Prevention of venous thromboembolism – Related resources

Cochrane reviews

• Slow subcutaneous injection of LMWH appears to have slightly lower pain intensity and bruising size at the injection site compared with fast injection .
• Alerts, such as computerized reminders and stickers on patient charts, appear to increase the use of thromboprophylaxis in hospitalized medical and surgical patients .
• Use of thromboprophylaxis may prevent deep vein thrombosis in severe trauma patients .
Primary prophylaxis for venous thromboembolism (VTE) with LMWH appears to reduce the incidence of symptomatic VTE in ambulatory cancer patients receiving chemotherapy. It has no effect on 1-year total mortality but may increase the risk of major bleeding .
• Direct thrombin inhibitors (ximelagatran, dabigatran and desirudin) may be as effective as LMWH and vitamin K antagonists in the prevention of major venous thromboembolism in total hip or knee replacement but seem to show higher mortality and cause more bleeding than LMWH .
• Prolonged thromboprophylaxis with low-molecular weight heparin (LMWH) reduces the risk of venous thromboembolism compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications after major abdominal or pelvic surgery, at least in cancer patients .
• Use of low molecular weight heparin (LMWH) in outpatients reduces the number of venous thromboembolic events when a plaster cast or brace is required, also for patients with below-knee casts .
• Combined mechanical intermittent pneumatic leg compression and pharmacological prophylaxis appear to decrease the incidence of deep vein thrombosis when compared to compression, and incidence of pulmonary embolism when compared to anticoagulation.
• Heparin plus graduated compression stockings appears to be better than either treatment alone for thrombus prophylaxis in colorectal surgery .
• Low molecular weight heparin MWH may reduce the incidence of distal DVT diagnosed by sonogram in adults undergoing knee arthroscopy .
• There is insufficient evidence to make a definitive conclusion about the use of anticoagulant drugs (with or without mechanical devices) for deep vein thrombosis prophylaxis in patients undergoing abdominal aortic surgery .

Other evidence summaries

• Pneumatic compression has lower incidence of thromboembolism than aspirin, warfarin or low molecular weight heparins after knee arthroplasty. A combination of regimes might be best strategy to incorporate their advantages . Three-times daily dosing of subcutaneous unfractionated heparin compared to twice-daily dosing may reduce thromboembolism rates but may increase the risk of bleeding among non-surgical hospital patients .
• Low-molecular weight (LMWH) or unfractionated heparin combined with mechanical prophylaxis may be more effective than heparin alone, and high-dose LMWH may be more effective than low-dose LMWH in preventing deep venous thrombosis in cancer patients undergoing surgery .

Clinical guidelines

• Guyatt GH, Akl EA, Crowther M et al. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):7S-47S.
• Kearon C, Akl EA, Comerota AJ et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):e419S-94S.
• Bates SM, Greer IA, Middeldorp S et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):e691S-736S.

Literature

• Morris RJ, Woodcock JP. Intermittent pneumatic compression or graduated compression stockings for deep vein thrombosis prophylaxis? A systematic review of direct clinical comparisons. Ann Surg 2010 Mar;251(3):393-6.
• Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med 2008 Nov 6;359(19):2025-33.
• Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med 1997 May 22;336(21):1506-11.
• Palmer A J, Koppenhagen K, Kirchhof B, Weber U, Bergemann R. Efficacy and safety of low molecular weight heparin, unfractionated heparin and warfarin for thrombo-embolism prophylaxis in orthopaedic surgery: a meta-analysis of randomised clinical trials. Haemostasis, 1997;27(2):75-84
• Blann AD, Lip GY. Venous thromboembolism. BMJ 2006 Jan 28;332(7535):215-9.
• Francis CW. Clinical practice. Prophylaxis for thromboembolism in hospitalized medical patients. N Engl J Med 2007 Apr 5;356(14):1438-44.
• Warkentin T,E, Greinacher A, Koster A, Lincoff AM. Treatment and prevention of heparin-induced thrombocytopenia. American College of Chest Physisicans Evidence-based Clinical Practice Guidelines (8th edition). Chest 2008;133:340S-380S)