Deep Venous Thrombosis and Pulmonary Embolism

We recommend that the American College of Chest Physicians (ACCP) recommendations should be followed (with a possible exception for orthopedic patients as discussed below). AHRQ has put out an implementation guide that is consistent with the ACCP recommendations. Upper extremity thromboses represent an under-appreciated risk. While consensus recommendations are not available for upper extremity thromboses, it is appropriate to empirically address patients at risk for upper extremity thromboses.

Resource 1 contains the ACCP recommendations. Resource 2 is the AHRQ implementation guide. Resource 3 makes the case for addressing the risk of upper extremity thromboses.

Note that the American Academy of Orthopedic Surgeons (AAOS) has recommendations differing from the American College of Chest Physicians (ACCP) recommendations. While efforts are underway to resolve these differences, a uniform consensus recommendation is not expected this year. The medical staff and the hospital should come to a conclusion regarding whether orthopedic patients are to be treated according to the AAOS recommendations or the ACCP ones. Resource 4 contains the AAOS recommendations.

The UK National Health Service released a detailed guide in 2010 for venous thromboembolism reduction. It and the accompanying editorials are included below.

1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):381S-453S. (free full access).
2. Maynard G., Stein J. Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Management. AHRQ Publication No. 08-0075, August 2008. (free full access).
3. Muñoz FJ, Mismetti P, Poggio R, et al. Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry. Chest. 2008;133(1):143-8. (free full access).
4. Johanson NA, Lachiewicz PF, Lieberman JR, et al. Prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. The Journal of the American Academy of Orthopaedic Surgeons. 2009;17(3):183-96.
5. Selby, R., & Geerts, W. Prevention of venous thromboembolism: consensus, controversies, and challenges. Hematology. 2009;286–92. (free full access).
6. Society of Hospital Medicine Venous Thromboembolism resource room. (free full access).
7. UK National Health Service’s National Institute for Health and Clinical Excellence (NICE) clinical guideline: Venous Thromboembolism — reducing the risk. Released January, 2010. (free full access).
8. Treasure T, Hill J. NICE guidance on reducing the risk of venous thromboembolism in patients admitted to hospital. Journal of the Royal Society of Medicine. 2010;103(6):210-2. (free full access).