Previous evaluation for thrombophilia
Family history of thromboembolism
Evaluation generally not indicated purely for perioperative purposes - treat as high-risk for VTE if history or exam suggests hereditary or acquired thrombophilia
Indications for Surgical Delay
VTE within 3 months, especially within 1 month
The below recommendations are a combination of various guidelines, studies, and the author's institutional protocols. These have not been published or validated. For more information on the rationale for these recommendations, click here.
Use table below for specific recommendations. If specific surgery not listed below, assess for additional VTE risk factors. If present and significant immobility anticipated, consider prophylactic dose LMWH until baseline mobility restored.
If pharmacologic prophylaxis indicated, start on the morning of POD#1 unless otherwise indicated. Bleeding risk should be assessed daily, and if bleeding risk too high for pharmacologic prophylaxis, provide mechanical prophylaxis alone & reassess safety of starting pharmacologic prophylaxis following day.
ASA, aspirin; HIT, heparin-induced thrombocytopenia; DOAC, direct oral anticoagulant; IPCs, intermittent pneumatic compressions devices; UFH, unfractionated heparin; TURP, transurethral resection of prostate; BID, twice daily; TID, three times daily
1 See table of DOAC VTE Prophylaxis Indications & Dosage
2 40 mg SQ daily for all indications except for total knee/hip arthroplasty where 30 mg SQ BID can be used for the first 7-10 days, followed by 40 mg SQ daily for another 3 weeks. Do not use if eGFR <30.
3 Target INR 2-3
4 Aspirin contraindications: aspirin allergy, severe gastroesophageal reflux, peptic ulcer disease within 3 months
5 Other VTE risk factors: personal history of VTE (triggered or spontaneous), known thrombophilia, active malignancy, >1 first degree relative with VTE
6 Given high variability of bleeding risk in cases of trauma, consult with surgeon to determine bleeding risk
7 If other VTE risk factors or prolonged immobility, consider extending prophylaxis beyond hospitalization
8 Based on recommendations from 2020 ASCE Guideline