Based on a very low overall certainty in the evidence, the panel determined that the balance of effects did not favor LMWH or UFH. At low risk, mechanical prophylaxis (preferably with intermittent pneumatic compression) is suggested over no prophylaxis. EAU Guidelines on Thromboprophylaxis in Urological Surgery 2018. This corresponds to 1 fewer (0-1 fewer) symptomatic proximal DVT per 1000 lower-risk patients to 4 fewer (0-5 fewer) per 1000 higher-risk patients. Given the very low certainty in the evidence of effects this is based upon, there is a critical need for higher-quality studies comparing extended vs short-term prophylaxis using clinically important outcomes in contemporary surgical practices, which are marked by early patient mobilization and shorter hospital stays. Resources requirements of warfarin were deemed moderate, particularly with regard to the need for, and the complexity of, anticoagulant monitoring, but cost-effectiveness data probably did not favor warfarin or LMWH. Similarly, equity, acceptability, and feasibility each favored the use of DOACs and contributed to the recommendation in their favor. Finally, the panel acknowledges that, for some questions, limited direct data were available (eg, VTE prophylaxis following urological and gynecological procedures and for major trauma). Question: Should ASA vs anticoagulants be used for patients undergoing total hip or knee arthroplasty? wrote the first draft of the manuscript and revised the manuscript based on the authors’ suggestions; C.B., F.D., C.W.F., D.A.G., S.R.K., M.R., A.R., F.B.R., M.A.S., K.A.O.T., and A.J.Y. Part D describes new interests disclosed by individuals after appointment. Pharmacological prophylaxis may result in more major bleeding than no prophylaxis (RR, 1.24; 95% CI, 1.12-1.37; very low certainty in the evidence of effects), but this finding is uncertain. The panel judged that there was possibly important uncertainty or variability in how much people value the main outcomes. For patients undergoing major surgery, the ASH guideline panel suggests using combined mechanical and pharmacological prophylaxis or mechanical prophylaxis alone, depending on the risk of VTE and bleeding based on the individual patient and the type of surgical procedure (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯). These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery. Question: Should LMWH vs UFH be used for patients undergoing total hip or knee arthroplasty? A randomized trial comparing graduated compression stockings alone or graduated compression stockings plus intermittent pneumatic compression with control, Thrombosis prophylaxis using external compression, Prevention of venous thrombosis after coronary artery bypass surgery (a randomized trial comparing two mechanical prophylaxis strategies), Prevention of thromboembolic disease by external pneumatic compression in patients undergoing total hip arthroplasty, Effect of mechanical compression on the prevalence of proximal deep venous thrombosis as assessed by magnetic resonance venography, Prevention of deep-vein thrombosis after total hip and knee replacement. AHRQ Publication No. The risks of bleeding may be similar with LMWH and UFH (RR, 0.97; 95% CI, 0.78-1.20; low certainty in the evidence of effects), corresponding to 0 fewer (4 fewer to 3 more) major bleeding events per 1000 patients undergoing radical prostatectomy. The panel recognized that cardiac surgery itself is associated with a risk for the development of heparin-induced thrombocytopenia (HIT). The panel did not consider potential harms of IVC filters beyond VTE. Distal DVTs may be reduced (RR, 0.52; 95% CI, 0.31-0.87; low certainty in the evidence of effects), but this also corresponds to a negligible effect of 0 fewer symptomatic distal DVT events, irrespective of baseline risk category. A dose finding study (ONYX-2), Darexaban for the prevention of venous thromboembolism in Asian patients undergoing orthopedic surgery: results from 2 randomized, placebo-controlled, double-blind studies, Efficacy and safety of edoxaban versus enoxaparin for the prevention of venous thromboembolism following total hip arthroplasty: STARS J-V, Safety and efficacy of edoxaban in patients undergoing hip fracture surgery, Safety and efficacy of edoxaban, an oral factor xa inhibitor, for thromboprophylaxis after total hip arthroplasty in Japan and Taiwan, Safety and efficacy of edoxaban, an oral factor Xa inhibitor, versus enoxaparin for thromboprophylaxis after total knee arthroplasty: the STARS E-3 trial, Oral direct factor Xa inhibition with edoxaban for thromboprophylaxis after elective total hip replacement. Likewise, other questions, such as the duration of pharmacological prophylaxis and timing of the initiation of pharmacological prophylaxis, were also assessed across all surgical domains. This recommendation is relevant for patients considered at high risk