Other purposes are to inform policy, education, and advocacy and to state future research needs. A wandlike device (transducer) placed over the part of your body where there's a clot sends sound waves into the area… For patients experiencing major trauma at low to moderate risk for bleeding, the ASH guideline panel suggests using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). The panel judged that the balance between desirable and undesirable effects does not favor combined pharmacological and mechanical prophylaxis vs mechanical prophylaxis alone. The panel was unable to assess the relative effect of mechanical prophylaxis on potential hazards, such as falls or skin complications. There is no difference in mortality between pneumatic compression and graduated compression stockings prophylaxis (RR, 1.04; 95% CI, 0.16-6.63; low certainty in the evidence of effects); this corresponds to 2 more (41 fewer to 274 more) per 1000 patients. Because LMWH and UFH are in widespread use for this indication, the panel did not judge there to be major implementation considerations with either intervention. [ 1] Acute-Phase Treatment of … 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. Decision aids may be useful in helping patients to make decisions consistent with their individual risks, values, and preferences. The panel was unable to assess the impact of adding mechanical prophylaxis on the risk of other outcomes, such as falls or skin complications. Supplement 2 provides the complete “Disclosure of Interests” forms of all panel members. We are very uncertain about the effect of LMWH on symptomatic PEs (RR, 2.13; 95% CI, 0.06-81.3; very low certainty in the evidence of effect). A double-blind, randomised trial, Postoperative deep vein thrombosis of the lower limb and prophylactic value of heparin evaluated by phlebography, Clinical and haemostatic parameters related to thromboembolism and low-dose heparin prophylaxis in major surgery, Prevention of postoperative thromboembolic disease in general surgery: a randomized trial of 2 therapeutic procedures evaluated by the labelled fibrinogen method [in French], Prophylaxis of postoperative deep vein thromboses by means of weak doses of subcutaneous heparin [in French], Effects of fixed minidose warfarin on coagulation and fibrinolysis following major gynaecological surgery, Necessity of routine postoperative heparinization in non-risky live-donor renal transplantation: results of a prospective randomized trial, The prophylazis of deep vein thrombosis with low-dose heparin: a trial, Failure of low-dose heparin to improve efficacy of peroperative intermittent calf compression in preventing postoperative deep vein thrombosis, Prophylaxis of postoperative leg vine thrombosis by low dose subcutaneous heparin or peroperative calf muscle stimulation: a controlled clinical trial, Low-dose heparin prophylaxis against fatal pulmonary embolism, Small heparin doses as prophylaxis against deep-vein thrombosis in major surgery, Hemorrhages caused by “low dose” heparin and placebo (NaCl solution) in surgical gynecology [in German], Prevention of postoperative deep-vein thrombosis with perioperative subcutaneous heparin, Low molecular weight heparin versus unfractionated heparin for perioperative thromboprophylaxis in patients with cancer, Comparison of low molecular weight heparin CY 216 and unfractionated heparin in preventing post-operative venous thromboembolism in general surgery: a preliminary results of a cooperative study, Prevention of postoperative deep vein thrombosis by one daily injection of low molecular weight heparin and dihydroergotamine, Comparison of enoxaparin and standard heparin in gynaecologic oncologic surgery: a randomised prospective double-blind clinical study, Efficacy and safety of enoxaparin versus unfractionated heparin for prevention of deep vein thrombosis in elective cancer surgery: a double-blind randomized multicentre trial with venographic assessment, Thromboprophylactic effect of low molecular weight heparin started in the evening before elective general abdominal surgery: a comparison with low-dose heparin, Low molecular weight heparin once daily compared with conventional low-dose heparin twice daily. For the subset of patients undergoing TURP for 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 ⊕◯◯◯). Similarly, equity, acceptability, and feasibility each favored the use of DOACs and contributed to the recommendation in their favor. The guideline panel recommends LMWH rather than UFH for patients undergoing total hip arthroplasty or total knee arthroplasty. For patients undergoing major neurosurgical procedures, the ASH guideline panel suggests against using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). There was possibly important uncertainty or variability about how patients may value these outcomes. Other researchers participated to fulfill requirements of an academic degree or program. The EtD framework is available online at https://guidelines.gradepro.org/profile/BC1783C1-D62B-AECB-B9F7-87A9D474A834. Potential harms included reduced mobility, and pneumatic compression prophylaxis may be uncomfortable. Our update of the systematic review did not identify any additional studies that fulfilled the inclusion criteria. We are very uncertain whether pharmacological prophylaxis results in little or no difference in reoperation (RR, 0.93; 95% CI, 0.35-2.50; very low certainty in the evidence of effects); this corresponds to 1 fewer (8 fewer to 18 more) reoperation per 1000 patients. Under the direction of the McMaster GRADE Centre, researchers followed the general methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions (handbook.cochrane.org) for conducting updated or new systematic reviews of intervention effects. You'll also have a physical exam so that your doctor can check for areas of swelling, tenderness or discoloration on your skin. When the risk for VTE is very low, it was recommended not to use pharmacological or mechanical prophylaxis. For mechanical interventions, such as graduated or mechanical compression devices or IVC filters, the effectiveness of these interventions was assessed across all surgical domains. Question: Should LMWH prophylaxis vs UFH prophylaxis be used for patients undergoing hip fracture repair? Pharmacological prophylaxis may not reduce overall mortality compared with no pharmacological prophylaxis (RR, 0.75; 95% CI, 0.61 to 0.93; low certainty in the evidence of effects). Pharmacological prophylaxis does not appear to reduce mortality (RR, 1.27; 95% CI, 0.57-2.69; low certainty in the evidence of effects) when considering the body of evidence from RCTs, in which we have more confidence than the nonrandomized data. Comparison of warfarin and dalteparin, Low molecular weight heparin (enoxaparin) compared with unfractionated heparin in prophylaxis of deep venous thrombosis and pulmonary embolism in patients undergoing hip replacement, Comparison of the efficacy and tolerance of Kabi 2165 and standard heparin in the prevention of deep venous thrombosis in total hip prosthesis [in French], Use of enoxaparin, a low-molecular-weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement. For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. Rates of major bleeding may be similar (RR, 1.05; 95% CI, 0.32-3.40; low certainty in the evidence of effects), corresponding to 0 fewer (5 fewer to 17 more) events per 1000 patients. Members of the guideline panel received travel reimbursement for attendance at in-person meetings. Five studies reported the effect of LMWH compared with that of UFH on development of mortality,348,365-368  2 studies reported on the development of PEs,365,366  1 study reported on the development of screening-detected proximal DVTs,348  and 1 study reported on screening-detected distal DVTs.366  Four studies reported risk of major bleeding348,365-367  and 1 study reported on risk of reoperation.366, All participants wore compression stockings, with the exception of 1 study in which their use was not reported.368. The final guidelines, including recommendations, were reviewed and approved by all members of the panel. We tested potential differences in the effects with ASA and anticoagulant prophylaxis and performed a subgroup analysis. It can detect blockages or blood clots in the deep veins. The panel judged, based on the available very low certainty evidence, that the expected net benefit favored no prophylaxis following major neurosurgical procures, because the potential small benefit of reducing VTE events was outweighed by the potential moderate increased risk of major bleeding. Pharmacological prophylaxis vs no prophylaxis may not reduce mortality (RR, 0.75; 95% CI, 0.61 to 0.93; low certainty in the evidence of effects), corresponding to 0 fewer deaths per 1000 patients. The risks of reoperation may be similar with LMWH and UFH (RR, 0.79; 95% CI, 0.57-1.08; low certainty in the evidence of effects), corresponding to 1 fewer (0-2 fewer) event based on a baseline risk of 0.4%.380. Following these guidelines cannot guarantee successful outcomes. 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). The panel suggests using LMWH or UFH for patients undergoing major gynecological surgery procedures based upon very low certainty in the evidence of effects. Additionally, we conducted a sensitivity analysis excluding dose-finding studies. It may also be considered for patients with persistent mobility restrictions after the bleeding risk subsides following surgery. There would probably be no impact on health equity; pneumatic compression prophylaxis would probably be acceptable to stakeholders and probably feasible to implement. Our systematic search for RCTs identified 3 studies70,381,382  that fulfilled our inclusion criteria and measured outcomes relevant to this context. 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 inconsistency. We identified 40 studies304-343  in these reviews that fulfilled our inclusion criteria and measured outcomes relevant to this context. 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. For patients undergoing major general surgery, the ASH guideline panel suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). Question: Should ASA vs anticoagulants be used for patients undergoing total hip or knee arthroplasty? Cost-effectiveness was considered to favor LMWH based upon results of a single study.271  Using LMWH or UFH would probably not impact health equity, and either drug was deemed to be probably acceptable to stakeholders and feasible to implement. Pharmacological prophylaxis results in little or no difference in reoperation (RR, 0.75; 95% CI, 0.21-2.77; low certainty in the evidence of effects). We were unable to estimate an effect on symptomatic PEs (RR, not estimable). 