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ACC/AHA
Guideline Update for Perioperative Cardiovascular Evaluation
for Noncardiac Surgery
A
Report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines
(Committee to Update the 1996 Guidelines on Perioperative
Cardiovascular Evaluation for Noncardiac Surgery)
(Printer-friendly
version)
Revised
Table 11. General
Guidelines for Perioperative Prophylaxis for Venous
Thromboembolism*
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Type
of Patient/Surgery
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Recommendation
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Minor
surgery in a patient less than 40 years old
with no correlates of venous thromboembolism
risk†
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Early
ambulation
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Moderate-risk
surgery in a patient more than 40 to 60 years
old with no correlates of thromboembolism risk
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ES;
LDH (2 h preoperatively and every 12 h after)
or IPC (intraoperatively and postoperatively)
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Major
surgery in a patient less than 40 to 60 years
old with clinical conditions associated with
venous thromboembolism risk, or older than 60
years old without risk factors
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LDH
(every 8 h) or LMWH, IPC if prone to wound bleeding
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Very-high-risk
surgery in a patient with multiple clinical
conditions associated with thromboembolism risk
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LDH,
LMWH, or dextran combined with IPC. In selected
patients, perioperative warfarin (INR 2 to 3)
may be used.
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Total
hip replacement
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LMWH
(postoperative, subcutaneous twice daily, fixed
dose unmonitored) or warfarin (INR 2 to 3, started
preoperatively or immediately after surgery) or
adjusted-dose unfractionated heparin (started
preoperatively). ES or IPC may provide additional
efficacy.
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Total
knee replacement
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LMWH
(postoperative, subcutaneous, twice daily, fixed
dose unmonitored) or IPC
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Hip
fracture surgery
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LMWH
(preoperative, subcutaneous, fixed dose unmonitored)
or warfarin (INR 2 to 3). IPC may provide additional
benefit.
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Intracranial
neurosurgery
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IPC
with or without ES. Consider addition of LDH or
LMWH in high-risk patients.
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Acute
spinal cord injury with lower-extremity paralysis
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LMWH
for prophylaxis. Warfarin may also be effective.
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Patients
with multiple trauma
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LMWH
when feasible; serial surveillance with duplex
ultrasonography may be useful. In selected very-high-risk
patients, consider prophylactic caval filter.
If LMWH not feasible, IPC may be useful.
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ES
indicates graded-compression elastic stockings; LDH,
low-dose subcutaneous heparin; IPC, intermittent pneumatic
compression; LMWH, low-molecular-weight heparin; INR,
international normalized ratio.
*Developed
from Clagett Chest 114: 531s-560s
1998.
†Clinical
conditions associated with increased risk of venous
thromboembolism: advanced age; prolonged immobility
or paralysis; previous venous thromboembolism; malignancy;
major surgery of abdomen, pelvis, or lower extremity;
obesity; varicose veins; heart failure; myocardial infarction;
stroke; fracture(s) of the pelvis, hip, or leg; hypercoagulable
states; and possibly high-dose estrogen use.
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