for VTEs. Sixteen studies122,125,274-278,284,285,291,293,296,297,299,300,302 reported the effect of pharmacological prophylaxis vs no pharmacological prophylaxis on the risk of mortality, and 11 studies125,273,276-279,285,286,289,293,295 reported the effect on the development of symptomatic PEs. The guideline panel suggests against pharmacological prophylaxis for patients undergoing TURP. When pharmacological prophylaxis is used for patients undergoing cardiac or major vascular surgery, the ASH guideline panel suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). For researchers: the recommendation is supported by credible research or other convincing judgments that make additional research unlikely to alter the recommendation. After publication of these guidelines, ASH will maintain them through surveillance for new evidence, ongoing review by experts, and regular revisions. As a result, recommendations do not distinguish between cancer and noncancer patients. The panel discounted the mortality difference observed in this analysis as unlikely to relate to pharmacological prophylaxis, given the very low baseline risk of VTE. In this case, the recommendation was sufficiently supported by the favorable impact on desirable effects for which there was higher quality evidence. Future large studies using clinically relevant end points would help to better inform this recommendation, although this research question would not be regarded as high priority. ANZ-Organon Investigators’ Group, Post-surgical deep vein thrombosis prevention: evaluation of the risk/benefit ratio of fractionated and unfractionated heparin, Enoxaparin in the prevention of deep venous thrombosis after major surgery: multicentric study, Comparison of the efficacy and safety of subcutaneous rd heparin vs subcutaneous unfractionated heparin for the prevention of deep-vein thrombosis in patients undergoing abdominal or pelvic-surgery for cancer, Prevention of fatal pulmonary embolism and mortality in surgical patients: a randomized double-blind comparison of LMWH with unfractionated heparin, Prophylaxis of thromboembolism in general surgery: comparison between standard heparin and Fragmin. Further, they recommend considering mechanical prophylaxis on admission for people who are undergoing open vascular surgery or major endovascular procedures, including endovascular aneurysm repair, if pharmacological prophylaxis is contraindicated. In most circumstances, these innovations would be expected to reduce the overall risk of postoperative VTEs. Conflicts of interest of all participants were managed according to ASH policies based on recommendations of the Institute of Medicine17 and the Guidelines International Network.4 At the time of appointment, a majority of the guideline panel, including the chair and the vice chair, had no conflicts of interest as defined and judged by ASH (ie, no current material interest in any commercial entity with a product that could be affected by the guidelines). LMWH likely results in a small decrease in the risk of major bleeding (RR, 0.55; 95% CI, 0.27-1.13; moderate certainty in the evidence of effects); this corresponds to 19 fewer (30 fewer to 5 more) major bleeds per 1000 patients. The guidelines were reviewed by the ASH Guideline Oversight Subcommittee on 28 August 2019, approved by the Committee on Quality on 6 September 2019 and by the ASH officers on 13 September 2019, and then subjected to peer review. Based on RCT evidence, pharmacological prophylaxis may result in little or no difference in symptomatic PEs (RR, 0.84; 95% CI, 0.03-27.42; very low certainty in the evidence of effects), but we are very uncertain of this finding. The risks of reoperation may be similar with LMWH and UFH (RR, 0.79; 95% CI, 0.57-1.08; low certainty in the evidence of effects), corresponding to 1 fewer (0-2 fewer) event based on a baseline risk of 0.4%.380. Both patient representatives participated in question prioritization, and 1 participated in all remaining steps of the development process. Major bleeding definitions varied across clinical studies. This includes largely outdated means (eg, venography) to assess for VTEs postoperatively. For patients undergoing transurethral resection of the prostate (TURP), the ASH guideline panel suggests against using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). The EtD framework is available online at https://guidelines.gradepro.org/profile/BC1783C1-D62B-AECB-B9F7-87A9D474A834. Formal decision aids are not likely to be needed to help individual patients make decisions consistent with their values and preferences. The ultimate judgment of a conditional recommendation for DOACs was based on anonymous voting by panel members without direct financial conflicts, with a majority of 5 voting for this recommendation (vs 4 in favor of a recommendation for using either). Given the very low baseline risk of VTE events in this