash HE. Prospective randomized trial of sequential compression devices vs low-dose war-farin for deep venous thrombosis prophylaxis in total hip arthroplasty. J Arthroplasty . 1991;6: S29-S35.Crossref 24. Levine MN, Hirsh J, Gent M. Prevention of deep vein thrombosis after elective hip surgery: a ran-domized trial comparing low molecular weight heparin with standard unfractionated heparin. Ann Intern Med . 1991;114:545-551.Crossref 25. Hull R, Raskob G, Pineo G, et al. A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implatation , N Engl J Med . 1993;329:1370-1376.Crossref 26. Colwell CW, Spiro TE, Trowbridge AA, et al. Use of enoxaparin, a low-molecular-weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement. J Bone Joint Surg Am . 1994;76:3-14. 27. Heit J, Kessler C, Mammen E, et al. Efficacy and safety of RD heparin (a LMWH) versus warfarin for prevention of deep-vein thrombosis after hip or knee replacement. Blood . 1991;78( (suppl 1) ): 187. Abstract A739. 28. Francis CW, Marder VJ, Evarts CM, Yaukoolbodi S. Two-step warfarin therapy: prevention of post-operative venous thrombosis without excessive bleeding. JAMA . 1983;249:374-378.Crossref 29. Green D, Lee MY, Ito VY, et al. Fixed- vs adjusteddose heparin in the prophylaxis of thromboembolism in spinal cord injury. JAMA . 1988;260: 1255-1258.Crossref 30. Heatley RV, Morgan A, Hughes LE, Okwonga W. Preoperative or postoperative deep-vein throm-bosis? Lancet . 1976;1:437-439.Crossref 31. Powers P, Gent M, Klimek M, et al. A randomized, double-blind trial comparing a low-molecular weight heparinoid, orgaran, with aspirin in the prevention of venous thromboembolism following surgery for hip fracture. Thromb Hae-most . 1993:69:1116. 32. Consensus Conference. Prevention of venous thrombosis and pulmonary embolism. JAMA . 1986;256:744-749.Crossref 33. Conference. Prevention of deep venous thrombosis and pulmonary embolism. Lancet . 1986; 1:1202-1203. 34. European Consensus Statement. Prevention of venous thromboembolism. Int Angiol . 1992;11: 151-159. 35. Bergqvist D. Prevention of postoperative throm boembolism in Sweden: the development of practice during five years. Thromb Haemost . 1985; 53:239-241. 36. Anderson FA, Wheeler HB, Goldberg RJ, Hosmer DW, Forcier A, Patwardhan NA. Physician practices in the prevention of venous throm boembolism. Ann Intern Med . 1991;115:591-595.Crossref 37. Maynard MJ, Sculco TP, Ghelman B. Progression and regression of deep vein thrombosis after total knee arthroplasty. Clin Orthop Rel Res . 1991;273:125-130. 38. Parmet JL, Berman AT, Horrow JC, Harding S, Rosenberg H. Thromboembolism coincident with tourniquet deflation during total knee arthroplasty. Lancet . 1993;341:1057-1058.Crossref 39. Kakkar W, Howe CT, Flanc C, Clarke MB. Natural history of postoperative deep-vein thrombosis. Lancet . 1969;2:230-232.Crossref 40. Sevitt S, Gallagher NG. Prevention of venous thrombosis and pulmonary embolism in injured patients. Lancet . 1959;2:981-989.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Starting Prophylaxis for Venous Thromboembolism Postoperatively

Kearon, Clive; Hirsh, Jack
Archives of Internal Medicine , Volume 155 (4) – Feb 27, 1995
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References (52)

Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430040034004
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Abstract

