UHN/MSH Medical Consult Service
Anticoagulation
UHN Pre-op Thrombosis Guidelines
Thrombosis Risk
Value
Mechanical heart valve
3
Dilated cardiomyopathy
3
Grade IV LV
3
Mitral stenosis
3
Thrombus on Echo
3
Large akinetic segment on Echo
2
Atrial fibrillation
2
HOCM
1
Hypercoagulable state
3
Precarious cerebral circulation
3
Thromboembolic event < 30 days
3
Thromboembolic event > 30 days
1
Age > 75
1
  • Patients with score >= 3 should be referred to the thrombosis clinic for interim homecare injections
    of LMWH, last dose being given the day before surgery
  • Patients with score < 3 do not need pre-op anticoagulation
  • All ophthalmologic or superficial procedures can continue coumadin until the day of surgery
  • All other patients should stop coumadin 5 days pre-op
  • For open procedures where local hemostatis can be obtained, INR 1.5-2.0 is acceptable
  • For closed procedures where local hemostasis cannot be achieved, INR <= 1.5 is suggested
GENERAL SURGERY
DVT Prophylaxis
Low Risk Patient
  • Minor procedure, < 40 y.o.
None
Moderate Risk Patient
  • Minor procedure, additional thrombotic risk factors
  • Non major surgery, 40-60 yo, no additional risk factors
  • Major surgery, < 40 yo, no additional risk factors
LDUH bid, LMWH, ES, IPC
High Risk Patient
  • Non major surgery, > 60 yo OR additional risks
  • Major surgery, > 40 yo OR additional risks
LDUH bid, LMWH, IPC
ORTHOPEDIC SURGERY
DVT Prophylaxis
Elective hip
LMWH started 12 hrs pre and post (or 1/2 the
dose 4-6 hrs post op)
Coumadin started pre-op or immediately post-op
Elective knee
LMWH or warfarin
Hip Fracture
LMWH or warfarin
Duration of therapy
at least 7-10 days post op
out of hospital prophylaxis is warranted for high
risk patients
GYNECOLOGIC SURGERY
DVT Prophylaxis
Brief procedures, benign disease
None
Major surgery benign disease, no risk factors
LDUH bid, LMWH, IPC
Extensive surgery for malignancy
LDUH tid, LMWH
UROLOGIC SURGERY
DVT Prophylaxis
Transurethral or other low risk procedure
None
Major open procedures
LDUH bid, LMWH, ES, IPC
NEUROSURGERY
DVT Prophylaxis
Undergoing intracranial neurosurgery
IPC, ES
LDUH bid or LMWH post op acceptable
ACUTE SPINAL CORD INJURY
DVT Prophylaxis
Acutely
LMWH
Rehab
LMWH or coumadin
MEDICAL CONDITIONS
DVT Prophylaxis
Acute MI
LDUH or IV Heparin
Ischemic Stroke
LDUH, LMWH, ES or IPC
Other medical condiiitons with VTE risks
LDUH, LMWH
DEFINITIONS

LDUH =   low dose unfractionated heparin 5000 units sc
LMWH = dalteparin - moderate risk 2500 units sc daily; high risk 5000 units sc daily
            enoxaparin - moderate risk 20 mg sc daily; high risk 40 mg sc daily
IPC =      intermittent pneumatic compression
ES =       elastic compression stockings