specific patient population,350 this would be expected to result in 0 fewer (0 fewer to 0 more) symptomatic PEs per 1000 patients. In settings where pneumatic compression devices are not available, the use of graduated compression stockings is reasonable, because mechanical prophylaxis is an acceptable and feasible option. The EtD framework is available online at https://guidelines.gradepro.org/profile/9AC669C6-30BB-C8DF-8430-3EDA0D4842C8. The panel also recognized that mechanical methods of thromboprophylaxis are commonly used in this patient population. However, this is likely a lower priority for research than studies evaluating mechanical prophylaxis in combination with pharmacological prophylaxis. This corresponds to 0 fewer deaths per 1000 patients. Cancer (known or undiagnosed). Remark: For patients considered at high risk for bleeding, the balance of effects may favor mechanical methods over pharmacological prophylaxis. Based on these findings, the panel judged that the balance of effects did not favor any particular DOAC over another. DVT Treatment Procedures. SCGH ED DVT Assessment & Management Guideline 2019 ED-DVT-Guideline-Sept-2019-complete-update. There is also a small risk for inappropriate use of pneumatic compression prophylaxis for some patients (eg, those with lower extremity fractures). Early vs delayed antithrombotic prophylaxis, 11. The EtD framework is available online at https://guidelines.gradepro.org/profile/C5A1B92D-0E70-50BA-847C-0497617938F5. This corresponds to 1 fewer (0-1 fewer) death per 1000 patients undergoing TURP. The guideline panel suggests early administration (postoperative, within 12 hours) or late administration (postoperative, after 12 hours) of antithrombotic prophylaxis in major surgical patients, based on very low certainty in the evidence of effects. For cardiac surgery patients with an uncomplicated postoperative course, the 2012 ACCP guideline suggested the use of mechanical prophylaxis, preferably with optimally applied intermittent pneumatic compression, over no prophylaxis or pharmacological prophylaxis.398 For cardiac surgery patients whose hospital course is prolonged by ≥1 nonhemorrhagic surgical complication, the guideline suggested adding pharmacological prophylaxis with UFH or LMWH to mechanical prophylaxis. This corresponds to 1 more (1 fewer to 6 more) per 1000 patients. The panel reviewed the available literature and found that the risk of HIT among heparin preparations was higher with the use of UFH than with LMWH. Furthermore, the panel recognized that these studies were largely limited to 2 high-risk surgical scenarios (total hip or knee arthroplasty and major cancer general surgical procedures). The American Academy of Family Physicians endorsed these guidelines in March 2019 and provided the following key recommendations from the guidelines. There would probably be no impact on equity, and the panel foresaw no issues with regard to acceptability and feasibility of using pharmacological prophylaxis in this patient population. There is likely a reduction in symptomatic PEs (RR, 0.34; 95% CI, 0.13-0.90; moderate certainty in the evidence of effects) favoring combined prophylaxis. Remarks: For patients considered at high risk of bleeding, the balance of effects may favor mechanical methods over pharmacological prophylaxis. The majority of radical prostatectomies performed by urologists in the United States are performed robotically, typically with no or only a limited lymph node dissection. Paul C Kruger, John W Eikelboom, James D Douketis and Graeme J Hankey, Email me when people comment on this article, Online responses are no longer available. We rated the overall certainty in the evidence of effects as low based on the lowest certainty in the evidence for the critical outcomes, downgrading for very serious imprecision. Overall, the balance of effects did not favor LMWH or UFH, nor did cost-effectiveness or issues surrounding equity, acceptability, and feasibility, at least for inpatient prophylaxis. This corresponds to 2 more (4 fewer to 54 more) deaths per 1000 trauma patients receiving LMWH vs UFH. Three studies reported the effect of LMWH prophylaxis vs UFH prophylaxis on risk of mortality, on development of any PEs, and on major bleeding,393-395 whereas 2 studies informed on the risk of development of proximal and distal DVTs.393,394. In light of the very low certainty in the evidence of effects, further high-quality studies using clinically important outcomes are important to provide greater certainty about the benefits and risks of early pharmacological prophylaxis. The EtD framework is available online at https://guidelines.gradepro.org/profile/1584FD2F-9CC6-9C59-8DF5-48F0045F1BE5. We identified 1 systematic review385 of RCTs and observational studies that addressed this research question. Five studies186,188-191 reported the effect on the risk of any proximal and any distal DVTs, and 1 reported the effect on the risk of any DVT.187 Only the 5 studies that specified the location of the DVT were included in the evidence profile. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Based on this finding, the panel assumed that the undesirable effects were likely similar for different DOACs. Comparison of LMW heparin and placebo, Ardeparin (low-molecular-weight heparin) vs graduated compression stockings for the prevention of venous thromboembolism. Question: Should pharmacological prophylaxis vs no pharmacological prophylaxis be used for patients undergoing laparoscopic cholecystectomy? They considered that the risk of VTE following cardiac surgery is uncertain but judged that most patients were at moderate risk for VTEs and at high risk for anticoagulant prophylaxis-related bleeding. The panel recognized that the comparative resources associated with LMWH and UFH prophylaxis were probably negligible. The panel judged the desirable effects to be of moderate magnitude and the undesirable effects to be of small magnitude. Cost-effectiveness probably favors pneumatic compression prophylaxis. LMWH is already widely used, and the panel had no concern about the feasibility of implementation. The International Consensus Statement on Prevention and Treatment of Venous Thromboembolism published by the European Venous Forum, in cooperation with several other organizations, offers guidelines for general, vascular, bariatric, and plastic surgical patients.403 Major vascular surgery was considered with other “major surgery,” and patients were judged to generally be at moderate risk in the absence of specific high-risk characteristics, such as age older than 60 years or prior VTE. We found no study that compared different classes of DOACs or individual DOACs of the same class head to head. Pharmacological prophylaxis combined with mechanical prophylaxis vs pharmacological prophylaxis alone, 5. In such instances, further research may provide important information that alters the recommendations. Typically, included studies reported outcomes as any PE, any DVT, or any proximal or distal DVT. Question: Should mechanical prophylaxis vs no prophylaxis be used for patients undergoing major surgery? The EtD framework is available online at https://guidelines.gradepro.org/profile/E9D1EF22-EEC9-560E-A0CC-9FD435188BBE. For patients at moderate risk for VTE who are not at high risk for major bleeding complications, it was suggested to use LMWH, low-dose UFH, or mechanical prophylaxis with intermittent pneumatic compression over no prophylaxis. The guideline panel suggests using LMWH rather than warfarin for patients undergoing total hip arthroplasty or total knee arthroplasty. The EtD framework is available online at https://guidelines.gradepro.org/profile/59BDE78B-362E-9573-980D-41A280D79D9E. The EtD framework is available online at https://guidelines.gradepro.org/profile/4885EDB9-B445-5554-BD62-CFE2EED6D08E. For most patients undergoing radical prostatectomy, the panel recommended against the use of pharmacological prophylaxis (see Recommendation 23). Sixteen individuals or organizations submitted comments. We rated the overall certainty in the evidence of effects as very low based on the lowest certainty in the evidence for the critical outcomes informed by observational studies. The EtD framework is available online at https://guidelines.gradepro.org/profile/AEF71CF4-AB9F-1DDF-A08B-1F5E2484EA5F. The purpose of these guidelines is to provide evidence-based recommendations about the prevention of VTE for patients undergoing major surgical procedures. The panel acknowledged that pharmacological prophylaxis might still be warranted in a higher-risk subgroup of patients, such as those experiencing prolonged immobility following surgery. No high-priority research needs were identified. There may also be no difference in symptomatic PEs (RR, 0.56; 95% CI, 0.17-1.86; low certainty in the evidence of effects). For patients at high bleeding risk, mechanical prophylaxis methods alone may be preferred. The filter is … Baseline risk estimates specific to gynecological procedures396,397 were applied to determine the desirable and undesirable effects of prophylaxis in absolute terms. In this group, the panel judged the desirable effects of pharmacological prophylaxis as trivial and undesirable effects as small. Pharmacological prophylaxis may increase major bleeding (RR, 1.24; 95% CI, 1.12-1.37; low certainty in the evidence of effects). For patients undergoing surgery, the ASH guideline panel suggests using any of the DOACs approved for use (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯). The panel used an explicit process to rate the clinical severity of DVTs and PEs. This corresponds to 2 fewer (0-2 fewer) deaths per 1000 patients based on a baseline risk of 0.6% from observational data.357 It may not reduce symptomatic PEs following laparoscopic