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 indirectness. For patients undergoing TURP, the ASH guideline panel suggests against using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). For patients experiencing major trauma and who are at high risk for bleeding, the ASH guideline panel suggests against pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). We identified 1 systematic review of RCTs addressing this research question.30  We identified only 4 studies374,376,377,379  overall that were conducted with patients undergoing major gynecological surgery. Clinical documentation of low molecular weight heparin. Cost-effectiveness probably favors mechanical prophylaxis. The panel reviewed the available literature and found that the risk of HIT among heparin preparations was higher with the use of UFH than with LMWH. The EtD framework is available online at https://guidelines.gradepro.org/profile/79bce70d-c689-4fbf-b0e4-c2ec3142bb2c. Depending upon baseline risk, this benefit corresponds to 3 fewer (2-5 fewer) patients with symptomatic PEs per 1000 moderate-risk patients and 2 fewer (1-2 fewer) patients per 1000 low-risk patients. The American Society of Hematology (ASH) has developed new guidelines for managing venous thromboembolism (VTE). Studies addressing this question outside the orthopedic setting are most needed. 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. Pharmacological prophylaxis probably increases major bleeding (RR, 1.37; 95% CI, 0.89-2.13; moderate certainty in the evidence of effects). Similarly, there may be little difference for the other outcomes of symptomatic PEs (RR, 0.84; 95% CI, 0.59-1.20; very low certainty in the evidence of effects), symptomatic proximal DVTs (RR, 1.01; 95% CI, 0.20-5.0; very low certainty in the evidence of effects), and symptomatic distal DVTs (RR, 1.01; 95% CI, 0.30-3.44; very low certainty in the evidence of effects), with all 95% CIs crossing the line of no effect and very small absolute effect sizes. Remark: Twelve hours following surgery was arbitrarily selected to be the cutoff point between early and late postoperative antithrombotic administration. As a result, in this analysis, studies with ASA are pooled with those of anticoagulant prophylaxis compared with no pharmacological prophylaxis. 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 undergoing major surgery, the ASH guideline panel suggests against using inferior vena cava (IVC) filters for prophylaxis of VTE (conditional recommendation based on very low certainty in the evidence of effects, ⊕◯◯◯). This corresponds to 4 fewer (1-6 fewer) pulmonary embolic events per 1000 patients undergoing major general surgery. The EtD framework is available at https://guidelines.gradepro.org/profile/B57A59FE-FCA9-8C9A-8C8D-55089B4E8FB1. Comparison of efficacy and safety of low molecular weight heparin and unfractionated heparin [in German]. A randomized, double-blind trial comparing enoxaparin with warfarin, Prevention of deep-vein thrombosis after total hip arthroplasty. Framing the question and deciding on important outcomes, McMaster University (developed by Evidence Prime, Inc.), Mechanical compression versus subcutaneous heparin therapy in postoperative and posttrauma patients: a systematic review and meta-analysis, Efficacy of intermittent pneumatic compression for venous thromboembolism prophylaxis in patients undergoing gynecologic surgery: A systematic review and meta-analysis, Stratified meta-analysis of intermittent pneumatic compression of the lower limbs to prevent venous thromboembolism in hospitalized patients, Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism, Intermittent pneumatic compression or graduated compression stockings for deep vein thrombosis prophylaxis? This corresponds to 9 more deaths (15 fewer to 65 more) per 1000 patients. Question: If pharmacological prophylaxis is indicated, should LMWH vs UFH be used for patients undergoing radical prostatectomy? Morbidity and mortality after surgery for lower urinary tract symptoms: a study of 95 577 cases from a nationwide German health insurance database, Urology Section of the Bavarian Working Group for Quality Assurance, Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients, Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA Guideline, Comparison of low molecular weight heparin vs. unfractionated heparin in gynecological surgery. Three studies reported the effect of LMWH prophylaxis vs UFH prophylaxis on risk of mortality, on development of any PEs, and on major bleeding,393-395  whereas 2 studies informed on the risk of development of proximal and distal DVTs.393,394. The guideline panel suggests against pharmacological prophylaxis for patients undergoing TURP. Continuing or intrinsic risk factors include: A history of DVT. The EtD framework is available online at https://guidelines.gradepro.org/profile/9AC669C6-30BB-C8DF-8430-3EDA0D4842C8. Should either agent be given, the panel recommended the periodic monitoring of platelet counts. For patients undergoing major surgery, the ASH guideline panel suggests using combined mechanical and pharmacological prophylaxis or mechanical prophylaxis alone, depending on the risk of VTE and bleeding based on the individual patient and the type of surgical procedure (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯). Pharmacological prophylaxis likely leads to more major bleeding (RR, 2.87; 95% CI, 1.68-4.92; moderate certainty in the evidence of effects). Pharmacological prophylaxis may increase major bleeding (RR, 1.24; 95% CI, 1.12-1.37; low certainty in the evidence of effects). We identified 1 systematic review254  that addressed this question. 