Abstract A large proportion of hospitalized patients who are at high risk for venous thrombo-embolism (VTE) do not receive prophylaxis. Reluctance to use VTE prophylaxis in surgical patients may be due to fear of perioperative bleeding when anticoagulants are given preoperatively. We preformed a literature review to determine (1) whether prophylaxis for VTE is effective when it is started postoperatively and (2) the relative efficacy of preoperatively and postoperatively initiated prophylaxis. Studies were included in the review (1) if they were randomized trials with "blind" assessment of appropriate VTE outcomes, and (2) if prophylaxis was started postoperatively. Randomized, controlled trials establish that pharmacologic and nonpharmacologic methods of prophylaxis that are effective when started preoperatively are also effective when they are started postoperatively, with relative risks for VTE of 0.16 to 0.49. Low rates of VTE in noncontrolled randomized trials that included postoperatively intitiated prophylactic regimens support this finding. The relative efficacy of preoperatively and postoperatively initiated VTE prophylaxis could not be determined definitively, as direct comparisons of the same regimens have not been performed. Indirect comparisons suggest that any loss of efficacy resulting from deferring VTE prophylaxis until after surgery is unlikely to be marked. Randomized trials are required to resolve this question. This comparison may be of greatest clinical importance when twice-daily, low-molecular-weight heparin is used to prevent VTE after major orthopedic surgery. (Arch Intern Med. 1995;155:366-372) References 1. Clagett GP, Anderson FA, Levine MN, Salzman EW, Wheeler HB. Prevention of venous throm-boembolism. Chest . 1992;102:391 S-407S.Crossref 2. Flanc C, Kakkar VV, Clarke MB. The detection of venous thrombosis of the legs using 125-I fibrinogen. Br J Surg . 1968;55:742-747.Crossref 3. Pinto DJ. Controlled trial of an anticoagulant (war-farin sodium) in the prevention of venous thrombosis following hip surgery. Br J Surg . 1970: 57:349-352.Crossref 4. Browse NL, Clemenson G, Croft DN. Fibrinogen-detectable thrombosis in the legs and pulmonary embolism. BMJ . 1974;1:603-604.Crossref 5. Gallus AS, Salzman EW, Hirsh J. Prevention of venous thromboembolism . In: Colman RW, Hirsh J, Marder VJ, Salzman EW, eds. Hemostasis and Thrombosis: Basic Principles and Clinical Practice . Philadelphia, Pa: JB Lippincott Co; 1993: 1331-1345. 6. Collins R, Scrimgeour A, Yusuf S, Phil D, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. N Engl J Med . 1988; 318:1162-1173.Crossref 7. Nurmohamed MT, Rosendaal FR, Buller HR, et al. Low-molecular-weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis. Lancet . 1992;340:152-156.Crossref 8. Laverick MD, Croal SA, Mollan RAB. Orthopaedic surgeons and thromboprophylaxis. BMJ . 1991: 303:549-550.Crossref 9. Paiement GD, Wessinger SJ, Harris WH. Survey of prophylaxis against venous thromboembolism in adults undergoing hip surgery. Clin Orthop Rel Res . 1987;223:188-193. 10. Conti S, Daschbach M. Venous thromboembolism prophylaxis. Arch Surg . 1982;117:1036-1040.Crossref 11. O'Reilly R, Aggeler PM. Studies on coumarin anticoagulant drugs: initiation of warfarin therapy without a loading dose. Circulation . 1968:38: 169-177.Crossref 12. Hirsh J. Oral anticoagulant drugs. N Engl J Med . 1991;324:1865-1875.Crossref 13. Leizorovicz A, Haugh MC. Chapuis F-R, Samama MM, Boissel JP. Low molecular weight heparin in prevention of perioperative thrombosis. BMJ . 1992;305:913-920.Crossref 14. Thomas DG, Gart JJ. A table of exact confidence limits for differences and ratios of two proportions and their odds ratio. J Am Stat Assoc . 1977;72:73-76.Crossref 15. Turpie AGG, Gallus AS, Beattie WS, Hirsh J. Prevention of venous thrombosis in patients with intracranial disease by intermittent pneumatic compression of the calf. Neurology . 1977;27:435-438.Crossref 16. Hull RD, Raskob GE, Gent M, et al. Effectiveness of intermittent pneumatic leg compression for preventing deep vein thrombosis after total hip replacement. JAMA . 1990;263:2313-2317.Crossref 17. Wilson NV, Das SK, Kakkar VV, et al. Thrombo-embolic prophylaxis in total knee replacement: evaluation of the A-V impulse system. J Bone Joint Surg Br . 1992;74:50-52. 18. Lynch AF, Biurne RB, Rorabeck CH, et al. Deepvein thrombosis and continuous passive motion after total knee arthroplasty. J Bone J Surg Am . 1988;70:11-14. 19. Soreff J, Johnsson H, Diener L, Goransson L. Acetylsalicylic acid in a trial to diminish thromboembolic complications after elective hip surgery. Acta Orthop Scand . 1975;46:246-255.Crossref 20. Belch JJF, Meek DR, Lowe GDO, et al. Subcutaneous ancrod in prevention of deep vein thrombosis after hip replacement surgery. Thromb Res . 1982;25:23-31.Crossref 21. Turpie AGG, Levine MN, Hirsh J, et al. A randomized controlled trial of a low molecular weight heparin (enoxaparin) to prevent deep vein thrombosis in patients undergoing elective hip surgery. N Engl J Med . 1986;315:925-929.Crossref 22. Leclerc JR, Geerts WH, Desjardins L, et al. Prevention of deep vein thrombosis after major knee surgery: a randomized, double-blind trial comparing a low molecular weight heparin fragment (enoxaparin) to placebo. Thromb Hae-most . 1992;67:417-423. 23. Bailey JP, Kruger MP, Solano FX, Zajko AB, Rubash HE. Prospective randomized trial of sequential compression devices vs low-dose war-farin for deep venous thrombosis prophylaxis in total hip arthroplasty. J Arthroplasty . 1991;6: S29-S35.Crossref 24. Levine MN, Hirsh J, Gent M. Prevention of deep vein thrombosis after elective hip surgery: a ran-domized trial comparing low molecular weight heparin with standard unfractionated heparin. Ann Intern Med . 1991;114:545-551.Crossref 25. Hull R, Raskob G, Pineo G, et al. A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implatation , N Engl J Med . 1993;329:1370-1376.Crossref 26. Colwell CW, Spiro TE, Trowbridge AA, et al. Use of enoxaparin, a low-molecular-weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement. J Bone Joint Surg Am . 1994;76:3-14. 27. Heit J, Kessler C, Mammen E, et al. Efficacy and safety of RD heparin (a LMWH) versus warfarin for prevention of deep-vein thrombosis after hip or knee replacement. Blood . 1991;78( (suppl 1) ): 187. Abstract A739. 28. Francis CW, Marder VJ, Evarts CM, Yaukoolbodi S. Two-step warfarin therapy: prevention of post-operative venous thrombosis without excessive bleeding. JAMA . 1983;249:374-378.Crossref 29. Green D, Lee MY, Ito VY, et al. Fixed- vs adjusteddose heparin in the prophylaxis of thromboembolism in spinal cord injury. JAMA . 1988;260: 1255-1258.Crossref 30. Heatley RV, Morgan A, Hughes LE, Okwonga W. Preoperative or postoperative deep-vein throm-bosis? Lancet . 1976;1:437-439.Crossref 31. Powers P, Gent M, Klimek M, et al. A randomized, double-blind trial comparing a low-molecular weight heparinoid, orgaran, with aspirin in the prevention of venous thromboembolism following surgery for hip fracture. Thromb Hae-most . 1993:69:1116. 32. Consensus Conference. Prevention of venous thrombosis and pulmonary embolism. JAMA . 1986;256:744-749.Crossref 33. Conference. Prevention of deep venous thrombosis and pulmonary embolism. Lancet . 1986; 1:1202-1203. 34. European Consensus Statement. Prevention of venous thromboembolism. Int Angiol . 1992;11: 151-159. 35. Bergqvist D. Prevention of postoperative throm boembolism in Sweden: the development of practice during five years. Thromb Haemost . 1985; 53:239-241. 36. Anderson FA, Wheeler HB, Goldberg RJ, Hosmer DW, Forcier A, Patwardhan NA. Physician practices in the prevention of venous throm boembolism. Ann Intern Med . 1991;115:591-595.Crossref 37. Maynard MJ, Sculco TP, Ghelman B. Progression and regression of deep vein thrombosis after total knee arthroplasty. Clin Orthop Rel Res . 1991;273:125-130. 38. Parmet JL, Berman AT, Horrow JC, Harding S, Rosenberg H. Thromboembolism coincident with tourniquet deflation during total knee arthroplasty. Lancet . 1993;341:1057-1058.Crossref 39. Kakkar W, Howe CT, Flanc C, Clarke MB. Natural history of postoperative deep-vein thrombosis. Lancet . 1969;2:230-232.Crossref 40. Sevitt S, Gallagher NG. Prevention of venous thrombosis and pulmonary embolism in injured patients. Lancet . 1959;2:981-989.Crossref

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Archives of Internal Medicine – American Medical Association

Published: Feb 27, 1995

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