Skip to main content
SpringerLink
Log in

Perioperative Thromboprophylaxis

  • Chapter
  • First Online:
Perioperative Hemostasis

Abstract

Arterial and venous thromboembolic events occur commonly after surgery and cause potentially preventable morbidity and mortality. Current evidence-based management strategies have significantly reduced the incidence of venous thromboembolism, although there is room for further improvements with the administration of safer antithrombotic agents and the implementation of specific guidelines coupled with rigorous clinical audits.

Novel antithrombotic agents (oral formulations of direct thrombin inhibitors or inhibitors of factor Xa) offer the advantages of more predictable biological responses, low potential for drug or dietary interactions, and greater specificity, with no need for routine patient monitoring. Further studies are needed to assess their risk–benefit and cost–utility compared to classic thromboprophylaxis.

The plethora of official recommendations can be confusing, if not overwhelming. In this review, we summarize the most effective methods of thromboprophylaxis available, taking into account the risks of bleeding and venous thromboembolism.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 139.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Notes

  1. 1.

    www.nice.org.uk/guidance/index.

References

  • Akl EA, Terrenato I et al (2008) Low-molecular-weight heparin vs unfractionated heparin for perioperative thromboprophylaxis in patients with cancer: a systematic review and meta-analysis. Arch Intern Med 168(12):1261–1269

    Article  PubMed  CAS  Google Scholar 

  • Astrup T (1958) The haemostatic balance. Thromb Diath Haemorrh 2(3–4):347–357

    PubMed  CAS  Google Scholar 

  • Bahl V, Hu M, Henke PK (2010) A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg 251(2):344–350

    Article  PubMed  Google Scholar 

  • Baser O, Supina D et al (2011) Clinical and cost outcomes of venous thromboembolism in Medicare patients undergoing total hip replacement or total knee replacement surgery. Curr Med Res Opin 27(2):423–429

    Article  PubMed  Google Scholar 

  • Bauer KA et al (2011) Recent progress in anticoagulant therapy: oral direct inhibitors of thrombin and factor Xa. J Thromb Haemost 9(Suppl 1):12–19

    Article  PubMed  CAS  Google Scholar 

  • Becattini C, Agnelli G et al (2012) Venous thromboembolism after laparoscopic bariatric surgery for morbid obesity: clinical burden and prevention. Surg Obes Relat Dis 8(1):108–115

    Article  PubMed  Google Scholar 

  • Bikdeli B, Sharif-Kashani B (2012) Prophylaxis for venous thromboembolism: a great global divide between expert guidelines and clinical practice? Semin Thromb Hemost 38(2):144–155

    Article  PubMed  CAS  Google Scholar 

  • Budnitz DS, Pollock DA et al (2006) National surveillance of emergency department visits for outpatient adverse drug events. JAMA 296(15):1858–1866

    Article  PubMed  CAS  Google Scholar 

  • Burness CB, McKeage K (2012) Dabigatran etexilate: a review of its use for the prevention of venous thromboembolism after total hip or knee replacement surgery. Drugs 72(7):963–986

    Article  PubMed  CAS  Google Scholar 

  • Caprini JA, Arcelus JI et al (2001) Effective risk stratification of surgical and nonsurgical patients for venous thromboembolic disease. Semin Hematol 38(2 Suppl 5):12–19

    Article  PubMed  CAS  Google Scholar 

  • Carlquist JF, Anderson JL (2011) Using pharmacogenetics in real time to guide warfarin initiation: a clinician update. Circulation 124(23):2554–2559

    Article  PubMed  Google Scholar 

  • Chee YL, Crawford JC et al (2008) Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol 140(5):496–504

    Article  PubMed  CAS  Google Scholar 

  • Cohen AT, Alikhan R et al (2005) Assessment of venous thromboembolism risk and the benefits of thromboprophylaxis in medical patients. Thromb Haemost 94(4):750–759

    PubMed  Google Scholar 

  • Cohen AT, Tapson VF et al (2008) Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 371(9610):387–394

    Article  PubMed  Google Scholar 

  • Darvall K, Bradbury A (2012) Pathways for venous thromboembolic prophylaxis in medical and surgical patients. Phlebology 27(Suppl 2):33–42

