Based on the tests for interaction, we did not demonstrate any evidence for a clinically relevant subgroup effect for any of the potentially desirable outcomes. Similarly, LMWH may result in little or no difference in symptomatic PEs (RR, 1.04; 95% CI, 0.11-9.92; low certainty in the evidence of effects). In such instances, further research may provide important information that alters the recommendations. Well-designed trials using clinically important VTE end points are required for patients at low to moderate risk for bleeding following trauma to determine the incremental benefits of pharmacological prophylaxis beyond mechanical methods alone. We are uncertain about the effect of pharmacological prophylaxis compared with no prophylaxis on reoperations (RR, 0.93; 95% CI, 0.35-2.50; very low certainty in the evidence of effects); this corresponds to 0 fewer (3 fewer to 6 more) reoperations per 1000 men based on a baseline risk of 0.4%.380. For patients undergoing laparoscopic cholecystectomy, the ASH guideline panel suggests against using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). To ensure that recent studies were not missed, searches (Supplement 5) were updated during October and November 2016, and panel members were asked to suggest any studies that may have been considered missed and fulfilled the inclusion criteria for the individual questions. doi: https://doi.org/10.1182/bloodadvances.2019000975. Part C summarizes ASH decisions about which interests were judged to be conflicts. wrote the first draft of the manuscript and revised the manuscript based on the authors’ suggestions; C.B., F.D., C.W.F., D.A.G., S.R.K., M.R., A.R., F.B.R., M.A.S., K.A.O.T., and A.J.Y. We rated the overall certainty in the evidence of effects as very low based on the lowest certainty in the evidence for the critical outcomes, downgrading for study limitations and very serious imprecision. Question: Should LMWH vs UFH be used for patients undergoing total hip or knee arthroplasty? Based on overall low certainty in the evidence of effects, the panel judged that there were no net benefits in favor of any DOAC vs another. Pharmacological prophylaxis compared with no pharmacological prophylaxis probably reduces mortality (RR, 0.76; 95% CI, 0.61-0.93; moderate certainty in the evidence of effects). We identified 4 studies in this review that fulfilled our inclusion criteria and measured outcomes relevant to this context.348,365-367  Our update of the systematic review identified 1 additional study that fulfilled the inclusion criteria.368  All studies included patients undergoing neurosurgical procedures. Procedure-specific risks of thrombosis and bleeding in urological cancer surgery: systematic review and meta-analysis, A randomized study of the safety and efficacy of fondaparinux versus placebo in the prevention of venous thromboembolism after coronary artery bypass graft surgery, Perioperative heparin prophylaxis of deep venous thrombosis in patients with peripheral vascular disease, Comparative effectiveness of preventative therapy for venous thromboembolism after coronary artery bypass graft surgery, Incidence of venous thromboembolism and benefits and risks of thromboprophylaxis after cardiac surgery: a systematic review and meta-Analysis, Primary prophylaxis for venous thromboembolism in patients undergoing cardiac or thoracic surgery, Prevention of deep venous thrombosis by a new low molecular weight heparin (Fluxum) in cardiac surgery, A randomised controlled trial of a low-molecular-weight heparin (Enoxaparin) to prevent deep-vein thrombosis in patients undergoing vascular surgery, Low molecular weight heparin prevention of post-operative deep vein thrombosis in vascular surgery, Efficacy of deep venous thrombosis prophylaxis in trauma patients and identification of high-risk groups, Venous thromboembolism after severe trauma: incidence, risk factors and outcome, The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients, Heparin versus enoxaparin for prevention of venous thromboembolism after trauma: A randomized noninferiority trial, A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma, Prospective trial of low-molecular-weight heparin versus unfractionated heparin in moderately injured patients, Incidence and timing of venous thromboembolism after surgery for gynecological cancer, Venous thromboembolism and use of prophylaxis among women undergoing laparoscopic hysterectomy, Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, Determining venous thromboembolic risk assessment for patients with trauma: the Trauma Embolic Scoring System, Scottish Intercollegiate Guidelines Network, Prevention and Management of Venous Thromboembolism: A National Clinical Guideline. The EtD framework is available online at https://guidelines.gradepro.org/profile/4885EDB9-B445-5554-BD62-CFE2EED6D08E. The panel acknowledges that the overall certainty in the evidence was very low, given the issue of indirectness, with most of the available trial data not being specific to gynecological procedures. The 2011 AAOS guideline402  recommends some form of chemoprophylaxis (including ASA) along with intermittent pneumatic compression after total hip or knee arthroplasty. For patients undergoing radical prostatectomy in whom pharmacological prophylaxis is used, the ASH guideline panel suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). A randomized, double-blind trial comparing enoxaparin with warfarin, Prevention of deep-vein thrombosis after total hip arthroplasty. There may be no difference in mortality between mechanical prophylaxis and no prophylaxis (RR, 1.33; 95% CI, 0.71-2.51; low certainty in the evidence of effects); this corresponds to 6 more (5 fewer to 28 more) deaths per 1000 patients. These studies should include detailed clinical characteristics