What are the American College of Chest Physicians (ACCP) guidelines for perioperative management of anticoagulation?

Updated: May 08, 2018
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: William A Schwer, MD  more...
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Answer

Answer

Perioperative management of anticoagulation entails an understanding of all thromboembolic events, indications for treatment, and duration of treatment. [18, 19, 20] The American College of Chest Physicians for Prevention of Thromboembolism published the following guidelines. [21] An updated guideline was published in 2008 [5] and 2012 [6] . A full listing is available at American College of Chest Physicians.

  • Low-risk general surgery patients - Early ambulation

  • Moderate-risk general surgery patients - Low-dose unfractionated heparin (LDUH), LMWH, intermittent pneumatic compression (IPC), or elastic stockings (ES)

  • Higher-risk general surgery patients - LDUH or higher-dose LMWH

  • Higher-risk general surgery patients prone to wound complications (eg, hematomas, infection) - IPC is an alternative.

  • Very high-risk general surgery patients with multiple risk factors - LDUH or LMWH combined with IPC

  • Selected very high-risk general surgery patients - Perioperative warfarin (goal INR 2.5, range 2-3)

  • Patients undergoing total hip replacement surgery - LMWH started 12-24 hours after surgery or warfarin started before or immediately after surgery (goal INR 2.5, range 2-3) if adjusted-dose heparin is started preoperatively; possible adjuvant use of ES or IPC

  • Patients undergoing total knee replacement surgery - LMWH, warfarin, or IPC

  • Patients undergoing hip fracture surgery - LMWH or warfarin (goal INR 2.5, range 2-3) started preoperatively or immediately after surgery

  • High-risk patients undergoing orthopedic surgery - Inferior vena cava (IVC) filter placement only if other forms of anticoagulant-based prophylaxis are not feasible because of active bleeding (should rarely be necessary)

  • Patients undergoing intracranial neurosurgery - IPC with or without ES; LMWH and LDUH may be acceptable alternatives; consider IPC or ES, with LMWH or LDUH, for high-risk patients

  • Patients with acute spinal cord injury - LMWH; although ES and IPC appear ineffective when used alone, ES and IPC may have benefit when used with LMWH or if anticoagulants are contraindicated; during rehabilitation, consider continuation of LMWH or conversion to full-dose oral anticoagulation

  • Trauma patients with an identifiable risk factor for thromboembolism - LMWH, as soon as considered safe; consider initial prophylaxis with IPC if administration of LMWH is delayed or is contraindicated; in high-risk patients with suboptimal prophylaxis, consider screening with duplex ultrasonography or filter placement in the IVC

  • Patients with myocardial infarction - LDUH or full-dose anticoagulation; IPC and possibly ES may be useful when heparin is contraindicated

  • Patients with ischemic stroke and lower extremity paralysis - LDUH or LMWH; IPC with ES also probably is effective

  • General medical patients with clinical risk factors for VTE, particularly those with congestive heart failure (CHF) or chest infections - LDUH or LMWH

  • Patients with long-term indwelling central vein catheters - Warfarin (1 mg/d) or daily LMWH to prevent axillary-subclavian venous thrombosis

  • Patients having spinal puncture or epidural catheters placed for regional anesthesia or analgesia - LMWH should be used with caution (additional data are now reported on timing of catheter removal), ES, LDUH


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