    Article  PubMed  Google Scholar 

  • Deitelzweig SB, McKean SC et al (2008) Prevention of venous thromboembolism in the orthopedic surgery patient. Cleve Clin J Med 75(Suppl 3):S27–S36

    Article  PubMed  Google Scholar 

  • Delis KT, Knaggs AL et al (2004) Effects of epidural-and-general anesthesia combined versus general anesthesia alone on the venous hemodynamics of the lower limb. A randomized study. Thromb Haemost 92(5):1003–1011

    PubMed  CAS  Google Scholar 

  • Dobesh PP (2009) Economic burden of venous thromboembolism in hospitalized patients. Pharmacotherapy 29(8):943–953

    Article  PubMed  Google Scholar 

  • Douketis JD, Spyropoulos AC et al (2012) Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e326S–e350S

    PubMed  CAS  PubMed Central  Google Scholar 

  • Duran A, Sengupta A et al (2012) Cost effectiveness of rivaroxaban versus enoxaparin for prevention of post-surgical venous thromboembolism from a U.S. payer’s perspective. Pharmacoeconomics 30(2):87–101

    Article  PubMed  Google Scholar 

  • Dzik WS (2012) Reversal of drug-induced anticoagulation: old solutions and new problems. Transfusion 52(Suppl 1):45S–55S

    Article  PubMed  CAS  Google Scholar 

  • Eerenberg ES, Kamphuisen PW et al (2011) Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects. Circulation 124(14):1573–1579

    Article  PubMed  CAS  Google Scholar 

  • Eriksson BI, Ekman S et al (1997a) Prevention of thromboembolism with use of recombinant hirudin. Results of a double-blind, multicenter trial comparing the efficacy of desirudin (Revasc) with that of unfractionated heparin in patients having a total hip replacement. J Bone Joint Surg Am 79(3):326–333

    PubMed  CAS  Google Scholar 

  • Eriksson BI, Wille-Jorgensen P et al (1997b) A comparison of recombinant hirudin with a low-molecular-weight heparin to prevent thromboembolic complications after total hip replacement. N Engl J Med 337(19):1329–1335

    Article  PubMed  CAS  Google Scholar 

  • Eriksson BI, Quinlan DJ et al (2009) Comparative pharmacodynamics and pharmacokinetics of oral direct thrombin and factor Xa inhibitors in development. Clin Pharmacokinet 48(1):1–22

    Article  PubMed  CAS  Google Scholar 

  • Falck-Ytter Y, Francis CW et al (2012) Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e278S–e325S

    PubMed  CAS  PubMed Central  Google Scholar 

  • Fareed J, Thethi I et al (2012) Old versus new oral anticoagulants: focus on pharmacology. Annu Rev Pharmacol Toxicol 52:79–99

    Article  PubMed  CAS  Google Scholar 

  • Galante M, Languasco A et al (2012) Venous thromboprophylaxis in general surgery ward admissions: strategies for improvement. Int J Qual Health Care 24(6):649–656

    Article  PubMed  Google Scholar 

  • Geerts WH, Bergqvist D et al (2008) Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133(6 Suppl):381S–453S

    Article  PubMed  CAS  Google Scholar 

  • Geraghty AJ, Welch K (2011) Antithrombotic agents for preventing thrombosis after infrainguinal arterial bypass surgery. Cochrane Database Syst Rev (6):CD000536

    Google Scholar 

  • Gogarten W, Vandermeulen E et al (2010) Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 27(12):999–1015

    Article  PubMed  CAS  Google Scholar 

  • Gomez-Outes A, Terleira-Fernandez AI et al (2012) Dabigatran, rivaroxaban, or apixaban versus enoxaparin for thromboprophylaxis after total hip or knee replacement: systematic review, meta-analysis, and indirect treatment comparisons. BMJ 344:e3675

    Article  PubMed  PubMed Central  Google Scholar 

  • Gould MK, Garcia DA et al (2012a) Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e227S–e277S

    PubMed  CAS  PubMed Central  Google Scholar 

  • Gould MK, Garcia DA et al (2012b) Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e227S–e277S