cholecystectomy (RR, 0.48; 95% CI, 0.26-0.88; very low in the evidence of effects), but we are very uncertain of this finding. The EtD framework is available online at https://guidelines.gradepro.org/profile/96D5A309-8606-4469-B732-E1844465CC75. It has been estimated to cause >50 000 deaths per annum in the United States alone.7 The importance of preventative measures to minimize the risk of VTE following major surgery has been recognized for decades; however, even with the use of prophylaxis, surgery accounts for ∼25% of VTEs observed in communities.8, Although most surgical procedures carry some risk for VTE, this risk varies considerably across surgical procures and among individual patients undergoing surgery. We are also very uncertain about the effect of LMWH on symptomatic proximal DVTs (RR, 1.33; 95% CI, 0.30-6.01; very low certainty in the evidence of effects) and symptomatic distal DVTs (RR, 1.20; 95% CI, 0.45-3.22; very low certainty in the evidence of effects). For clinicians: most individuals should follow the recommended course of action. The panel followed best practice for guideline development recommended by the Institute of Medicine (now the National Academy of Medicine) and the Guidelines International Network.1-4 The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach5,6 to assess the certainty in the evidence and formulate recommendations. For patients undergoing major surgery who do not receive pharmacologic prophylaxis, the ASH guideline panel suggests using mechanical prophylaxis over no mechanical prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). The authors thank Joyce Kirkman and Tracy Minichiello for participation on the panel during the initial stages of the guideline-development process, including to prioritize questions and health outcomes. The panel determined that there was possibly important uncertainty or variability in how much affected individuals valued the main outcomes. In addition to conducting systematic reviews of intervention effects, the researchers searched for evidence related to baseline risks, values, preferences, and costs and summarized findings within the EtD frameworks.12,13,16 Subsequently, the certainty in the body of evidence (also known as quality of the evidence or confidence in the estimated effects) was assessed for each effect estimate of the outcomes of interest following the GRADE approach based on the following domains: risk of bias, precision, consistency and magnitude of the estimates of effects, directness of the evidence, risk of publication bias, presence of large effects, dose-response relationship, and an assessment of the effect of residual, opposing confounding. We were unable to assess the effect on reoperations. Pharmacological prophylaxis likely has little or no effect on symptomatic distal DVTs (RR, 0.85; 95% CI, 0.56-1.29; very low certainty in the evidence of effects), but once again we are very uncertain of this finding. Patients with other risk factors for VTE (eg, history of VTE, thrombophilia, or malignancy) may benefit from pharmacological prophylaxis. Development of these guidelines, including systematic evidence review, was supported by the McMaster University GRADE Centre, a world leader in guideline development. Thus, for this recommendation, the benefits and harms of postoperative pharmacological prophylaxis are being considered in an incremental context. In light of the very low certainty in the evidence, further high-quality comparative studies, using appropriate clinical outcomes, would be of value to add more certainty to this recommendation. We rated the overall certainty in the evidence of effects as very low based on the lowest certainty in the evidence for the critical outcomes, downgrading for study limitations, indirectness, and very serious imprecision. The very low certainty in the evidence justifies conditional recommendations for both scenarios. There were no concerns about the feasibility of implementation. This corresponds to 4 fewer (1-6 fewer) pulmonary embolic events per 1000 patients undergoing major general surgery. For patients experiencing major trauma at high risk for bleeding, the ASH guideline panel suggests against pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). Most individuals in this situation would want the recommended course of action, and only a small proportion would not. Similarly, pharmacological prophylaxis may not reduce symptomatic proximal DVTs (RR, 0.38; 95% CI, 0.14-1.00; very low certainty in the evidence of effects) or symptomatic distal DVTs (RR, 0.52; 95% CI, 0.31-0.87; very low certainty in the evidence of effects). Pharmacological prophylaxis probably does not reduce symptomatic PEs (RR, 0.48; 95% CI, 0.26-0.88; moderate certainty in the evidence of effects). Overall, mechanical prophylaxis is recommended for most neurosurgical patients. The use of these guidelines is also facilitated by the links to the EtD frameworks and interactive summary-of-findings tables in each section. We identified 1 systematic review of RCTs addressing this research question.30 We identified 2 studies118,349 in that review that fulfilled our inclusion criteria and measured outcomes relevant to this context. Prophylaxis with LMWH vs UFH probably does not reduce mortality following major general surgery (RR, 1.03; 95% CI, 0.89-1.18; moderate certainty in the evidence of effects). We are uncertain of the effect of pharmacological prophylaxis on distal DVTs (RR, 0.85; 95% CI, 0.5-1.29, very low certainty in the evidence of effects). 