Protocol for prophylaxis of venous thromboembolism in varicose vein surgery of the lower limbs

MARQUES, MARCOS ARÊAS; FIORELLI, STÊNIO KARLOS ALVIM; BARROS, BERNARDO CUNHA SENRA; RIBEIRO, ALCIDES JOSÉ ARAÚJO; RISTOW, ARNO VON; FIORELLI, ROSSANO KEPLER ALVIM

doi:10.1590/0100-6991e-20223326-en

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Sumário

Quality and safety in surgery • Rev. Col. Bras. Cir. 49 • 2022 • https://doi.org/10.1590/0100-6991e-20223326-en copy

Protocol for prophylaxis of venous thromboembolism in varicose vein surgery of the lower limbs

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Pulmonary embolism is the most feared complication of venous thromboembolism (VTE) and the third leading cause of cardiovascular mortality in the world, after acute myocardial infarction and stroke. The risk of VTE is virtually universal in hospitalized patients, especially those with reduced mobility. Although variable in incidence between clinical and surgical patients, up to 66.6% of events related to hospitalizations can occur after discharge, with this risk remaining for up to 90 days. Despite all the investment made in VTE prophylaxis in recent decades, there is still no consensus or specific guidelines for its prevention in patients undergoing conventional surgery for varicose veins of lower limbs. The adoption of a validated risk assessment model for VTE prophylaxis, based on the current literature, may help in the implementation and standardization of VTE prophylaxis in conventional lower limb varicose vein surgery, in addition to this benefit, it may lead to a reduction in the length of hospital stay and the number of readmissions.

Keywords:
Venous Thromboembolism; Pulmonary Embolism; Patient Safety; Prevention & Control; Protocols

1 point	2 points	3 points	5 points
41-60 years old	61-74 years old	>75 years old	Stroke (<1 month)
Minor surgery	Arthroscopy	VTE history	Elective arthroplasty
BMI* >25kg/m²	Neoplasia	Family history of VTE	Fracture of hip, pelvis, or leg
Lower limb edema	Major surgery (>45 minutes)	Leiden’s Factor V	Acute spinal trauma (<1 month)
Varicose veins	Laparoscopy (>45 minutes)	Prothrombin 20210 mutation
History of recurrent or unexplained miscarriage	Restriction to bed (>72 hours)	Lupus anticoagulant
OCC** or HRT#	Plaster immobilization	Anticardiolipin antibody
1 point	2 points	3 points	5 points
Sepsis (<1 month)	Central venous access	Elevated serum homocysteine
Severe lung disease, including pneumonia (<1 month)		Heparin-induced thrombocytopenia
Abnormal lung function		Other acquired or hereditary thrombophilia
Acute myocardial infarction
Congestive heart failure (<1 month)
Inflammatory bowel disease
Clinical patient confined to bed
Pregnancy or puerperium

General risk factors	Active bleeding
	Prior major bleeding
	Known untreated coagulopathy
	Severe liver or kidney dysfunction
	Thrombocytopenia
	Acute cerebrovascular accident
	Lumbar puncture, epidural, or spinal anesthesia 4 hours before or 12 hours after
	Concomitant use of anticoagulant, thrombolytic or antiplatelet
Risk factors inherent to the procedure	Abdominal surgery: male, hemoglobin <13g/dL, neoplasia, and complex surgery
	Pancreatoduodenectomy: sepsis, sentinel bleeding, and leakage
	Liver resection: number of segments, extrahepatic resection, primary liver cancer, anemia, and thrombocytopenia
	Cardiac surgery: use of ASA or clopidogrel up to 3 days before the procedure, BMI* >25kg/m², emergency surgery, advanced age, >5 bypasses, chronic renal failure, and long surgical time
	Thoracic surgery: pneumonectomy or extensive resection
Procedures for which bleeding consequences can be potentially dangerous	Craniotomy, spinal surgery, spinal trauma, and reconstructive surgery involving vascularized or non-vascularized free flaps

	Dose	Via	Dose interval for neuroaxis puncture (hours)	Interval of the last dose for catheter removal (hours)	Interval for administration after puncture or removal of the catheter (hours)
UFH*	5,000 UI, t.i.d. or b.i.d.	SC	4 to 6	4 to 6	1
LMWH**	20 or 40mg q.d.	SC	12	12	4

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[1] Mailing address:
Marcos Arêas Marques E-mail: mareasmarques@gmail.com

Absolute	Relative
Patient already on anticoagulation for any reason	Recent intracranial or eye surgery
History of known allergy to any anticoagulant	Hemorrhagic diathesis
History of heparin-induced thrombocytopenia	Thrombocytopenia (<50,000)
Active bleeding	INR* >1.5
	Uncontrolled systemic arterial hypertension (>180 x 110mmHg)