Perioperative venous thromboembolism prophylaxis

Management

• Non-orthopedic surgery
  • Can estimate risk using Caprini and Rogers scores
  • If very low risk, no prophylaxis
  • If low risk, intermittent pneumatic compression (IPC)
  • If moderate risk, IPC or UFH/LMWH
  • If high risk, UFH/LMWH
  • If cancer, continue prophylaxis for 4 weeks
  • If significant bleeding risk, consider fondaparinux or aspirin
• Orthopedic surgery
  • Total hip or knee arthroplasty: LMWH for 14 to 35 days ± IPC
• Start prophylaxis 12 hours post-operatively unless significant bleeding concerns

Medications

• In general, prefer low molecular weight heparin (LMWH): enoxaparin 40 mg daily or 30 mg BID, or dalteparin 5000 u daily
• If renal failure, can use unfractionated heparin (UFH) 5000 u BID
• Alternatives include:
  • Fondaparinux 2.5 mg daily
  • Direct oral anticoagulants
    • Dabigatran 220 mg daily
    • Rivaroxaban 10 mg daily
    • Apixaban 2.5 mg BID
  • Warfarin

Further Reading

• Perioperative Management of Antithrombotic Therapy. CHEST. 2012;141(2):e326S-e350S. doi: 10.1378/chest.11-2298