of the patient populations. We identified 40 studies304-343  in these reviews that fulfilled our inclusion criteria and measured outcomes relevant to this context. Overall, the balance of effects did not favor LMWH or UFH, nor did cost-effectiveness or issues surrounding equity, acceptability, and feasibility, at least for inpatient prophylaxis. Performance measures should assess whether decision making is appropriate. Monthly search alerts were created and monitored to capture relevant new studies up to 1 July 2019, prior to submission of the manuscript for publication. The panel used an explicit process to rate the clinical severity of DVTs and PEs. The risks of mortality may be similar for patients treated with LMWH and UFH (RR, 1.03; 95% CI, 0.89-1.18; very low certainty in the evidence of effects), but we are very uncertain of this finding. Given the very low certainty in the evidence of effects this is based upon, there is a critical need for higher-quality studies comparing extended vs short-term prophylaxis using clinically important outcomes in contemporary surgical practices, which are marked by early patient mobilization and shorter hospital stays. Large RCTs using clinically important outcomes are needed to better define the relative benefits and risks of LMWH compared with UFH following hip fracture surgery. We are also very uncertain about the effect of LMWH on symptomatic proximal DVTs (RR, 1.33; 95% CI, 0.30-6.01; very low certainty in the evidence of effects) and symptomatic distal DVTs (RR, 1.20; 95% CI, 0.45-3.22; very low certainty in the evidence of effects). An international multicentre trial, Dihydroergotamine-heparin prophylaxis of postoperative deep vein thrombosis. Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. Twelve hours following surgery was arbitrarily selected to be the cutoff point between early and late postoperative antithrombotic administration. Remark: Patients with other risk factors for VTE (such as history of VTE, thrombophilia, or malignancy) may benefit from pharmacological prophylaxis. 368. The guideline panel suggests using combined mechanical and pharmacological prophylaxis or mechanical prophylaxis alone for patients undergoing major surgery (based on low certainty in the evidence of effects). There were no major implementation considerations. Please note: institutional and Research4Life access to the MJA For the subset of patients undergoing major neurosurgical procedures for whom pharmacological prophylaxis is used, the ASH guideline panel suggests using LMWH over UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). They recommend considering pharmacological VTE prophylaxis for a minimum of 7 days for patients who are undergoing open vascular surgery or major endovascular procedures, including endovascular aneurysm repair, and whose risk of VTE outweighs their risk of bleeding. Statements about the underlying values and preferences, as well as qualifying remarks accompanying each recommendation, are its integral parts and serve to facilitate more accurate interpretation. The evidence base to inform the relative effectiveness of pharmacological prophylaxis vs no pharmacological prophylaxis was comparable to that used to inform this question for patients undergoing laparoscopic cholecystectomy (see Recommendation 18). Overall, the balance of effects did not favor LMWH or UFH, nor did cost-effectiveness or issues surrounding equity, acceptability, and feasibility, at least for inpatient prophylaxis. The panel emphasized the need to periodically reevaluate bleeding risk as patients recover from major trauma. Further research into pharmacological prophylaxis following laparoscopic cholecystectomy was not regarded as high priority given the low baseline incidence of VTE complications in this patient population. Ten trials were performed on patients undergoing total hip arthroplasty,242-244,246,247,249-253  and 2 trials were conducted on patients undergoing total knee arthroplasty.245,248  Five trials reported the effect of LMWH compared with UFH on mortality,244,247,249,251,252  10 studies reported the effect on the development of symptomatic PEs,242-245,247-249,251-253  8 studies reported the effect on any proximal DVT,242,244-249,251  and 6 studies reported the effect on any distal DVT.242,244-249,251  Six studies reported the effect on the risk of major bleeding,244,245,249-251,253  and 2 studies reported the effect on the risk of reoperation.247,248. For patients at high baseline risk for major bleeding, mechanical prophylaxis would more clearly be favored because of the incremental risk of bleeding with pharmacological prophylaxis. Rates of symptomatic proximal DVT may be increased with use of IVC filters (RR, 2.19; 95% CI, 1.07-4.50; very low certainty in the evidence of effects), but we are once again very uncertain of this finding. Pharmacological prophylaxis appears to result in little or no difference in symptomatic PEs (RR, 2.40; 95% CI, 0.10-55.7; low certainty in the evidence of effects); this corresponds to 5 more (3 fewer to 198 more) PEs per 1000 patients receiving pharmacological prophylaxis based on a baseline risk of 0.4%.384  We are very uncertain whether pharmacological prophylaxis results in little or no difference in proximal DVTs (RR, 2.85; 95% CI, 0.12-67.83; low certainty in the evidence of effects). SIGN publication No. Prevention of thromboembolism in hysterectomies with low molecular weight heparin Fragmin [in German]. For patients who receive pharmacologic prophylaxis, using combined prophylaxis with mechanical and pharmacological methods over prophylaxis with pharmacological agents alone (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). Performance measures about the suggested course of action should focus on whether an appropriate decision-making