Venous Thromboembolism

Purpose

This document provides guidance to perioperative team members for developing and implementing a protocol for venous thromboembolism (VTE) prevention, including prevention of deep vein thrombosis (DVT) by mechanical and pharmacologic prophylaxis and prevention of pulmonary embolism (PE) as a complication of DVT. The recommendations are informed by a systematic review of the evidence and an assessment of the benefits and harms of alternative options in the area of VTE prevention in the perioperative setting.

According to the Centers for Disease Control and Prevention, approximately 900,000 people in the United States experience VTE each year.¹  Estimates suggest that almost 100,000 deaths result from VTE¹  and that 33% of patient deaths related to VTE in the United States occur following a surgical procedure.²  Among patients who underwent general surgical procedures, approximately 40% of the VTE events occurred after discharge from the hospital.³  In some patient populations, the risk of developing VTE remains elevated for several weeks after surgery.^3-7 

Among people who develop VTE,

• 30% to 50% have long-term complications (eg, swelling, pain, discoloration, scaling in the affected limb) as part of a condition called post-thrombotic syndrome,^1,8 

• 33% have a recurrence within 10 years,¹ 

• 10% to 30% die within 1 month of diagnosis,¹ 

• 25% with PE experience sudden death as the first symptom,¹  and

• 4% who survive PE develop chronic thromboembolic pulmonary hypertension.⁹ 

Treatment for VTE involves therapeutic anticoagulation, often for a minimum of 3 months; this treatment is associated with minor bruising and hematoma as well as major bleeding events that can be fatal.⁹  Many patients with VTE after surgery require readmission to the hospital for treatment.¹  Patients who have survived VTE have experienced anxiety, adverse effects from anticoagulant treatment, financial burden, loss of function, and fear of recurrence.⁹ 

Hospital-associated VTE, including DVT and PE, has been identified as a major public health concern.^1,9  Although as many as 70% of hospital-associated VTE cases could be prevented, fewer than half of hospitalized patients receive preventive measures according to the standard of care.¹  Up to 80% of VTE events occur in patients with known VTE risk factors, suggesting that VTE prevention efforts have been inadequate.¹⁰  The gap between evidence-based practice and actual clinical practice for VTE prevention is concerning and presents a major opportunity for improvement in individualized patient care.^9,10 

Prevention of VTE is also important for reducing economic burden,¹¹  as costs attributed to hospital-associated VTE in the United States currently exceed $5 billion per year.¹  Medical costs related to VTE treatment in surgical patients have been found to be 1.5 times greater than costs for care of patients without VTE, and the expenses may persist for up to 5 years.¹²  Although the prevention of VTE should be a priority for the entire health care organization, the particular risks facing surgical patients make it critical that perioperative registered nurses (RNs) take an active role in VTE prevention.^13-15 

All perioperative patients, including children,^16,17  may be at risk for VTE because of immobility, vessel injury, compression of tissue caused by retraction, and patient positioning requirements. As such, recommendations for assessment and prevention of VTE are applicable to all perioperative patients, including children. The patient may have one or more of the three primary contributing factors of venous thrombus formation, which are together commonly referred to as Virchow’s triad (ie, venous stasis, vessel wall injury, hypercoagulability). Although DVT usually occurs in the lower extremities, it also may occur in the upper extremities.¹⁸ 

Pulmonary embolism can result as a complication of DVT and is potentially fatal.¹⁹  Additional research is needed to determine the ideal means to prevent PE and DVT in perioperative patients.²⁰ 

The selection of VTE prophylaxis, including inferior vena cava filter use, is a medical decision and is outside the scope of this document. The following topics are also outside the scope of this document:

• diagnosis of VTE,

• treatment of VTE and complications (eg, post-thrombotic syndrome, venous stasis ulcers, chronic thromboembolic pulmonary hypertension),

• arterial thrombosis,

• superficial vein thrombosis,

• thrombosis at the surgical site (eg, flap, brain, portal vein thrombosis),

• use of regional anesthesia with DVT prophylaxis,

• laboratory testing of D-dimer levels to assess VTE risk,

• surveillance of VTE (eg, ultrasound surveillance),

• thromboprophylaxis for a patient with an implanted stent,

• anticoagulation for cardiac bypass,

• medication administration, and

• recommendations for bridging anticoagulant therapy.

Note: Information about the systematic review supporting this guideline, including the PROSPERO registration number, systematic review questions, description of the search strategy and evidence review, and evidence summary table is available at https://www.aorn.org/guidelines/about-aorn-guidelines/evidence-rating.