Benefits, Harms, and Costs
RECOMMENDATIONS (GRADE ratings in parentheses)
- 1The risk of venous thromboembolism should be considered pre-operatively and a standard approach to prophylaxis should be encouraged through standardized order sets where available (strong, moderate). A team approach is encouraged in difficult cases.
- 2Patients should be counselled about the risk of venous thromboembolism and informed discharge should include discussion of the signs and symptoms of venous thromboembolism along with the recommended course of action should these occur (strong, moderate).
- 3Patients should be encouraged to ambulate as soon as possible (within the first 24 h) after surgery in order to decrease the risk of venous thromboembolism (strong, moderate).
- 4Intermittent compression stockings, when available, are preferred to graduated compression stockings (strong, moderate).
- 5Either low-molecular-weight heparin or low-dose unfractionated heparin is recommended as the first choice for pharmacological thromboprophylaxis in most cases (strong, high).
- 6For patients undergoing gynaecological surgery for benign disease, postoperative low-dose unfractionated heparin should be administered every 12 hours (twice daily) (strong, moderate). For patients undergoing gynaecological surgery for malignant disease, postoperative low-dose unfractionated should be administered every 8 hours (3 times a day) (strong, moderate).
- 7If patients with renal dysfunction require pharmacological thromboprophylaxis, low-dose unfractionated heparin is recommended (strong, high). The use of low-molecular-weight heparin or fondaparinux is not recommended when creatinine clearance is <30 mL/min (strong, high).
- 8For patients at high risk for venous thromboembolism and using low-molecular-weight heparin or low-dose unfractionated heparin for thromboprophylaxis, continued dosing for 4 weeks postoperatively is recommended (strong, moderate).
- 9In general, patients already on low-dose aspirin for primary or secondary cardiovascular prevention should discontinue it 5–7 days prior to surgery, and restart once hemostasis is guaranteed. Patients on antiplatelet therapy with recent cardiac stenting, coronary artery bypass graft, or other significant cardiovascular disease may continue these agents after consulting with the appropriate specialist for operative planning (strong, low).
- 10Thromboprophylaxis should be implemented based on the pre-operative risk assessment as described in this guideline. For most patients, mechanical prophylaxis is recommended with or without pharmacotherapy based on risks and anticipated benefits (strong, moderate).
- 11When patients are both at high risk of venous thromboembolism and at high risk for major bleeding complications, a team approach including consultation with the department of medicine is recommended (strong, moderate). There may be benefits to combining intermittent pneumatic compression and graduated compression stockings in this population (conditional, low).
- 12For patients at high risk of venous thromboembolism and with contraindication to heparins, the use of fondaparinux and mechanical prophylaxis can be used (strong, moderate). Increased surveillance for bleeding complications is recommended when fondaparinux is used for thromboprophylaxis (strong, moderate).
- 13Awareness of the risk of venous thromboembolism should be extended to pediatric and adolescent patients and a team approach to venous thromboembolism prophylaxis, involving a pediatrician and/or pediatric hematologist, is recommended for patients at high risk (strong, low).
- 14Dose adjustment of pharmacologic thromboprophylaxis is recommended for patients with a BMI >40 kg/m2 (strong, moderate).
- 15There is no indication for stopping hormone replacement therapy preoperatively, and it is not necessary to stop oral contraceptives preoperatively in patients who are at low risk for venous thromboembolism (strong, moderate).
- 16Preoperative consultation with anesthesia is recommended when pharmacologic thromboprophylaxis is indicated and regional anesthesia is being considered (strong, very low).
Abbreviations:ACCP (American College of Clinical Pharmacy), ASRA (American Society of Regional Anesthesia and Pain Medicine), DVT (deep vein thrombosis), GCS (graduated compression stockings), HIT (heparin-induced thrombocytopenia), HRT (hormone replacement therapy), IPC (intermittent pneumatic compression), LDUH (low-dose unfractionated heparin), LMWH (low-molecular-weight heparin), PE (pulmonary embolism), VTE (venous thromboembolism)
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This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not meant to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however, that they adequately document any such amendments.
Informed consent: Everyone has the right and responsibility to make informed decisions about their care together with their health care providers. In order to facilitate this, the SOGC recommends that health care providers provide patients with information and support that is evidence-based, culturally appropriate, and personalized.
Language and inclusivity: This document uses gendered language in order to facilitate plain language writing but is meant to be inclusive of all individuals, including those who do not identify as a woman/female. The SOGC recognizes and respects the rights of all people for whom the information in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages healthcare providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to apply these guidelines in a way that is sensitive to each person's needs.