    PubMed  CAS  PubMed Central  Google Scholar 

  • Graetz TJ, Tellor BR et al (2011) Desirudin: a review of the pharmacology and clinical application for the prevention of deep vein thrombosis. Expert Rev Cardiovasc Ther 9(9):1101–1109

    Article  PubMed  CAS  Google Scholar 

  • Greinacher A, Warkentin TE (2008) The direct thrombin inhibitor hirudin. Thromb Haemost 99(5):819–829

    PubMed  CAS  Google Scholar 

  • Hahnenkamp K, Theilmeier G et al (2002) The effects of local anesthetics on perioperative coagulation, inflammation, and microcirculation. Anesth Analg 94(6):1441–1447

    PubMed  CAS  Google Scholar 

  • Hamilton MG, Yee WH et al (2011) Venous thromboembolism prophylaxis in patients undergoing cranial neurosurgery: a systematic review and meta-analysis. Neurosurgery 68(3):571–581

    Article  PubMed  Google Scholar 

  • Heron R, Davie A et al (2001) Interrater reliability of the Glasgow Coma Scale scoring among nurses in sub-specialties of critical care. Aust Crit Care 14(3):100–105

    Article  PubMed  CAS  Google Scholar 

  • Hirsh J, Warkentin TE et al (2001) Heparin and low-molecular-weight heparin: mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy, and safety. Chest 119(1 Suppl):64S–94S

    Article  PubMed  CAS  Google Scholar 

  • Horlocker TT, Wedel DJ et al (2010) Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 35(1):64–101

    Article  PubMed  CAS  Google Scholar 

  • Huber O, Bounameaux H et al (1992) Postoperative pulmonary embolism after hospital discharge. An underestimated risk. Arch Surg 127(3):310–313

    Article  PubMed  CAS  Google Scholar 

  • Januel JM, Chen G et al (2012) Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review. JAMA 307(3):294–303

    Article  PubMed  CAS  Google Scholar 

  • Junqueira DR, Perini E et al (2012) Unfractionated heparin versus low molecular weight heparin for avoiding heparin-induced thrombocytopenia in postoperative patients. Cochrane Database Syst Rev (9):CD007557

    Google Scholar 

  • Kaatz S, Kouides PA et al (2012) Guidance on the emergent reversal of oral thrombin and factor Xa inhibitors. Am J Hematol 87(Suppl 1):S141–S145

    Article  PubMed  CAS  Google Scholar 

  • Kakkar VV, Spindler J et al (1972) Efficacy of low doses of heparin in prevention of deep-vein thrombosis after major surgery: a double-blind, randomised trial. Lancet 300(7768):101–106

    Article  Google Scholar 

  • Kakkar AK, Brenner B et al (2008) Extended duration rivaroxaban versus short-term enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a double-blind, randomised controlled trial. Lancet 372(9632):31–39

    Article  PubMed  CAS  Google Scholar 

  • Kakkos SK, Caprini JA et al (2008) Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Cochrane Database Syst Rev (4):CD005258

    Google Scholar 

  • Kakkos SK, Warwick D et al (2012) Combined (mechanical and pharmacological) modalities for the prevention of venous thromboembolism in joint replacement surgery. J Bone Joint Surg Br 94(6):729–734

    Article  PubMed  CAS  Google Scholar 

  • Kanchanabat B, Stapanavatr W et al (2011) Systematic review and meta-analysis on the rate of postoperative venous thromboembolism in orthopaedic surgery in Asian patients without thromboprophylaxis. Br J Surg 98(10):1356–1364

    Article  PubMed  CAS  Google Scholar 

  • Keeling D, Baglin T et al (2011) Guidelines on oral anticoagulation with warfarin – fourth edition. Br J Haematol 154(3):311–324

    Article  PubMed  Google Scholar 

  • Khaw FM, Moran CG et al (1993) The incidence of fatal pulmonary embolism after knee replacement with no prophylactic anticoagulation. J Bone Joint Surg Br 75(6):940–941

    PubMed  CAS  Google Scholar 

  • Kucher N, Koo S et al (2005) Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med 352(10):969–977

    Article  PubMed  CAS  Google Scholar 

  • Mauermann WJ, Shilling AM et al (2006) A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a meta-analysis. Anesth Analg 103(4):1018–1025

