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## Complete Summary

#### GUIDELINE TITLE

Practice parameters for the prevention of venous thromboembolism.

#### BIBLIOGRAPHIC SOURCE(S)

Stahl TJ, Gregorcyk SG, Hyman NH, Buie WD, Standards Practice Task Force
of The American Society of Colon and Rectal. Practice parameters for the
prevention of venous thrombosis. Dis Colon Rectum 2006
Oct;49(10):1477-83. \[51 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17041751)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Practice parameters for the
prevention of venous thromboembolism. The Standards Task Force of the
American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000
Aug;43(8):1037-47.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [February 28, 2008, Heparin Sodium
    Injection](http://www.fda.gov/medwatch/safety/2008/safety08.htm#HeparinInj2):
    The U.S. Food and Drug Administration (FDA) informed the public that
    Baxter Healthcare Corporation has voluntarily recalled all of their
    multi-dose and single-use vials of heparin sodium for injection and
    their heparin lock flush solutions. Alternate heparin manufacturers
    are expected to be able to increase heparin production sufficiently
    to supply the U.S. market. There have been reports of serious
    adverse events including allergic or hypersensitivity-type
    reactions, with symptoms of oral swelling, nausea, vomiting,
    sweating, shortness of breath, and cases of severe hypotension.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Venous thrombosis

#### GUIDELINE CATEGORY

Prevention\
Risk Assessment

#### CLINICAL SPECIALTY

Colon and Rectal Surgery\
Preventive Medicine

#### INTENDED USERS

Health Care Providers\
Patients\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide practice parameters for the prevention of venous thrombosis

#### TARGET POPULATION

Patients undergoing surgery of the colon and rectum

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Assessment of risk category (low, moderate, high, or highest)

2.  Physical prophylactic measures including early ambulation, elastic
    stockings, and intermittent pneumatic compression (IPC) devices

3.  Chemical prophylaxis including low-dose unfractionated heparin
    (LDUH) or low-molecular-weight heparin (LMWH)

#### MAJOR OUTCOMES CONSIDERED

-   Efficacy of venous thromboembolism (VTE) prophylaxis

-   Risk and rates of venous thromboembolism

-   Adverse effects associated with chemical prophylaxis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

I.  Meta-analysis of multiple well-designed, controlled studies;
    randomized trials with low false-positive and low false-negative
    errors (high power)

II. At least one well-designed experimental study; randomized trials
    with high false-positive or high false-negative errors or both (low
    power)

III. Well-designed, quasi-experimental studies, such as nonrandomized,
     controlled, single-group, preoperative-postoperative comparison,
     cohort, time, or matched case-control series

IV. Well-designed, nonexperimental studies, such as comparative and
    correlational descriptive and case studies

V.  Case reports and clinical examples

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendations**

A.  Evidence of Type I or consistent findings from multiple studies of
    Type II, III, or IV

B.  Evidence of Type II, III, or IV and generally consistent findings

C.  Evidence of Type II, III, or IV but inconsistent findings

D.  Little or no systematic empirical evidence

#### COST ANALYSIS

In numerous well-performed studies and several meta-analyses comparing
the efficacy of venous thromboembolism (VTE) prophylaxis between
low-molecular-weight-heparin (LMWH) and low-dose-unfractionated heparin
(LDUH) for VTE prophylaxis, unfractionated heparin has been shown to be
equally effective and more cost-effective.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The levels of evidence (I-V) and the grades of recommendations (A-D) are
defined at the end of the \"Major Recommendations\" field.

**Treatment Recommendations**

1.  Patients undergoing anorectal procedures who are younger than 40
    years of age and have no additional risk factors (see Table 1 in the
    original guideline document for a list of risk factors) for venous
    thromboembolism (VTE) require no specific prophylaxis. **Level of
    Evidence: V; Grade of Recommendation: D**

2.  Patients undergoing anorectal procedures who are older than 40
    and/or have additional risk factors for VTE should be considered for
    prophylaxis on a case-by-case basis. **Level of Evidence: V; Grade
    of Recommendation: D**

> Patients in the moderate-risk to high-risk group (see original
> guideline document for a description of each of the four risk
> categories: low-risk, moderate-risk, high-risk, and highest risk) are
> appropriately considered for prophylaxis based on the number of risk
> factors, the length and magnitude of the planned surgery, and the risk
> of bleeding. The appropriate means of prophylaxis would be mechanical
> compression or heparin (low-dose unfractionated heparin \[LDUH\] or
> low-molecular-weight heparin \[LMWH\]). Because of the frequent
> outpatient nature of this type of surgery and the potential for
> bleeding in many anorectal procedures, mechanical prophylaxis may be
> preferable in most cases.

3.  Patients in the moderate-risk to high-risk categories for VTE
    undergoing abdominal surgery should receive prophylaxis with LDUH or
    LMWH. Patients at risk for bleeding may receive mechanical
    prophylaxis instead. **Level of Evidence: I; Grade of
    Recommendation: A**

> Mechanical methods may be chosen in patients in whom the risk of
> bleeding is judged to outweigh the benefit of prophylactic heparin.

4.  Patients in the highest-risk category for VTE should receive both
    mechanical and heparin prophylaxis**. Level of Evidence: I; Grade of
    Recommendation: A**

> In this high-risk group, mechanical prophylaxis adds further
> protection compared with heparin alone.

