Prevention of venous thromboembolism in medical and surgical patients
PETER J. KABOLI, MD; ADAM BRENNER, BS;

■ ABSTRACT
Prophylaxis against venous thromboembolism (VTE) should be considered in all hospitalized patients, as VTE is a significant cause of morbidity and mortality in the hospital. Although VTE risk is greatest and VTE prophylaxis is more established in surgical patients, most hospitalized medical patients have one or more risk factors for VTE and are candidates for prophylaxis. Selection of a prophylaxis strategy should be guided by the patient’s risk factors for
VTE and the risks associated with prophylaxis options. This review surveys evidence and recommendations for various
VTE prophylaxis methods in medical and surgical patients.

T

he importance of venous thromboembolism
(VTE) as a preventable cause of morbidity and mortality in hospitalized patients cannot be overstated. Although not all patients in the hospital need to receive prophylaxis against VTE, prophylaxis needs to be considered in all hospitalized patients. While recent years have seen significant strides in the use of VTE prophylaxis in many hospital settings, thanks in part to the work of hospitalists,1 many patients—particularly medical patients—still do not receive adequate prophylaxis in community or tertiary care settings.
This review surveys pharmacologic and nonpharmacologic methods of prophylaxis against VTE (including pulmonary embolism [PE] and deep vein
From the Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center, and the
Division of General Internal Medicine, University of Iowa Carver
College of Medicine, Iowa City, Iowa (PJK); and the Division of
General Internal Medicine, Mount Sinai School of Medicine,
New York, N.Y. (AB and ASD).
Dr. Kaboli is supported by a Research Career Development Award from the Health Services Research and Development Service,
Department of Veterans Affairs (RCD 03-033-1).
Address: Peter J. Kaboli, MD, Division of General Internal Medicine, University of Iowa Hospitals and Clinics, SE615GH, 200
Hawkins Drive, Iowa City, IA 52242; peter-kaboli@uiowa.edu.

AND

ANDREW S. DUNN, MD

thrombosis [DVT]) in surgical and medical patients.
It also discusses considerations for prophylaxis in special surgical situations and identifies general strategies for optimizing VTE prophylaxis.
■ RELATIONSHIPS MATTER IN THE SURGICAL SETTING
One of the keys to successful VTE prophylaxis in surgical patients is a close working relationship among the surgeon, the anesthesiologist, nurses, and medical consultants. Because evidence and guidelines support many methods of prophylaxis in a variety of surgical settings, individual practice preferences need to be considered and respected. If a medical consultant recommends a form of prophylaxis that the surgeon is not comfortable with or the anesthesiologist is not aware of, complications or management conflicts can occur.
■ NONPHARMACOLOGIC PROPHYLAXIS
IN SURGICAL PATIENTS
Aggressive postoperative ambulation and physical therapy should be an integral part of all postsurgical management as well as of a global approach to VTE prophylaxis. Although there are scant data from randomized trials showing that early ambulation and physical therapy reduce the risk of VTE, the nonambulatory postoperative period is a high-risk time for thrombosis development and venous stasis. Physical therapists, nurses, and nurses’ aides should all work together to get patients out of bed and ambulating as soon as possible. Moreover, early postoperative ambulation helps to reduce length of stay in the hospital, and optimizing mobility prior to discharge is important to patients.2 For surgical patients considered to be at low risk (ie, < 40 years of age with no VTE risk factors), early ambulation is adequate VTE prophylaxis.
Elastic stockings have been shown to be effective in reducing VTE