    Article  PubMed  Google Scholar 

  • Mismetti P, Laporte S et al (2004) Prevention of venous thromboembolism in orthopedic surgery with vitamin K antagonists: a meta-analysis. J Thromb Haemost 2(7):1058–1070

    Article  PubMed  CAS  Google Scholar 

  • Morris RJ, Woodcock JP (2010) Intermittent pneumatic compression or graduated compression stockings for deep vein thrombosis prophylaxis? A systematic review of direct clinical comparisons. Ann Surg 251(3):393–396

    Article  PubMed  Google Scholar 

  • Muntz JE, Michota FA (2010) Prevention and management of venous thromboembolism in the surgical patient: options by surgery type and individual patient risk factors. Am J Surg 199(1 Suppl):S11–S20

    Article  PubMed  CAS  Google Scholar 

  • Muntz J, Scott DA et al (2004) Major bleeding rates after prophylaxis against venous thromboembolism: systematic review, meta-analysis, and cost implications. Int J Technol Assess Health Care 20(4):405–414

    Article  PubMed  Google Scholar 

  • Nagler M, Haslauer M et al (2012) Fondaparinux – data on efficacy and safety in special situations. Thromb Res 129(4):407–417

    Article  PubMed  CAS  Google Scholar 

  • Neumann I, Rada G et al (2012) Oral direct Factor Xa inhibitors versus low-molecular-weight heparin to prevent venous thromboembolism in patients undergoing total hip or knee replacement: a systematic review and meta-analysis. Ann Intern Med 156(10):710–719

    Article  PubMed  Google Scholar 

  • Oger E (2000) Incidence of venous thromboembolism: a community-based study in Western France. EPI-GETBP Study Group. Groupe d’Etude de la Thrombose de Bretagne Occidentale. Thromb Haemost 83(5):657–660

    PubMed  CAS  Google Scholar 

  • Ollendorf DA, Vera-Llonch M et al (2002) Cost of venous thromboembolism following major orthopedic surgery in hospitalized patients. Am J Health Syst Pharm 59(18):1750–1754

    PubMed  Google Scholar 

  • Pengo V, Lensing AW et al (2004) Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 350(22):2257–2264

    Article  PubMed  CAS  Google Scholar 

  • Petitou M, Nancy-Portebois V et al (2009) From heparin to EP217609: the long way to a new pentasaccharide-based neutralisable anticoagulant with an unprecedented pharmacological profile. Thromb Haemost 102(5):804–810

    PubMed  CAS  Google Scholar 

  • Phillips SM, Gallagher M et al (2008) Use graduated compression stockings postoperatively to prevent deep vein thrombosis. BMJ 336(7650):943–944

    Article  PubMed  PubMed Central  Google Scholar 

  • Poultsides LA, GonzalezDellaValle A et al (2012) Meta-analysis of cause of death following total joint replacement using different thromboprophylaxis regimens. J Bone Joint Surg Br 94(1):113–121

    Article  PubMed  CAS  Google Scholar 

  • Rahn DD, Mamik MM et al (2011) Venous thromboembolism prophylaxis in gynecologic surgery: a systematic review. Obstet Gynecol 118(5):1111–1125

    Article  PubMed  CAS  Google Scholar 

  • Rasmussen MS, Jorgensen LN et al (2009) Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev (1):CD004318

    Google Scholar 

  • Roderick P, Ferris G et al (2005) Towards evidence-based guidelines for the prevention of venous thromboembolism: systematic reviews of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis. Health Technol Assess 9(49):iii–iv, ix–x, 1–78

    PubMed  CAS  Google Scholar 

  • Rogers SO Jr, Kilaru RK et al (2007) Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg 204(6):1211–1221

    Article  PubMed  Google Scholar 

  • Salazar CA, Malaga G et al (2010) Direct thrombin inhibitors versus vitamin K antagonists or low molecular weight heparins for prevention of venous thromboembolism following total hip or knee replacement. Cochrane Database Syst Rev (4):CD005981

    Google Scholar 

  • Schenone M, Furie BC et al (2004) The blood coagulation cascade. Curr Opin Hematol 11(4):272–277

