Management of venous thromboembolism: ASH 2019 guidelines
The American Society of Hematology (ASH) has released updated guidelines for the management of venous thromboembolism. Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality. These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery.
Following are the major recommendations:
Mechanical vs pharmacological prophylaxis for patients undergoing major surgery
For patients undergoing major surgery, the ASH guideline panel suggests the following:
- Using pharmacological prophylaxis or mechanical prophylaxis (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯)
- For patients who do not receive pharmacologic prophylaxis, using mechanical prophylaxis over no mechanical prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).
- For patients who receive mechanical prophylaxis, using intermittent compression devices over graduated compression stockings (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).
- For patients who receive pharmacologic prophylaxis, using combined prophylaxis with mechanical and pharmacological methods over prophylaxis with pharmacological agents alone (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).
- Depending on the risk of VTE and bleeding based on the individual patient and the type of surgical procedure, using combined prophylaxis or mechanical prophylaxis alone (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯).
Prophylactic insertion of an inferior vena cava filter
For patients undergoing major surgery, the ASH guideline panel suggests against using inferior vena cava (IVC) filters for prophylaxis of VTE (conditional recommendation based on very low certainty in the evidence of effects, ⊕◯◯◯).
Timing of antithrombotic prophylaxis
Orthopaedic surgery
For patients undergoing total hip arthroplasty or total knee arthroplasty, the ASH guideline panel suggests using aspirin (ASA) or anticoagulants (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). When anticoagulants are used, the panel suggests using direct oral anticoagulants (DOACs) over low-molecular-weight heparin (LMWH) (conditional recommendation based on moderate certainty in the evidence of effects ⊕⊕⊕◯); the panel suggests using any of the DOACs approved for use (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯). If a DOAC is not used, the panel suggests using LMWH rather than warfarin (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯) and recommends LMWH rather than unfractionated heparin (UFH) (strong recommendation based on moderate certainty in the evidence of effects ⊕⊕⊕◯).
For patients undergoing hip fracture repair, the ASH guideline panel suggests using pharmacological prophylaxis over no pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯) and suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).
Major general surgery
For patients undergoing major general surgery, the ASH guideline panel suggests using pharmacological prophylaxis over no pharmacological prophylaxis (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯) and suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).
Laparoscopic cholecystectomy
For patients undergoing laparoscopic cholecystectomy, the ASH guideline panel suggests against using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). Remark: Patients with other risk factors for VTE (such as history of VTE, thrombophilia, or malignancy) may benefit from pharmacological prophylaxis.
Major neurosurgical procedures
For patients undergoing major neurosurgical procedures, the ASH guideline panel suggests against using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). For the subset of patients undergoing major neurosurgical procedures for whom pharmacological prophylaxis is used, the ASH guideline panel suggests using LMWH over UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).
Urological procedures
For patients undergoing transurethral resection of the prostate (TURP), the ASH guideline panel suggests against using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). For the subset of patients undergoing TURP for whom pharmacological prophylaxis is used, the ASH guideline panel suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). Remark: Patients with other risk factors for VTE (such as history of VTE, thrombophilia, or malignancy) may benefit from pharmacological prophylaxis.
For patients undergoing radical prostatectomy, the ASH guideline panel suggests against using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). For patients undergoing radical prostatectomy in whom pharmacological prophylaxis is used, the ASH guideline panel suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).
Cardiac or major vascular surgery
For patients undergoing cardiac or major vascular surgery, the ASH guideline panel suggests using pharmacological prophylaxis or no pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). When pharmacological prophylaxis is used, the panel suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).
Major trauma
For patients experiencing major trauma and who are at low to moderate risk for bleeding, the ASH guideline panel suggests using pharmacological prophylaxis over no pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).
For patients experiencing major trauma and who are at high risk for bleeding, the ASH guideline panel suggests against pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).
For patients experiencing major trauma in whom pharmacological prophylaxis is used, the ASH guideline panel suggests using LMWH or UFH (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯).
Major gynaecological surgery
For patients undergoing major gynaecological surgery, the ASH guideline panel suggests using pharmacological prophylaxis over no pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯) and suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).
For more details click on the link: https://doi.org/10.1182/bloodadvances.2019000975
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