CHEST-2012 Prevention in NONORTHOPEDIC Surgical Patients

Question 1

Is VTE prophylaxis recommended for general and abdominal-pelvic surgery patients at VERY LOW RISK for VTE?

Answer 1

No, only early ambulation.

For general and abdominal-pelvic surgery
patients at very low risk for VTE ( <0.5%;
Rogers score, <7; Caprini score, 0), we recommend
that no specifi c pharmacologic (Grade 1B)
or mechanical (Grade 2C) prophylaxis be used
other than early ambulation.

Question 2

Is prophylaxis recommended for general and abdominal-pelvic surgery patients at LOW RISK for VTE?

Answer 2

Yes, IPC mechanical prophylaxis

For general and abdominal-pelvic surgery
patients at low risk for VTE ( 1.5%; Rogers
score, 7-10; Caprini score, 1-2), we suggest
mechanical prophylaxis, preferably with IPC,
over no prophylaxis (Grade 2C) .

Question 3

Prophylaxis options for general and abdominal-pelvic surgery patients at moderate risk for VTE?

Answer 3

LMWH or LDUH (Grade 2B)
IPC mechanical (Grade 2C)

For general and abdominal-pelvic surgery
patients at moderate risk for VTE ( 3.0%;
Rogers score, . 10; Caprini score, 3-4) who are
not at high risk for major bleeding complications,
we suggest LMWH (Grade 2B) , LDUH
(Grade 2B) , or mechanical prophylaxis, preferably
with IPC (Grade 2C) , over no prophylaxis.

Question 4

Prophylaxis options for general and abdominal-pelvic surgery patients at moderate risk for VTE AND high risk for major bleeding?

Answer 4

IPC mechanical prophylaxis

For general and abdominal-pelvic surgery
patients at moderate risk for VTE (about 3.0%;
Rogers score, >10; Caprini score, 3-4) who are
at high risk for major bleeding complications
or those in whom the consequences of bleeding
are thought to be particularly severe, we suggest
mechanical prophylaxis, preferably with IPC,
over no prophylaxis (Grade 2C) .

Question 5

Prophylaxis options for general and abdominal-pelvic surgery patients at high risk for VTE and not high risk of bleed?

Answer 5

LMWH or LDUH (1B) with IPC mechanical (2C)

For general and abdominal-pelvic surgery
patients at high risk for VTE ( 6.0%;
Caprini score, 5) who are not at high risk for
major bleeding complications, we recommend
pharmacologic prophylaxis with LMWH (Grade
1B) or LDUH (Grade 1B) over no prophylaxis.
We suggest that mechanical prophylaxis with ES
or IPC should be added to pharmacologic prophylaxis
(Grade 2C) .

Question 6

Prophylaxis duration for high-VTE-risk patients undergoing abdominal or pelvic surgery for cancer who are not otherwise at high risk for major bleeding?

Answer 6

4 weeks of LMWH

For high-VTE-risk patients undergoing
abdominal or pelvic surgery for cancer who are
not otherwise at high risk for major bleeding complications,
we recommend extended-duration
pharmacologic prophylaxis (4 weeks) with LMWH
over limited-duration prophylaxis (Grade 1B) .
Remarks: Patients who place a high value on minimizing
out-of-pocket health-care costs might prefer
limited-duration over extended-duration prophylaxis
in settings where the cost of extended-duration prophylaxis
is borne by the patient

Question 7

Prophylaxis for high-VTE-risk general and abdominal pelvic surgery patients who are at high risk for
major bleeding?

Answer 7

IPC mechanical until bleed risk decreases, then switch to pharmacologic

For high-VTE-risk general and abdominal pelvic
surgery patients who are at high risk for
major bleeding complications or those in whom the consequences of bleeding are thought to be
particularly severe, we suggest use of mechanical
prophylaxis, preferably with IPC, over no
prophylaxis until the risk of bleeding diminishes
and pharmacologic prophylaxis may be initiated
(Grade 2C) .

Question 8

Prophylaxis for general and abdominal-pelvic surgery

patients at high risk for VTE and low risk of major bleed, but LMWH or UFH is CI or unavailable?

Answer 8

Low-dose aspirin, fondaparinux, or IPC mechanical

For general and abdominal-pelvic surgery
patients at high risk for VTE ( 6%; Caprini
score, 5 or greater) in whom both LMWH and unfractionated heparin are contraindicated or unavailable and who are not at high risk for major
bleeding complications, we suggest low-dose
aspirin (Grade 2C) , fondaparinux (Grade 2C) , or
mechanical prophylaxis, preferably with IPC
(Grade 2C) , over no prophylaxis.

Question 9

Can an IVC filter be used for primary VTE prophylaxis in general and abdominal-pelvic surgery patients?

Answer 9

No.

For general and abdominal-pelvic surgery
patients, we suggest that an IVC filter should not
be used for primary VTE prevention (Grade 2C) .

Question 10

Should you conduct surveillance with VCU for general and abdominal-pelvic surgery patients?

Answer 10

No.

For general and abdominal-pelvic surgery
patients, we suggest that periodic surveillance
with VCU should not be performed (Grade 2C) .

Question 11

Recommended prophylaxis for cardiac surgery patients with an uncomplicated postoperative course?

