I. Overall recommendation
1. Physical prophylaxis should be used primarily in patients with a high likelihood of bleeding (level 1C+) or as an adjunct to anticoagulant prophylaxis (level 2A). Care should be taken to ensure proper use of physical prophylaxis devices (Grade 1C+).
2. Aspirin alone should not be used as prophylaxis for venous embolism in any patient population (Class 1A).
3. Clinicians should refer to the dosing guidelines provided by the drug manufacturer when using each anticoagulant (Class 1C).
4, Decreased renal function should be considered when deciding to apply low molecular heparin (LMWH), fondaparinux (pentosan, a new anticoagulant), direct inhibitors of thrombin and other renally metabolized anticoagulants, especially when used in patients of advanced age and at greater risk of bleeding.
5. Anticoagulant prophylaxis should be used with caution in patients undergoing intravertebral anesthesia or analgesia.
Second, general surgery, vascular surgery, obstetrics and gynecology and urology
1.General surgery
① Low-risk patients who perform minor general surgery, age 3400 U/day (all grade 1A).
④ High-risk patients with combined multiple risk factors for general surgery should be recommended for pharmacological prophylaxis (i.e., LDUH tid or LMWH >3400 U/day) in combination with gradient compression stockings (GCS) and/or intermittent inflation compression (IPC) (Grade 1C+).
⑤ Physical prophylaxis with appropriate GCS or IPC is recommended in high-risk patients with a high likelihood of bleeding, at least until the risk of bleeding is reduced.
⑥ High-risk patients undergoing elective surgery, including those undergoing larger radical cancer surgery, are recommended to continue to use LMWH for prophylaxis after discharge (Grade 2A)
2.Vascular surgery
① Patients undergoing vascular surgery without other thromboembolic risk factors, it is recommended that physicians do not routinely use prophylaxis (level 2B).
② Patients undergoing vascular surgery with other thromboembolic risk factors are recommended to use LDUH or LMWH for prophylaxis (level 1C+).
3.Obstetrical and gynecological surgery
①Obstetrical and gynecological patients with benign disease and short operation time (≤30 minutes) are recommended to be continuously out of bed at an early stage without special prophylactic measures (grade 1C+).
② Patients undergoing obstetrical and gynecologic laparoscopic surgery in combination with other risk factors for venous thromboembolism are recommended one or more of the following prophylactic measures: LDUH, LMWH, IPC, or GCS (all grade 1C).
③ Prophylaxis is recommended for all patients undergoing major obstetrical and gynecologic surgery (level 1A).
(iv) LDUH 5000U bid is recommended for patients with benign disease and no other risk factors in combination with major obstetrical and gynecological surgery (Class 1A). LMWH ≤3400U/day (level 1C+) or IPC started preoperatively and used all the time when the patient is inactive (level 1B) is also available.
⑤ For patients who require extended surgery due to malignant disease, and for patients with other combined venous thromboembolism risk factors, LDUH 5000 U tid (class 1A), or a higher dose of LMWH (>3400 U/day) (class 1A) is recommended routinely for prophylaxis. Other measures such as IPC alone continued until patient discharge (level 1A), or drugs such as LDUH or LMWH combined with physical prophylaxis such as GCS or IPC (all level 1C) can also be considered.
(6) Patients undergoing major obstetrical and gynecological surgery are recommended to remain on prophylaxis until discharge (level 1C). Patients at particularly high risk, including those who have undergone radical cancer surgery, are >60 years old, or have a previous history of venous thromboembolism, are recommended to continue prophylaxis for 2-4 weeks after discharge (level 2C).
4.Urology
① Patients with transurethral or other low-risk surgery, early continued bed mobility is recommended and no special prophylaxis is required (level 1C+).
② For patients undergoing major open surgery, routine prophylaxis with LDUH administered twice or three times daily is recommended (Grade 1A). Other optional prophylactic measures include IPC and/or GCS (Grade 1B), or LMWH (Grade 1C+).
③ Patients undergoing urologic surgery with active bleeding or a high likelihood of bleeding are recommended to use physical prophylaxis such as GCS and/or IPC at least until the risk of bleeding is reduced.
④ For patients with a combination of multiple risk factors, physical prophylaxis such as GCS or IPC in combination with drugs such as LDUH or LMWH is recommended.
5.Patients undergoing laparoscopic surgery
① It is recommended that these patients should just get out of bed voluntarily without taking preventive measures routinely (level 1A).
② For laparoscopic surgery patients with combined thromboembolic risk factors, one or more of the following thromboprophylaxis measures are recommended: LDUH, LMWH, IPC, or GCS (grade 1C+).
III. Orthopaedic surgery
1.Elective hip arthroplasty
① For patients undergoing elective total hip replacement (THR), prophylaxis is recommended routinely from any one of the following three anticoagulants: (1) LMWH (usual high-risk dose, administered 12 hours before or 12 to 24 hours after surgery, or half the usual high-risk dose given 4 to 6 hours after surgery and subsequently increased to the usual high-risk dose); (2) fondaparinux ( 2.5 mg, administered starting 6 to 8 hours postoperatively); and (3) adjustable doses of VKA (vitamin K antagonist), administered preoperatively or starting the evening after surgery (target INR 2.5; INR range 2.0 to 3.0) (all Class 1A).