    Article  PubMed  CAS  Google Scholar 

  • Schulman S, Majeed A (2012) The oral thrombin inhibitor dabigatran: strengths and weaknesses. Semin Thromb Hemost 38(1):7–15

    Article  PubMed  CAS  Google Scholar 

  • Shantsila E, Lip GY et al (2009) Heparin-induced thrombocytopenia. A contemporary clinical approach to diagnosis and management. Chest 135(6):1651–1664

    Article  PubMed  CAS  Google Scholar 

  • Stringer MD, Steadman CA et al (1989) Deep vein thrombosis after elective knee surgery. An incidence study in 312 patients. J Bone Joint Surg Br 71(3):492–497

    PubMed  CAS  Google Scholar 

  • Tanaka KA, Key NS et al (2009) Blood coagulation: hemostasis and thrombin regulation. Anesth Analg 108(5):1433–1446

    Article  PubMed  CAS  Google Scholar 

  • Turpie AG (1998) Pharmacology of the low-molecular-weight heparins. Am Heart J 135(6 Pt 3 Su):S329–S335

    Article  PubMed  CAS  Google Scholar 

  • Turpie AGG, Bauer KA et al (2002) Fondaparinux vs enoxaparin for the prevention of venous thromboembolism in major orthopedic surgery: a meta-analysis of 4 randomized double-blind studies. Arch Intern Med 162(16):1833–1840

    Article  PubMed  CAS  Google Scholar 

  • Urbankova J, Quiroz R et al (2005) Intermittent pneumatic compression and deep vein thrombosis prevention. A meta-analysis in postoperative patients. Thromb Haemost 94(6):1181–1185

    PubMed  CAS  Google Scholar 

  • Van De Car DA, Rao SV et al (2010) Bivalirudin: a review of the pharmacology and clinical application. Expert Rev Cardiovasc Ther 8(12):1673–1681

    Article  Google Scholar 

  • Weinz C, Schwarz T et al (2009) Metabolism and excretion of rivaroxaban, an oral, direct factor Xa inhibitor, in rats, dogs, and humans. Drug Metab Dispos 37(5):1056–1064

    Article  PubMed  CAS  Google Scholar 

  • White RH, Zhou H et al (2003) Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures. Thromb Haemost 90(3):446–455

    PubMed  CAS  Google Scholar 

  • White RH, Chew H et al (2007) Targeting patients for anticoagulant prophylaxis trials in patients with cancer: who is at highest risk? Thromb Res 120(Suppl 2):S29–S40

    Article  PubMed  Google Scholar 

  • Wilde MI, Markham A (1997) Danaparoid. A review of its pharmacology and clinical use in the management of heparin-induced thrombocytopenia. Drugs 54(6):903–924

    Article  PubMed  CAS  Google Scholar 

  • Windisch C, Kolb W et al (2011) Pneumatic compression with foot pumps facilitates early postoperative mobilisation in total knee arthroplasty. Int Orthop 35(7):995–1000

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  • Wolberg AS, Aleman MM et al (2012) Procoagulant activity in hemostasis and thrombosis: Virchow’s triad revisited. Anesth Analg 114(2):275–285

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  • Wozniak M, Kruit A et al (2012) Prothrombin complex concentrate for the urgent reversal of warfarin. Assessment of a standard dosing protocol. Transfus Apher Sci 46(3):309–314

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil, Geneva, CH-1211, Switzerland

    Marc Aldenkortt & Marc Licker

Authors
  1. Marc Aldenkortt
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marc Licker
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marc Licker .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, University Hospital of Lausanne, Lausanne, Switzerland

    Carlo Enrique Marcucci

  2. Department of Anesthesiology, University Hospital of Lausanne, Lausanne, Switzerland

    Patrick Schoettker

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer-Verlag Berlin Heidelberg

About this chapter

Cite this chapter

Aldenkortt, M., Licker, M. (2015). Perioperative Thromboprophylaxis. In: Marcucci, C., Schoettker, P. (eds) Perioperative Hemostasis. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-55004-1_23

Download citation

  • DOI: https://doi.org/10.1007/978-3-642-55004-1_23

  • Published:

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-642-55003-4

  • Online ISBN: 978-3-642-55004-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation