Deep Venous Thrombosis Prophylaxis

The importance of thromboembolism prophylaxis cannot be overstated. As the length of hospitalizations is being reduced, any event that delays discharge assumes significance. The first step is to assess the patient’s risk. Broad guidelines have been defined by Consensus Conferences and the American College of Chest Physicians (ACCP).
They provide categories of risk based upon medical condition, surgical intervention, length of operative time, and age. In addition to these factors, the patient’s individual characteristics need to be factored in, such as coexisting disease, mobility, inherited defects of coagulation, and prior history of DVT. Levels of intervention range from early ambulation and elastic stockings among those at low risk to combination therapy at the
high end. Interventions include both mechanical and pharmacologic methods. Intermittent compression devices are effective in preventing DVT in patients undergoing major surgery or with neurologic injuries.
However, their effectiveness against pulmonary embolism (PE) has not been demonstrated. The foot pump has been studied in patients undergoing orthopedic procedures and has been shown to decrease DVT.
The major advantage of these devices is their ability to be used in patients at high risk of bleeding.
Heparin has been a mainstay in prophylaxis of both DVT and PE. Standard unfractionated heparin given pre- and post- operatively or to medical patients significantly reduces the risk of thromboembolism. The newer low molecular weight heparins (LMWH) have also proved efficacious in prevention of DVT and PE. They are approved for use in both abdominal and orthopedic cases.
The use of warfarin as prophylaxis has been controversial. The potential for bleeding complications and the availability of other effective agents has limited its use; however, new evidence based on clinical trial data has led the ACCP to reevaluate its position.