VTE prophylaxis for surgical patients

The choice of venous thromboembolism (VTE) (ie deep vein thrombosis [DVT] or pulmonary embolism [PE]) prophylaxis for surgical patients in hospital depends on an assessment of the patient’s risk of developing VTE weighed against their risk of bleeding. Multiple factors are usually involved and need to be considered, such as:

the type of surgical procedure (see VTE prophylaxis for surgical patients in hospital)
other VTE risk factors, such as the need for general anaesthesia or those listed in Risk factors for VTE in nonsurgical patients in hospital
bleeding risk factors (eg active peptic ulcer disease, bleeding in the 3 months before admission, acquired bleeding disorders, acute stroke, thrombocytopenia or uncontrolled systolic hypertension)
clinical consequences of bleeding, should it occur.

If VTE prophylaxis is used in surgical patients during a hospital admission, see VTE prophylaxis for surgical patients in hospital for recommendations of the suitable type and duration.

Do not start anticoagulant prophylaxis in the first 6 hours after surgery because the bleeding risk is increased; it should be started between 6 and 12 hours postoperatively, provided the surgeon judges that the bleeding risk is low. However, dabigatran can be started with a low first dose 1 to 4 hours after a total hip or knee replacement.

An epidural catheter should be inserted or withdrawn by an anaesthetist or general practitioner (GP) trained in anaesthesia. Wait at least 12 hours after giving a prophylactic dose of low molecular weight heparin (LMWH) (eg enoxaparin 40 mg), or 24 hours after a therapeutic dose of LMWH (eg enoxaparin 1 mg/kg or 1.5 mg/kg) to insert or withdraw an epidural catheter. Once the catheter is inserted or withdrawn, wait at least 4 hours before giving a subsequent dose of LMWHHorlocker, 2018. For patients who are receiving other anticoagulants, or patients with kidney impairment, seek expert advice about inserting or withdrawing an epidural catheter.

Table 1. VTE prophylaxis for surgical patients in hospital
Type of surgery	Prophylaxis and duration [NB1] [NB2]
total hip replacement	A DOAC [NB3] or LMWH or fondaparinux; continue for 28 to 35 days PLUS Graduated compression stockings or IPC or foot pump until fully mobile If pharmacological prophylaxis is contraindicated, use graduated compression stockings PLUS foot pump until fully mobile
total knee replacement	A DOAC [NB3] or LMWH or fondaparinux; continue for 10 to 14 days PLUS IPC or foot pump until fully mobile
hip fracture surgery	LMWH or fondaparinux; continue for 28 to 35 days If pharmacological prophylaxis is contraindicated, use IPC or foot pump until fully mobile
major general surgery (eg abdominal, gynaecological, cardiac, thoracic or vascular surgery)	LMWH or UFH [NB4]; continue for up to 1 week or until fully mobile PLUS Graduated compression stockings or other mechanical prophylaxis (eg IPC for cardiac, thoracic or vascular surgery, foot pump for major general surgery) until fully mobile
transurethral resection of the prostate (TURP) or radical prostatectomyAnderson, 2019	IPC or graduated compression stockings For patients at high risk of VTE, the surgeon may consider LMWH or UFH [NB5] in addition to or instead of IPC or graduated compression stockings. Caution is required because TURP and radical prostatectomy convey a significant bleeding risk
neurosurgeryAnderson, 2019	IPC or graduated compression stockings For patients at high risk of VTE, the surgeon may consider LMWH or UFH [NB5] in addition to or instead of IPC or graduated compression stockings. Caution is required because neurosurgery conveys a significant bleeding risk
trauma	From admission, foot pump PLUS Consider LMWH when bleeding risk becomes low
cancer patients having general, abdominal, pelvic or neurosurgery	LMWH or UFH [NB4] depending on bleeding risk; continue for at least 7 to 10 days postoperatively Consider 28 days of LMWH in patients having major abdominal or pelvic surgery for cancer If pharmacological prophylaxis is contraindicated, use graduated compression stockings See also VTE prophylaxis for patients with active cancer
caesarean section	LMWH for 5 to 7 days after delivery or until fully mobile [NB6], following: emergency caesarean section elective caesarean section—for patients with one or more additional risk factors for VTE PLUS Consider IPC or graduated compression stockings until fully mobile If pharmacological prophylaxis is contraindicated, consider IPC during surgery and for 24 hours postoperatively See also VTE prophylaxis during pregnancy and the postpartum period
Note: DOAC = direct-acting oral anticoagulant; IPC = intermittent pneumatic compression; LMWH = low molecular weight heparin; UFH = unfractionated heparin; VTE = venous thromboembolism NB1: For drug dosages, see Parenteral anticoagulants for VTE prophylaxis or Direct-acting oral anticoagulants for VTE prophylaxis. See also Mechanical VTE prophylaxis. NB2: Do not start an anticoagulant in the first 6 hours postoperatively (except for dabigatran, which can be started with a low first dose 1 to 4 hours after total hip or knee replacement). Exercise care in patients with an epidural catheter (see VTE prophylaxis for surgical patients for information on timing of insertion and withdrawal of epidural catheters). NB3: Some clinicians switch to aspirin monotherapy for VTE prophylaxis after 5 days of rivaroxaban therapy; see Aspirin for VTE prophylaxis following total hip or knee replacement. NB4: The efficacy of LMWH is at least the same as for UFH. LMWH has the advantage of once-daily dosing. NB5: The American Society of Hematology guidelines suggest using LMWH over UFH (a conditional recommendation based on very low certainty in the evidence of effects). NB6: For pregnant patients with additional risk factors for VTE (eg a pregnant patient who has had a prior VTE, received pharmacological prophylaxis antenatally, or has certain thrombophilias), extend duration of anticoagulant therapy to 6 weeks postpartum.