Answer 11

IPC mechanical

For cardiac surgery patients with an
uncomplicated postoperative course, we suggest
use of mechanical prophylaxis, preferably with
optimally applied IPC, over either no prophylaxis
(Grade 2C) or pharmacologic prophylaxis
(Grade 2C)

Question 12

Recommended prophylaxis for cardiac surgery patients with one or more nonhemorrhagic surgical complications?

Answer 12

IPC mechanical plus LDUH or LMWH

For cardiac surgery patients whose hospital
course is prolonged by one or more nonhemorrhagic
surgical complications, we suggest adding
pharmacologic prophylaxis with LDUH or
LMWH to mechanical prophylaxis (Grade 2C) .

Question 13

Prophylaxis for thoracic surgery patients with moderate

risk for VTE but not high risk for major bleeding?

Answer 13

LDUH or LMWH (2B), or IPC mechanical (2C)

For thoracic surgery patients at moderate
risk for VTE who are not at high risk for major
bleeding, we suggest LDUH (Grade 2B) , LMWH
(Grade 2B) , or mechanical prophylaxis with optimally
applied IPC (Grade 2C) over no prophylaxis .

Question 14

Prophylaxis for thoracic surgery patients at high risk

for VTE but not at high risk for major bleeding?

Answer 14

LDUH or LMWH (1B)
Add ES or IPC mechanical (2C)

For thoracic surgery patients at high risk
for VTE who are not at high risk for major bleeding,
we suggest LDUH (Grade 1B) or LMWH
(Grade 1B) over no prophylaxis. In addition, we
suggest that mechanical prophylaxis with ES or
IPC should be added to pharmacologic prophylaxis
(Grade 2C)

Question 15

Prophylaxis for thoracic surgery patients at high risk for major bleeding?

Answer 15

IPC mechanical until bleed risk decreases, then switch to pharmacologic (2C)

For thoracic surgery patients who are at
high risk for major bleeding, we suggest use of
mechanical prophylaxis, preferably with optimally
applied IPC, over no prophylaxis until the
risk of bleeding diminishes and pharmacologic
prophylaxis may be initiated (Grade 2C)

Question 16

Prophylaxis for craniotomy patient?

Answer 16

IPC mechanical (2C)

For craniotomy patients, we suggest that
mechanical prophylaxis, preferably with IPC,
be used over no prophylaxis (Grade 2C) or pharmacologic
prophylaxis (Grade 2C)

Question 17

Prophylaxis for craniotomy patient at high risk of VTE?

Answer 17

Add pharmacologic to mechanical when bleed risk decreases (2C)

For craniotomy patients at very high risk
for VTE (eg, those undergoing craniotomy for
malignant disease), we suggest adding pharmacologic
prophylaxis to mechanical prophylaxis
once adequate hemostasis is established and the
risk of bleeding decreases (Grade 2C)

Question 18

Prophylaxis for spinal surgery?

Answer 18

IPC mechanical (2C)

For patients undergoing spinal surgery, we
suggest mechanical prophylaxis, preferably with
IPC, over no prophylaxis (Grade 2C) , unfractionated
heparin (Grade 2C) , or LMWH (Grade 2C) .

Question 19

Prophylaxis for spinal surgery and high risk of VTE?

Answer 19

Add pharmacologic to mechanical once bleed risk decreases (2C)

For patients undergoing spinal surgery at
high risk for VTE (including those with malignant
disease and those undergoing surgery with
a combined anterior-posterior approach), we
suggest adding pharmacologic prophylaxis to
mechanical prophylaxis once adequate hemostasis
is established and the risk of bleeding
decreases (Grade 2C)

Question 20

Prophylaxis for major trauma?

Answer 20

LDUH, LMWH, or IPC mechanical (2C)

For major trauma patients, we suggest
use of LDUH (Grade 2C) , LMWH (Grade 2C) , or
mechanical prophylaxis, preferably with IPC
(Grade 2C) , over no prophylaxis.

Question 21

Prophylaxis for major trauma + high risk VTE?

Answer 21

Add mechanical to pharmacologic if not contraindicated by lower extremity injury

For major trauma patients at high risk for
VTE (including those with acute spinal cord
injury, traumatic brain injury, and spinal surgery
for trauma), we suggest adding mechanical
prophylaxis to pharmacologic prophylaxis
(Grade 2C) when not contraindicated by lowerextremity
injury.

Question 22

Prophylaxis for major trauma but LMWH or LDUH contraindicated?

Answer 22

IPC mechanical if not CI by lower extremity injury, then add pharmacologic once no longer contraindicated

For major trauma patients in whom
LMWH and LDUH are contraindicated, we suggest mechanical prophylaxis, preferably with
IPC, over no prophylaxis (Grade 2C) when not
contraindicated by lower-extremity injury. We
suggest adding pharmacologic prophylaxis with
either LMWH or LDUH when the risk of bleeding
diminishes or the contraindication to heparin
resolves (Grade 2C) .

Question 23

Should you use IVC filter for propylaxis in major trauma?

Answer 23

No.

For major trauma patients, we suggest that
an IVC fi lter should not be used for primary
VTE prevention (Grade 2C) .

Question 24

Should you use surveillance with VCU for major trauma?

Answer 24

No.

For major trauma patients, we suggest
that periodic surveillance with VCU should not
be performed (Grade 2C) .