5.  Patients undergoing laparoscopic colorectal procedures should
    receive VTE prophylaxis according to the same risk assessment that
    would be applicable for the same surgery performed as an open
    procedure. **Level of Evidence: V; Grade of Recommendation: D**

6.  Patients who have undergone major cancer surgery may benefit from
    posthospital prophylaxis with LMWH. **Level of Evidence: II; Grade
    of Recommendation: C**

> The optimum duration of VTE prophylaxis is currently unknown. Although
> most deep vein thrombosis (DVT) occurs within the first week or two
> after surgery, VTE complications, including pulmonary embolism (PE),
> can occur beyond that time frame. These findings combined with
> shrinking hospital stays have generated an interest in the appropriate
> duration of VTE prophylaxis. There is evidence that in cancer-surgery
> patients, continued prophylaxis for two to three weeks after discharge
> reduces the incidence of asymptomatic DVT.

**[Definitions]{.underline}**

**Levels of Evidence**

I.  Meta-analysis of multiple well-designed, controlled studies;
    randomized trials with low false-positive and low false-negative
    errors (high power)

II. At least one well-designed experimental study; randomized trials
    with high false-positive or high false-negative errors or both (low
    power)

III. Well-designed, quasi-experimental studies, such as nonrandomized,
     controlled, single-group, preoperative-postoperative comparison,
     cohort, time, or matched case-control series

IV. Well-designed, nonexperimental studies, such as comparative and
    correlational descriptive and case studies

V.  Case reports and clinical examples

**Grades of Recommendations**

A.  Evidence of Type I or consistent findings from multiple studies of
    Type II, III, or IV

B.  Evidence of Type II, III, or IV and generally consistent findings

C.  Evidence of Type II, III, or IV but inconsistent findings

D.  Little or no systematic empirical evidence

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate use of practice parameters for the prevention of venous
thrombosis

#### POTENTIAL HARMS

-   Low-dose unfractionated heparin (LDUH) is associated with only a
    modest increase in minor bleeding complications, such as wound
    hematoma

-   A potential danger has been associated with the use of heparin
    prophylaxis in conjunction with spinal or epidural anesthesia. The
    most serious potential complication is the development of a
    perispinal hematoma, which can lead to spinal cord ischemia and
    paraplegia. This complication has been reported with both LDUH and
    LMWH, but more so with LMWH. Refer to the original guideline
    document for detailed instructions on the use of heparin prophylaxis
    in conjunction with spinal or epidural anesthesia.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

These guidelines are inclusive and not prescriptive. Their purpose is to
provide information on which decisions can be made, rather than dictate
a specific form of treatment. It should be recognized that these
guidelines should not be deemed inclusive of all proper methods of care
or exclusive of methods of care reasonably directed to obtaining the
same results. The ultimate judgment regarding the propriety of any
specific procedure must be made by the physician in light of all of the
circumstances presented by the individual patient.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Stahl TJ, Gregorcyk SG, Hyman NH, Buie WD, Standards Practice Task Force
of The American Society of Colon and Rectal. Practice parameters for the
prevention of venous thrombosis. Dis Colon Rectum 2006
Oct;49(10):1477-83. \[51 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17041751)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2000 Aug (revised 2006 Oct)

#### GUIDELINE DEVELOPER(S)

American Society of Colon and Rectal Surgeons - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Society of Colon and Rectal Surgeons

#### GUIDELINE COMMITTEE

Standards Practice Task Force of the American Society of Colon and
Rectal Surgeons

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors:* Thomas J. Stahl, MD; Sharon G. Gregorcyk, MD; Neil H. Hyman,
MD; W. Donald Buie, MD; and the Standards Practice Task Force of The
American Society of Colon and Rectal Surgeons (ASCRS)

*Contributing Members of the ASCRS Standards Committee*: Amir L.
Bastawrous, MD; Gary D. Dunn, MD; C. Neal Ellis, MD; Phillip R.
Fleshner, MD; Clifford Y. Ko, MD; Nancy A. Morin, MD; Richard L. Nelson,
MD; Graham L. Newstead, MD; Jason R. Penzer, MD; W. Brian Perry, MD;
Janice F. Rafferty, MD; Paul C. Shellito, MD; Charles A. Ternent, MD;
Joe J. Tjandra, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Practice parameters for the
prevention of venous thromboembolism. The Standards Task Force of the
American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000
Aug;43(8):1037-47.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Society of Colon and Rectal Surgeons (ASCRS) Web
site](http://www.fascrs.org/files/pp_thrombosis.pdf).

Print copies: Available from the ASCRS, 85 W. Algonquin Road, Suite 550,
Arlington Heights, Illinois 60005.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on February 13, 2001. The information
was verified by the guideline developer on May 9, 2002. This NGC summary
was updated by ECRI Institute on May 30, 2007. This summary was updated
by ECRI Institute on March 14, 2008 following the updated FDA advisory
on heparin sodium injection.

#### COPYRIGHT STATEMENT

American Society of Colon and Rectal Surgeons (ASCRS) parameters may be
downloaded for personal use (one copy); copies for other purposes,
please contact the ASCRS office at (847) 290-9184.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008