Professional Statements and Societal Positions
Guidance on Determining High Risk for Bleeding
American College of Chest Physicians (ACCP) 2012 guidelines on prevention of VTE in orthopedic surgery patients list the following general risk factors for bleeding:
- Previous major bleeding (and previous bleeding risk similar to current risk)
- Severe renal failure
- Concomitant antiplatelet agent Surgical factors: history of or difficult-to-control surgical bleeding during the current operative procedure, extensive surgical dissection, and revision surgery
The guidelines note, however, that specific thresholds for using mechanical compression devices or no prophylaxis instead of anticoagulant thromboprophylaxis have not been established.
Guidance on Risk Level for Patients Undergoing Non-orthopedic Surgery
The 2012 ACCP guidelines on prevention of VTE in non-orthopedic surgery patients included the following discussion of risk levels: "In patients undergoing general and abdominal-pelvic surgery, the risk of VTE varies depending on both patient-specific and procedure-specific factors. Examples of relatively low-risk procedures include laparoscopic cholecystectomy, appendectomy, transurethral prostatectomy, inguinal herniorrhaphy, and unilateral or bilateral mastectomy. Open abdominal and open-pelvic procedures are associated with a higher risk of VTE. VTE risk appears to be highest for patients undergoing abdominal or pelvic surgery for cancer..."
"Independent risk factors include age at least 60 years, prior VTE, and cancer; age >60 years, prior VTE, anesthesia at least 2 hours, and bed rest at least 4 days; older age, male sex, longer length of hospital stay, and higher Charlson comorbidity score; and sepsis, pregnancy or postpartum state, central venous access, malignancy, prior VTE, and inpatient hospital stay more than 2 days. In another study, most of the moderate to strong independent risk factors for VTE were surgical complications, including urinary tract infection, acute renal insufficiency, postoperative transfusion, perioperative myocardial infarction, and pneumonia".
The American College of Obstetricians and Gynecologists (ACOG 2007, 2012) proposed the following risk classification for VTE in patients undergoing major gynecological surgery:
- Low: Surgery lasting less than 30 minutes in patients younger than 40 years with no additional risk factors.
- Moderate: Surgery lasting less than 30 minutes in patients with additional risk factors; surgery lasting less than 30 minutes in patients age 40 to 60 years with no additional risk factors; major surgery in patients younger than 40 years with no additional risk factors.
- High: Surgery lasting less than 30 minutes in patients older than 60 years or with additional risk factors; major surgery in patients older than 40 years or with additional risk factors.
- Highest: Major surgery in patients older than 60 years plus prior venous thromboembolism, cancer, or molecular hypercoagulable state.