CHEST-2012 Prevention for ORTHOPEDIC Surgical Patients Flashcards
Prophylaxis for THA or TKA? Duration of therapy?
LMWH, LDUH, fonda, apix, dabi, rivarox, VKA, aspirin (1B) or IPCD (1C)
Duration of 10-14 days
In patients undergoing THA or TKA, we
recommend use of one of the following for a
minimum of 10 to 14 days rather than no antithrombotic
prophylaxis: LMWH, fondaparinux,
apixaban, dabigatran, rivaroxaban, LDUH,
adjusted-dose VKA, aspirin (all Grade 1B) , or an
IPCD (Grade 1C) .
Remarks: We recommend the use of only portable,
battery-powered IPCDs capable of recording and
reporting proper wear time on a daily basis for inpatients and outpatients. Efforts should be made to
achieve 18 h of daily compliance. One panel member
believed strongly that aspirin alone should not be
included as an option.
How long to hold LMWH before and after major orthopedic surgery (total hip, total knee, or hip fracture)?
Hold 12 hours prior, restart 12 hours after
For patients undergoing major orthopedic
surgery (THA, TKA, HFS) and receiving LMWH
as thromboprophylaxis, we recommend starting
either 12 h or more preoperatively or 12 h or
more postoperatively rather than within 4 h or
less preoperatively or 4 h or less postoperatively
(Grade 1B) .
Preferred pharmacologic prophylaxis for major orthopedic surgery (TKA, THA, HFS)?
LMWH over other agents
In patients undergoing THA or TKA, irrespective
of the concomitant use of an IPCD
or length of treatment, we suggest the use of
LMWH in preference to the other agents we
have recommended as alternatives: fondaparinux,
apixaban, dabigatran, rivaroxaban, LDUH (all
Grade 2B) , adjusted-dose VKA, or aspirin (all
Grade 2C) .
Remarks: If started preoperatively, we suggest administering
LMWH 12 h before surgery. Patients who
place a high value on avoiding the inconvenience of
daily injections with LMWH and a low value on the
limitations of alternative agents are likely to choose
an alternative agent. Limitations of alternative agents
include the possibility of increased bleed ing (which
may occur with fondaparinux, rivaroxaban, and VKA),
possible decreased effi cacy (LDUH, VKA, aspirin,
and IPCD alone), and lack of long-term safety data
(apixaban, dabigatran, and rivaroxaban). Furthermore,
patients who place a high value on avoiding
bleeding complications and a low value on its inconvenience
are likely to choose an IPCD over the drug
options.
Duration of prophylaxis therapy for major orthopedic surgery?
Extend duration to 35 days (instead of 10-14 days)
For patients undergoing major orthopedic
surgery, we suggest extending thromboprophylaxis
in the outpatient period for up to 35 days
from the day of surgery rather than for only 10 to
14 days (Grade 2B )
Should patients undergoing major orthopedic
surgery use dual prophylaxis with
an antithrombotic agent and an IPCD during
the hospital stay?
Yes
In patients undergoing major orthopedic
surgery, we suggest using dual prophylaxis with
an antithrombotic agent and an IPCD during
the hospital stay (Grade 2C) .
Remarks: We recommend the use of only portable,
battery-powered IPCDs capable of recording and reporting proper wear time on a daily basis. Efforts
should be made to achieve 18 h of daily compliance.
Patients who place a high value on avoiding the undesirable
consequences associated with prophylaxis
with both a pharmacologic agent and an IPCD are
likely to decline use of dual prophylaxis .
Prophylaxis for major orthopedic surgery and increased risk of bleed?
IPCD or no prophylaxis
In patients undergoing major orthopedic
surgery and increased risk of bleeding (Table 4),
we suggest using an IPCD or no prophylaxis
rather than pharmacologic treatment (Grade 2C)
Prophylaxis for major orthopedic surgery and decline injections or IPCD?
Apixaban or Dabigatran
VKA or Rivaroxaban if api and dabi are not available
In patients undergoing major orthopedic
surgery and who decline or are uncooperative
with injections or an IPCD, we recommend using
apixaban or dabigatran (alternatively rivaroxaban
or adjusted-dose VKA if apixaban or dabigatran
are unavailable) rather than alternative
forms of prophylaxis (all Grade 1B) .
Can you use IVC filter for major ortho surgery if CI to both pharmacologic and mechanical prophylaxis options?
No, choose no prophylaxis over IVC
In patients undergoing major orthopedic
surgery, we suggest against using IVC fi lter
placement for primary prevention over no thromboprophylaxis
in patients with an increased
bleeding risk (Table 4) or contraindications to
both pharmacologic and mechanical thromboprophylaxis
(Grade 2C)
Should major ortho surgical patients get DUS screening before hospital discharge if they are not symptomatic?
No.
For asymptomatic patients following major
orthopedic surgery, we recommend against DUS
screening before hospital discharge (Grade 1B)
Should you use pharmacologic prophylaxis for patients with isolated lower-leg injuries and require leg immobilization?
No. Choose no prophylaxis instead of pharmacologic.
We suggest no prophylaxis rather than pharmacologic
thromboprophylaxis in patients with
isolated lower-leg injuries requiring leg immobilization
(Grade 2C) .
Should you use prophylaxis for knee arthroscopy and no history of VTE?
No.
For patients undergoing knee arthroscopy
without a history of prior VTE, we suggest no
thromboprophylaxis rather than prophylaxis
(Grade 2B)
