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...
  • Print


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

Did this answer your question?
Additional feedback? (Optional)
Thank you for your feedback!