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). Perioperative prevention of thromboembolism with standard heparin and low molecular weight heparin, evaluation of postoperative hemorrhage. This relates to the very low baseline risk of VTE for patients undergoing laparoscopic cholecystectomy. The majority of individuals in this situation would want the suggested course of action, but many would not. Guidelines aim to present all the relevant evidence on a particular clinical issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. The panel recognized there was a paucity of high-quality evidence addressing this particular question, and this recommendation was made in the face of very uncertain evidence. Likewise, other questions, such as the duration of pharmacological prophylaxis and timing of the initiation of pharmacological prophylaxis, were also assessed across all surgical domains. For patients considered at high risk for VTE, combined prophylaxis is particularly favored over mechanical or pharmacological prophylaxis alone. The panel determined that there was possibly important uncertainty or variability in how much affected individuals might value the main outcomes. The panel based its recommendation on the judgment that the desirable benefits of pharmacological prophylaxis outweighed the likely small increased risk of major bleeding following major gynecological procedures. Further well-designed studies using clinically relevant end points are required to improve the quality of evidence related to this question. Pharmacological prophylaxis vs no pharmacological prophylaxis, 19. The trials were reviewed by the panel but were not included in the main meta-analysis because of differences in the comparator groups. DOACs probably slightly reduce the rate of symptomatic PEs (RR, 0.74; 95% CI, 0.50-1.10; moderate certainty in the evidence of effects); based on a baseline risk of 0.6% from observational data,202,203  this corresponds to 1 fewer (3 fewer to 1 more) symptomatic PE per 1000 patients. For patients undergoing major surgery, the ASH guideline panel suggests the following: Using pharmacological prophylaxis or mechanical prophylaxis (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯). A comparison between subcutaneous heparin and antithrombotic stockings, or both, Prophylaxis against deep-vein thrombosis in total hip replacement. The exception was that the need for a blood transfusion itself was not considered major bleeding unless other criteria for major bleeding were met. A randomized double-blind study [in German], Effect of aspirin on postoperative platelet kinetics and venous thrombosis, Low-dose heparin in postoperative patients: a prospective, coded study, Perioperative aspirin for prevention of venous thromboembolism: the PeriOperative ISchemia Evaluation-2 Trial and a pooled analysis of the randomized trials, Prevention of postoperative thromboembolism by various treatments. We found no evidence to inform the comparative risk of reoperation. Many recommendations have been retained or their validity has been reinforced; however, new data have extended or modified our knowledge in respect of the optimal diagnosis, assessment, and treatment of patients with PE. Low-dose heparin versus graded pressure stockings, Comparison of warfarin and external pneumatic compression in prevention of venous thrombosis after total hip replacement, Randomized clinical trial of intermittent pneumatic compression and low molecular weight heparin in trauma, Pneumatic sequential-compression boots compared with aspirin prophylaxis of deep-vein thrombosis after total knee arthroplasty, Safety and efficacy of pneumatic compression with foot-pumps for prophylaxis against deep vein thrombosis after total hip joint replacement. 368. It further judged that use of ASA saved costs and resources; however, the results of cost-effectiveness studies varied, with some favoring ASA and others favoring anticoagulant prophylaxis. A randomized clinical trial, Intermittent pneumatic compression versus coumadin. Remark: For patients considered at high risk for bleeding, the balance of effects may favor mechanical methods over pharmacological prophylaxis. The balance between desirable und undesirable effects probably favored LMWH. Decision aids may be useful in helping individuals to make decisions consistent with their individual risks, values, and preferences. Pharmacological prophylaxis may result in a small increase in major bleeding (RR, 1.24; 95% CI, 0.87-1.77; low certainty in the evidence of effects). Pharmacological prophylaxis may reduce symptomatic PEs (RR, 0.49; 95% CI, 0.33-0.72; very low certainty in the evidence of effects), but we are very uncertain of this finding. 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. The panel also advises periodic monitoring of the platelet count for patients receiving LMWH and, in particular, UFH, as postoperative prophylaxis in consideration of the risk of heparin-induced thrombocytopenia. The EtD framework is available online at https://guidelines.gradepro.org/profile/E664E38D-FA7C-DBC9-8E77-373D0582050E. There would probably be no impact on health equity, and combined prophylaxis and mechanical prophylaxis alone would be acceptable to stakeholders and probably feasible to implement. Seventeen studies reported the effect of extended vs short-term duration of pharmacological thromboprophylaxis on the development of mortality,166,167,170-173,175-185  17 studies reported the effect on the development of PEs,166,167,170-184  18 studies reported the effect on the development of proximal DVTs,166-173,175-184  14 studies reported the effect on the development of distal DVTs,166,169,171-173,175,177-184  16 studies reported the effect on the risk of major bleeding,167-173,177-185  and 6 studies reported the effect on the risk of reoperation.166,173,174,179,184,185  In general, these studies compared shorter courses of pharmacological prophylaxis (4-14 days) with extended courses of pharmacological prophylaxis (19-42 days) and then followed patients for a common period (3-9 months) for VTE and bleeding complications. 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