process is duly documented. Randomized prospective study [in Portuguese]. This includes largely outdated means (eg, venography) to assess for VTEs postoperatively. When the risk for VTE is very low, it was recommended not to use pharmacological or mechanical prophylaxis. For symptomatic distal DVTs, pharmacological prophylaxis likely results in a reduction in risk (RR, 0.16; 95% CI, 0.05-0.58; moderate certainty in the evidence of effects); however, this corresponds to a possibly small, and likely unimportant, reduction in symptomatic distal DVTs in absolute terms of 2 fewer (1-2 fewer) per 1000 patients, based on a baseline risk of 1.2% from observational data.73. We are very uncertain of its effect on symptomatic proximal DVTs (RR, 0.38; 95% CI, 0.14-1.00; very low certainty in the evidence of effects), which would correspond to 1 fewer (0-1 fewer) symptomatic event in 1000 lower-risk patients or 3 fewer (0-5 fewer) events per 1000 higher-risk patients. We rated the overall certainty in the evidence of effects as low based on the lowest certainty in the evidence for the critical outcomes, downgrading for indirectness and imprecision. For patients undergoing major general surgery, the ASH guideline panel suggests using pharmacological prophylaxis over no pharmacological prophylaxis (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯). Question: Should pharmacological prophylaxis vs no pharmacological prophylaxis be used for patients undergoing TURP? On occasion, a strong recommendation is based on low or very low certainty in the evidence. Efficacy and tolerance of Fraxiparine in prevention of deep vein thrombosis in general surgery with spinal anesthesia (subarachnoidal and peridural) [in Italian], Low-molecular-weight heparin and unfractionated heparin in prophylaxis against deep vein thrombosis in critically ill patients undergoing major surgery, Low molecular weight heparin and prevention of postoperative thrombosis in abdominal surgery, Low rate of venous thromboembolism after craniotomy for brain tumor using multimodality prophylaxis, Antithrombotic prophylaxis in patients undergoing laparoscopic cholecystectomy, Incidence and risk factors for symptomatic venous thromboembolism following cholecystectomy, The effect of low-dose heparin on blood loss at abdominal hysterectomy, Fixed minidose warfarin: a new approach to prophylaxis against venous thrombosis after major surgery, Surgical haemorrhage in patients given subcutaneous heparin as prophylaxis against thromboembolism, The effects of low-dose heparin treatment on patients undergoing transvesical prostatectomy, Prevention of postoperative deep-vein thrombosis by low-dose heparin in urological surgery. 2: Clinical practice guidelines, GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. This corresponds to 10 fewer (0-14 fewer) symptomatic proximal DVTs per 1000 patients based on a baseline risk of 1.6% from observational data.73  It may reduce symptomatic distal DVTs (RR, 0.57; 95% CI, 0.36-0.90; low certainty in the evidence of effects), which corresponds to 1 fewer (0-1 fewer) symptomatic distal DVT per 1000 patients undergoing major general surgery based on a baseline risk of 1.6% from observational data.73. For patients undergoing major gynecological surgery, the ASH guideline panel suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). Cost-effectiveness probably favors combined pharmacological and mechanical prophylaxis. Date Implemented – 9/2022 Review Date – 9/2022 Author – Richard Hay (with input from Haematology and Vascular) PDF To Download We are also uncertain of the effect of early prophylaxis on symptomatic proximal DVTs (RR, 0.88; 95% CI, 0.40-1.96; very low certainty in the evidence of effects), corresponding to 2 fewer (10 fewer to 16 more) to 3 fewer (16 fewer to 25 more) per 1000 patients when applying baseline risks of 1.6% and 2.6%, respectively.73  Early prophylaxis has an uncertain effect on distal DVTs (RR, 0.68; 95% CI, 0.41-1.12; very low certainty in the evidence of effects), with an absolute risk reduction from 0 fewer (0-1 fewer; baseline risk, 0.1%73 ) to 1 fewer (0-1 fewer; baseline risk, 0.2%73 ) symptomatic distal DVT per 1000 patients. Similarly, irrespective of the baseline risk chosen, which was derived from a cohort study of 172 320 patients,73  there may be no difference for symptomatic PEs (RR, 1.04; 95% CI, 0.36-2.96; low certainty in the evidence of effects), corresponding to 0 fewer events (2 fewer to 7 more). They further indicate a preference for LMWH over the other listed agents, with the exception of ASA. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. An evaluation of the conditions and criteria (and the related judgments, research evidence, and additional considerations) that determined the conditional (rather than strong) recommendation will help to identify possible research gaps. Prospective randomized clinical study in general surgery comparing a new low molecular weight heparin with unfractionated heparin in the prevention of thrombosis, Canadian Colorectal Surgery DVT Prophylaxis Trial investigators, Subcutaneous heparin versus low-molecular-weight heparin as thromboprophylaxis in patients undergoing colorectal surgery: results of the Canadian Colorectal DVT Prophylaxis Trial: a randomized, double-blind trial, Prophylaxis of thromboembolic disease with RO-11 (ROVI), during abdominal surgery. The absence of unusual bleeding risks and there Should be considered as high priority at this time of,! And would be expected to receive prophylaxis with another DOAC, 12 setting of major reoperation given that there a... Common source of perioperative morbidity and mortality following major neurosurgical procedures are expected to receive prophylaxis with another be... 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