Table 2.

ACCP guidelines for venous thromboembolism prophylaxis in hip fracture surgery, lower-extremity fractures, major trauma, and acute spinal cord injury

3.4 ACCP guidelines for hip fracture surgery 3.4.1. For patients undergoing Hip Fracture Surgery (HFS), we recommend routine thromboprophylaxis using fondaparinux (grade 1A), LMWH (grade 1B), adjusted dose Vitamin K Antagonist (VKA) (INR target, 2.5; INR range, 2.0-3.0) [grade 1B], or LDUH (grade 1B). 3.4.2. For patients undergoing HFS, we are against the use of aspirin alone (grade 1A). 3.4.3. For patients undergoing HFS in whom surgery is likely to be delayed, we recommend that thromboprophylaxis with LMWH or LDUH be initiated during the time between hospital admission and surgery (grade 1C). 3.4.4. For patients undergoing HFS who have high risk of bleeding, we recommend the optimal use of mechanical thromboprophylaxis (grade 1A). When the high bleedingrisk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for, or added to, the mechanical thromboprophylaxis (grade 1C). 3.5. Other thromboprophylaxis issues in major orthopedic surgery 3.5.1. Commencement of thromboprophylaxis 3.5.1.1. For patients receiving LMWH as thromboprophylaxis in major orthopedic surgery, we recommend starting thromboprophylaxis either preoperatively or postoperatively (grade 1A). 3.5.1.2. For patients receiving fondaparinux as thromboprophylaxis in major orthopedic surgery, we recommend starting the drug either 6 to 8 h after surgery or the next day (grade 1A). Screening for deep vein thrombosis before hospital discharge 3.5.2. For asymptomatic patients following major orthopedic surgery, we are against the routine use of Doppler ultrasound (DUS) screening before hospital discharge (grade 1A). 3.5.3.4. For patients undergoing HFS, we recommend that thromboprophylaxis be extended beyond 10 days and up to 35 days after surgery (grade 1A). The recommended options for extended thromboprophylaxis in HFS include fondaparinux (grade 1A), LMWH (grade 1C) or a VKA (grade 1C). 3.7. Isolated lower-extremity injuries distal to the knee 3.7.1. For patients with isolated lower-extremity injuries distal to the knee, we suggest that clinicians not routinely use thromboprophylaxis (grade 2A).

5.1. Trauma 5.1.1. For all major trauma patients, we recommend routine thromboprophylaxis if possible (grade 1A). 5.1.2. For major trauma patients, in the absence of a major contraindication, we recommend that clinicians use LMWH thromboprophylaxis starting as soon as it is considered safe to do so (grade 1A). An acceptable alternative is the combination of LMWH and the optimal use of a mechanical method of thromboprophylaxis (grade 1B). 5.1.3. For major trauma patients, if LMWH thromboprophylaxis is contraindicated due to active bleeding or high risk for clinically important bleeding, we recommend that mechanical thromboprophylaxis with Intermittent Pneumatic Compression (IPC) or possibly with Graduated Compression Stocking (GCS) alone be used (grade 1B). When the high bleedingrisk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for, or added to, the mechanical thromboprophylaxis (grade 1C). 5.1.4. In trauma patients, we are against routine DUS screening for asymptomatic deep vein thrombosis (DVT) (grade 1B). We do recommend DUS screening in patients who are at high risk for VTE (e.g., in the presence of a spinal cord injury, lower-extremity or pelvic fracture, or major head injury), and in those who have received suboptimal thromboprophylaxis or no thromboprophylaxis (grade 1C). 5.1.5. For trauma patients, we are against the use of an inferior vena cava (IVC) filter as thromboprophylaxis (grade 1C). 5.1.6. For major trauma patients, we recommend the continuation of thromboprophylaxis until hospital discharge (grade 1C). For trauma patients with impaired mobility who undergo inpatient rehabilitation, we suggest continuing thromboprophylaxis with LMWH or a VKA (target INR, 2.5; range, 2.0-3.0) (grade 2C). 5.2. Acute spinal cord injury (SCI) 5.2.1. For all patients with acute SCI, we recommend that routine thromboprophylaxis be provided (grade 1A). 5.2.2. For patients with acute SCI, we recommend thromboprophylaxis with LMWH, commenced once primary hemostasis is evident (grade 1B). Alternatives include the combined use of Intermittent Pneumatic Compression (IPC) and either LDUH (Grade 1B) or LWMH (grade 1C). 5.2.3. For patients with acute SCI, we recommend the optimal use of IPC and/or GCS if anticoagulant thromboprophylaxis is contraindicated because of high bleeding-risk early after injury (grade 1A). When the high bleeding-risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for, or added to, the mechanical thromboprophylaxis (grade 1C) 5.2.4. For patients with an incomplete SCI associated with evidence of a spinal hematoma on CT or MRI, we recommend the use of mechanical thromboprophylaxis instead of anticoagulant thromboprophylaxis at least for the first few days after injury (grade 1C). 5.2.5. Following acute SCI, we are against the use of LDUH alone (grade 1A). 5.2.6. For patients with SCI, we are against the use of an Inferior Venacaval Filter (IVC) filter as thromboprophylaxis (grade 1C). 5.2.7. For patients undergoing rehabilitation following acute SCI, we recommend the continuation of LMWH thromboprophylaxis or conversion to an oral VKA (INR target, 2.5; range, 2.0-3.0) (grade 1C).