Potential significance and preference. We do not recommend fondaparinux instead of LMWH and VKA, or LMWH instead of VKA, because prevention of venous thrombosis is relatively secondary to the more important issue of minimizing the risk of bleeding.
② It is recommended that such patients should not use only aspirin, dextrose, LDUH, GCS, IPC or VFP (foot vein compression pump) as the only method to prevent venous thrombosis.
2.Elective knee arthroplasty
① Patients undergoing elective total knee arthroplasty (TKA) are recommended to routinely apply LMWH (commonly used high-risk dose), fondaparinux, or adjustable-dose VKA (target INR 2.5; INR range 2.0 to 3.0) for prophylaxis (all grade 1A).
Potential significance and preference. We do not recommend fondaparinux instead of LMWH and VKA, or LMWH instead of VKA, because prevention of venous thrombosis is relatively secondary to the more important issue of minimizing the risk of bleeding.
② The use of IPC, if satisfactory, is also a prophylactic measure that can replace anticoagulants (Class 1B).
③ It is recommended not to use only any of the following measures as the only way to prevent venous thrombosis: aspirin (class 1A); LDUH (class 1A); or VFP (class 1B).
3. Knee arthroscopy
① It is recommended that physicians should not routinely take prophylactic measures for these patients, and early bed mobility is sufficient (Grade 2B).
② For high-risk patients undergoing knee arthroscopy, combined with thromboembolic risk factors, or with long operation time or complex operation, LMWH is recommended for prophylaxis (level 2B).
4.Hip fracture surgery (HFS)
① For patients undergoing hip fracture surgery, fondaparinux (class 1A), LMWH (commonly used high-risk dose, class 1C+), regulated dose of VKA (target INR 2.5; INR range 2.0~3.0) (class 2B), or LDUH (class 1B) are recommended for prophylaxis routinely.
(ii) Aspirin only (Grade 1A) is not recommended.
③ If surgery is likely to be delayed, LDUH or LMWH is recommended for prophylaxis during the period between admission and the start of surgery. (Grade 1C+).
④ If anticoagulant prophylaxis is contraindicated due to a high risk of bleeding, physical prophylaxis is recommended (grade 1C+).
5.Other issues of thromboembolism prevention in major orthopedic surgery
① For patients undergoing major orthopedic surgery, the side effects of bleeding caused by anticoagulant drugs should be weighed before deciding when to start administration of the drug before using pharmacological prophylaxis (level 1A). As in the case of LMWH, the difference between preoperative or postoperative dosing initiation is minimal, so both dosing times are possible (Class 1A).
② For patients after major orthopedic surgery, routine Doppler ultrasound is not recommended if they are asymptomatic at the time of discharge (Class 1A).
③ For patients undergoing procedures such as THR, TKA or HFS, prophylaxis with LMWH (high-risk dose), fondaparinux (2.5 mg/day) or VKA (target INR 2.5; INR range 2.0 to 3.0) is recommended for at least 10 days (Class 1A).
④ The recommended duration of prophylaxis for patients after THR or HFS is extended to 28 to 35 days postoperatively (Class 1A). The recommended choice for THR is LMWH (class 1A), VKA (class 1A), or fondaparinux (class 1C+). The recommended choice for HFS is fondaparinux (class 1A), LMWH (class 1C+), or VKA (class 1C+).
6. Elective spinal surgery
① For spine surgery patients without other risk factors, early and continuous bed mobility is recommended without routine prophylactic measures (class 1C).
② For spine surgery patients with other risk factors such as advanced age, malignant disease, neurological dysfunction, previous history of venous thromboembolism or anterior surgery, some precautions can be taken (level 1B).
(iii) For patients with a combination of other risk factors, prophylaxis is recommended by any of the following methods: postoperative LDUH alone (class 1C+); postoperative LMWH alone (class 1B) or preoperative IPC alone (class 1B). Other methods included GCS alone (grade 2B) or preoperative IPC in combination with GCS (grade 2C). In patients with combined multiple risk factors, LDUH or LMWH in combination with GCS and/or IPC is recommended (grade 1C+).
7.Simple lower limb trauma
①Patients with simple lower extremity trauma are not recommended to take preventive measures routinely by physicians (Grade 2A).
IV. Neurosurgery
1. Preventive measures are recommended for patients with major neurosurgery routinely (Grade 1A).
IPC (intermittent pneumatic compression) is recommended for patients undergoing intracranial surgery, which can be combined with GCS (graduated compression stockings) or without GCS (level 1A).
2, The above preventive measures can also be replaced by LDUH_ low-dose unfractionated heparin (level 2B) or pharmacological prophylaxis with LMWH (level 2A) given postoperatively.
3, For high-risk surgical patients in neurosurgery, the combination of physical prophylaxis (i.e. GCS and/or IPC) and pharmacological prophylaxis (i.e. LDUH or LMWH) is recommended.