2: Clinical practice guidelines, GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. The panel identified the need for more and better studies on how patients value the various outcomes in the perioperative setting and to what degrees these values vary by patients as a future research priority. Comparative Effectiveness Review No. The EtD framework is available online at https://guidelines.gradepro.org/profile/80C377E5-E3C0-36CD-B646-C2532AB4D4B9. In a moderate-risk population with a baseline risk of 2.5%,267 this corresponds to 12 fewer (8-16 fewer) per 1000 patients. The primary target population of this guideline is patients hospitalized for major surgical procedures that carry a risk for postoperative VTE. Therefore, it is important to establish the baseline risk for VTE and major bleeding in surgical patients. For patients undergoing major surgery who receive pharmacologic prophylaxis, the ASH guideline panel suggests using combined prophylaxis with mechanical and pharmacological methods over prophylaxis with pharmacological agents alone (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). Comparison between dihydroergotamine-heparin and intermittent pneumatic calf compression and evaluation of added graduated static compression, Intermittent sequential pneumatic compression of the legs in the prevention of venous stasis and postoperative deep venous thrombosis, Intermittent sequential pneumatic compression of the legs and thromboembolism-deterrent stockings in the prevention of postoperative deep venous thrombosis, Low incidence of deep vein thrombosis after total hip replacement: an interim analysis of patients on low molecular weight heparin vs sequential gradient compression prophylaxis, Prevention of deep vein thrombosis in knee arthroplasty. Likewise, use of LMWH prophylaxis vs UFH prophylaxis appears to result in little or no difference in symptomatic PEs (RR, 0.91; 95% CI, 0.63-1.3; low certainty in the evidence of effects). Aspirin versus dihydroergotamine-heparin, DVT prophylaxis after TKA: routine anticoagulation vs risk screening approach - a randomized study, Aspirin and warfarin for thromboembolic disease after total joint arthroplasty, VenaFlow plus Lovenox vs VenaFlow plus aspirin for thromboembolic disease prophylaxis in total knee arthroplasty, Administering aspirin, rivaroxaban and low-molecular-weight heparin to prevent deep venous thrombosis after total knee arthroplasty, Aspirin versus low-molecular-weight heparin for extended venous thromboembolism prophylaxis after total hip arthroplasty: a randomized trial, Aspirin or rivaroxaban for VTE prophylaxis after hip or knee arthroplasty, The effect of aspirin and low-molecular-weight heparin on venous thromboembolism after knee replacement: a non-randomised comparison using National Joint Registry Data, The effect of aspirin and low-molecular-weight heparin on venous thromboembolism after hip replacement: a non-randomised comparison from information in the National Joint Registry, Oral direct Factor Xa inhibitors versus low-molecular-weight heparin to prevent venous thromboembolism in patients undergoing total hip or knee replacement: a systematic review and meta-analysis, Oral dabigatran versus enoxaparin for thromboprophylaxis after primary total hip arthroplasty (RE-NOVATE II*). 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Account the extent of resource use associated with alternative Management options as Supplements 2 and 3 anticoagulants used. American Society of Hematology ( ASH ) intend to support decision making is appropriate need to periodically bleeding. Updates or adaptation ) by additional research unlikely to alter the recommendation likely... Would be of value to add more certainty to these guidelines is also facilitated by the panel recognized that undergoing. By lower extremity injury making about preventing VTE in patients with persistent mobility restrictions after the first 3–6 months extended... Standard imaging test to diagnose DVT, using LMWH over UFH, history of prophylactic. Measures against VTE, thrombophilia, or malignancy ) may benefit from pharmacological prophylaxis purposes of technique... The need to periodically reevaluate bleeding risk, mechanical prophylaxis vs no pharmacological prophylaxis alone therapy!