Guidelines: Use Compression, Heparin to Prevent VTE

BY JONATHAN GARDNER

Surgical inpatients should be offered thigh-length compression socks or other mechanical prophylaxis techniques at admission to prevent venous thromboembolism, according to a guideline published April 25 by the clinical effectiveness agency for England and Wales.

The guideline from the National Institute for Health and Clinical Excellence also calls on hospitals to offer low-molecular-weight heparin or fondaparinux to patients undergoing orthopedic surgery or to those with additional risk factors, such as active cancer or heart failure.

Regional anesthesia reduces the risk of venous thromboembolisms, and its suitability should be considered for individual patients, along with the patient's preferences, the guideline says.

Clinicians should also encourage patients to become active as soon as possible after surgery to lessen the risk of venous thromboembolism.

The NICE guideline comes 6 days after an expert group advising the U.K. Department of Health recommended that all National Health Service hospital patients be assessed for their risk of venous thromboembolism, and made recommendations similar to NICE's latest guideline (www.nice.org.uk/CG046).

For such procedures as hip fracture surgery, patients should remain on heparin or fondaparinux therapy for an additional 4 weeks, along with surgical patients with at least one risk factor. according to the guideline.

The Department of Health was silent on forms of mechanical prophylaxis other than compression socks, but NICE also recommends intermittent pneumatic compression or foot impulse devices in addition to or in place of compression socks.

NICE estimates that the guideline will save the NHS £4.4 million per year. The guideline will increase mechanical and pharmacologic prophylaxis costs by £21.8 million per year, but will avert £26.3 million in costs from treating deep vein thrombosis and pulmonary embolisms, according to NICE's costing report.

When asked to comment on this article, Dr. Ali AbuRahma, professor of surgery and chief of vascular and endovascular surgery, and medical director of the vascular laboratory at Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, stated: "The importance of deep vein thrombosis prevention is paramount; as seen in orthopedic patients in the National Confidential Inquiry Into Perioperative Deaths (NCEPOD) study, which indicates pulmonary embolism as the cause of death in 35% of patients at autopsy following hip replacement.

"Graduated compression stockings and intermittent leg compression devices decrease the incidence of DVT in moderate-risk surgical patients," he added.

"Their use is routine in surgical and trauma patients, with good reason, because approximately 50% of DVT occurs intraoperatively.

"With the ease of administration of low-molecular weight heparin products, and with no need for frequent laboratory work to assess the level of anticoagulation, anticoagulation therapy has become increasingly popular as a means of prophylaxis.

"This study is a timely one, and its recommendation is extremely appropriate, particularly since a significant number of hospitals in the United States still do not follow routine protocols for DVT prophylaxis for their inpatients," concluded Dr. AbuRahma, who is also an editorial advisor for VASCULAR SPECIALIST.