V. Trauma, spinal cord injury, burn injury
1.Trauma
① All trauma patients should take prophylactic measures whenever possible as long as even one risk factor for thrombosis is present (Class 1A).
② As long as there is no clear contraindication, physicians are recommended to start LMWH prophylaxis as early as possible to ensure safety (Level 1A).
③ If LMWH is not immediately available or cannot be used because of active bleeding or a high probability of bleeding, physical prophylaxis, i.e., IPC, or possibly only GCS, is recommended (Level 1B).
④ Doppler ultrasound is recommended for high-risk patients (e.g., spinal cord injury, lower extremity or pelvic fracture, major head surgery, or indwelling femoral vein catheter) and for patients with suboptimal prophylaxis or no prophylactic measures (Class 1C).
⑤ Inferior vena cava filtering (IVCF) is not recommended as the preferred prophylaxis for trauma patients (Level 1C).
⑥ Recommended prophylaxis should be continued until the patient is discharged from the hospital, including the entire hospital recovery period (level 1C+). It is recommended that prophylaxis with LMWH or VKA (target INR 2.5; INR range 2.0 to 3.0) be continued after discharge for patients with reduced mobility (level 2C).
2.Acute spinal cord injury
① Recommend all patients with acute spinal cord injury to take prophylaxis (level 1A).
② It is recommended not to use only LDUH, GCS or ICP as the only preventive measures (level 1A).
③ For patients with acute spinal cord injury, prophylaxis with LMWH is recommended to be started as soon as definitive hemostasis is achieved (Level 1B). As an alternative to LMWH, IPC can be combined with LDUH (grade 2B) or LMWH (grade 2C).
④ IPC and/or GCS are recommended for prophylaxis when anticoagulants are contraindicated early after the onset of trauma (Grade 1C+).
⑤ The inferior vena cava filter is not recommended as the preferred method of preventing pulmonary embolism (Grade 1C).
⑥ In the recovery period of spinal cord injury, continued prophylaxis with LMWH or a switch to oral VKA (target INR 2.5; INR range 2.0 to 3.0) is recommended (Grade 1C).
3.Burn injury
① Prophylaxis should be recommended whenever possible in burn patients with a combination of one or more of the following risk factors for venous thromboembolism: advanced age, morbid obesity, large burns or lower extremity burns, combined lower extremity trauma, indwelling femoral vein catheter and/or prolonged braking (Grade 1C+).
② If there is no contraindication, early application of LDUH or LMWH for prophylaxis is recommended to ensure safety (grade 1C+).
VI. Internal medical conditions
1, LDUH (class 1A) or LMWH (class 1A) is recommended for prophylaxis in emergency medical patients admitted for congestive heart failure or severe respiratory disease, or in patients who are chronically bedridden and in combination with one or more other risk factors including cancer, previous history of venous thromboembolism, sepsis, acute neurological disease or enterocolitis.
2. Internal medicine patients with risk factors for venous thromboembolism combined with contraindications to anticoagulant prophylaxis are recommended to use physical measures such as GCS or IPC for prophylaxis (grade 1C+).
VII. Patients with cancer
1. It is recommended that patients with cancer after surgery should take appropriate prophylactic measures according to their current risk level (level 1A). See the recommendations in the section related to surgery.
2. It is recommended that inpatients with cancer who are confined to bed due to acute medical illness should take appropriate precautions according to their current risk level (level 1A). See recommendations related to the management of medical patients.
3. Doctors are not recommended to take precautions against venous thrombosis in cancer patients with long-term indwelling central venous catheters (Level 2B). In particular, physicians are not recommended to use LMWH (Level 2B), nor are they recommended to use fixed doses of warfarin (Level 1B).
VIII. Emergency care
1. It is recommended that the risk level of venous thromboembolism be assessed in all patients in the intensive care unit. Therefore, prophylactic measures should be taken in most patients (level 1A).
2.Physical prophylaxis, i.e. GCS and/or IPC, is recommended for patients with a high risk of bleeding until the risk of bleeding is reduced (grade 1C+).
3, ICU patients at moderate risk of venous thromboembolism (e.g., post-surgical or medical patients), prophylaxis with LDUH or LMWH is recommended (level 1A).
4.High risk patients, such as severe trauma or orthopedic surgery, are recommended to use LMWH for prophylaxis (Grade 1A).
IX. Long-distance travel
1. The following methods are recommended for long-distance travelers routinely (e.g., flight time > 6 hours): avoid tight clothing on the lower extremities or waist; avoid dehydration; stretch calf muscles frequently (Grade 1C).
2. The above methods are recommended for long-distance travelers who combine other risk factors. Since the risk of venous thrombosis does increase, if active prophylaxis is considered, a well-fitting low knee gradient compression stocking (GCS) with 15 to 30 mmHg ankle pressure (level 2B) or a single injection of LMWH before departure at a prophylactic dose (level 2B) is recommended.
Aspirin is not recommended for travel-related venous thromboembolism prophylaxis (level 1B).