Editorial comment
Prophylaxis of venous thromboembolism – The guidelines are there
Prevenção do tromboembolismo venoso – as recomendações estão aí…
Paulo Pinho
Serviço de Cirurgia Cardiotorácica, Centro Hospitalar de S. João, Porto, Portugal

Venous thromboembolism (VTE) in its most common forms – deep vein thrombosis (DVT) and pulmonary embolism (PE) – is a well-known problem in hospitalized patients. It is the leading preventable cause of in-hospital death and results in considerable acute and chronic morbidity.1

It is thus extremely important to apply the existing guidelines on the prevention of VTE in the most vulnerable patients, those undergoing surgery.2

The multinational ENDORSE study, performed in the last decade, which assessed risk for VTE based on the American College of Chest Physicians (ACCP) guidelines, showed that in the nine randomly selected Portuguese hospitals included, 52.7% of patients were at risk of VTE (68.9% of surgical patients and 38.5% of medical patients). The rate of prophylaxis in patients at risk was 58.5%, but a third of both surgical and medical patients were also on prophylaxis despite not being at risk for VTE.3,4

Increasing awareness of this issue has prompted various initiatives in recent years by different entities. The Directorate-General of Health includes perioperative assessment of the indication for thromboprophylaxis in its guideline “Cirurgia Segura Salva Vidas” and has produced a guideline specifically for orthopedic surgery.5 The European Respiratory Society (ERS), together with the US Joint Commission, includes thromboprophylaxis in its assessment of performance in various surgical fields.6 More important in Portugal was the formation by the Portuguese Society of Anesthesiology of a multidisciplinary study group that produced guidelines for perioperative VTE prophylaxis,7 based on an updated bibliographic review and on the ninth edition of the ACCP guidelines (2012)8 and the UK's National Institute for Health and Care Excellence guidelines (2010, updated 2015).9 These recommendations have been adopted by a significant number of Portuguese medical societies.

The TREVO study10 is an analysis of a changing clinical situation. It studied a sample of 67635 admissions for surgery in a central university hospital between 2008 and 2012, and herein, in my opinion, lies its greatest value. It has significant limitations, which are acknowledged by its authors, but both its weaknesses and its strengths are informative. In particular, it highlights the following points:

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    Routine thromboprophylaxis for surgical patients improved steadily over the study period, with reduced overall risk of TVE and orthopedic surgery no longer posing an additional risk.

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    There is a clear need for protocols to assess risk of TVE and bleeding in all surgical patients.

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    A multidisciplinary approach is required that includes the patient's risk factors, the risk of the specific surgery to be performed (with or without central venous catheterization), and the type of anesthesia (neuraxial vs. general).

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    Prevention of thromboembolism, as pointed out in the article,10 is particularly complicated in neurosurgery, but also in cardiac surgery, in which the high bleeding risk requires specific measures.11,12

Conflicts of interest

The author has no conflicts of interest to declare.

References
1
A. Reis
Prevenção e tratamento do tromboembolismo venoso: o lugar dos novos anticoagulantes orais
Rev Port Cardiol, 31 (2012), pp. 45-50 http://dx.doi.org/10.1016/S0870-2551(12)70039-2
2
A.T. Cohen,G. Agnelli,F.A. Anderson
Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality
Thromb Haemost, 98 (2007), pp. 756-764
3
A.T. Cohen,V.F. Tapson,J.F. Bergmann
Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study
4
A. França,A. Reis,A. Paulino
Venous thromboembolism risk factors and practices of prophylaxis – ENDORSE study results in Portugal
Acta Med Port, 24 (2011), pp. 951-960
5
Normas da DGS 026/2012 e 02/2013. Available at: https://www.dgs.pt/normas-clinicas/normas-clinicas.aspx.
6
The Joint Commission. Specifications Manual for National Hospital Quality Measures. Available at: http://www.jointcommission.org.
7
C. Amaral,J. Reis,L. Guimaraes
Recomendações perioperatórias para profilaxia do tromboembolismo venoso no doente adulto. Consenso Nacional Multidisciplinar 2014
Rev Soc Por Anestesiol, 23 (2014), pp. 62-75
8
G.H. Guyatt,E.A. Akl,M. Crowther,for the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel
Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
CHEST, 141 (2012), pp. 7S-47S http://dx.doi.org/10.1378/chest.1412S3
9
NICE. Venous thromboembolism: reducing the risk for patients in hospital. Clinical Guideline. https://www.nice.org.uk/guidance/cg92.
10
C. Amaral,L.G. Pereira,A. Moreto
Estudo TromboEmbolismo Venoso pós-Operatório (TREVO) – risco e mortalidade por especialidade cirúrgica
Rev Por Cardiol, 9 (2017),
11
M.K. Gould,D.A. Garcia,S.M. Wren
Prevention of VTE in nonorthopedic surgical patients. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
CHEST, 141 (2012), pp. e227S-e277S http://dx.doi.org/10.1378/chest.11-2297
12
K.M. Ho,E. Bham,W. Pavey
Incidence of venous thromboembolism and benefits and risks of thromboprophylaxis after cardiac surgery: a systematic review and meta-analysis
J Am Heart Assoc, 4 (2015), pp. e002652 http://dx.doi.org/10.1161/JAHA.115.002652

Please cite this article as: Pinho P. Prevenção do tromboembolismo venoso – as recomendações estão aí…. Rev Port Cardiol. 2017;36:617–618.

Copyright © 2017. Sociedade Portuguesa de Cardiologia

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