Venous Thromboembolism Prophylaxis in Orthopedic Surgery
Comparative Effectiveness of Pharmacological Prophylaxis Versus No Pharmacological Prophylaxis
There is a high level of evidence that pharmacological prophylaxis versus no prophylaxis significantly decreases the occurrence of proximal deep vein thrombosis (DVT) [RR 0.53 (0.39 to 0.74)] and distal DVT [RR 0.59 (0.42 to 0.82)]. The analyses of DVT have higher levels of heterogeneity; this is likely due in part to the inclusion of trials evaluating multiple classes of pharmacological therapy within the analysis and the inclusion of trials that were published prior to 2001 within the analysis. There is a moderate level of evidence that pharmacological prophylaxis versus no prophylaxis significantly decreases the occurrence of DVT [RR 0.56 (0.47 to 0.68)] and asymptomatic DVT [RR 0.52 (0.40 to 0.69)]. There is a low level of evidence that pharmacological prophylaxis versus no prophylaxis significantly decreases major venous thromboembolism (VTE) [RR 0.21 (0.05 to 0.95)]. Major VTE events consist of proximal deep vein thrombosis, pulmonary embolism, or venous thromboembolism-related mortality.
Pharmacological prophylaxis did not significantly impact the occurrence of symptomatic, objectively confirmed VTE, although this was based on a single randomized controlled trial. Pharmacological prophylaxis did not significantly impact pulmonary embolism (PE) in the base case analysis. In patients who received pharmacological prophylaxis versus truly no prophylaxis the risk of pulmonary embolism was significantly decreased [RR 0.30 (0.09 to 0.99), NNT 20]. Pharmacological prophylaxis versus no prophylaxis did not significantly impact nonfatal PE, mortality, symptomatic DVT, or major bleeding in patients undergoing major orthopedic surgery. Pharmacological prophylaxis versus no prophylaxis did not significantly impact fatal PE, mortality due to bleeding, major bleeding leading to reoperation, and bleeding leading to transfusion in patients undergoing major orthopedic surgery; however, the impact is based on the results of a single trial for each end point because the rest of the trials evaluating these end points reported no events in the two comparative groups.
Abbreviations: 95% CI = 95-percent confidence interval; NNH = number needed to harm (the calculated range); NNT = number needed to treat (the calculated range; NR = not reported or insufficient evidence to permit conclusions; OR = odds ratio; RR = relative risk
- Sobieraj DM, Coleman CI, Tongbram V, et al. Venous Thromboembolism in Orthopedic Surgery. Comparative Effectiveness Review No. 49 (Prepared by the University of Connecticut/Hartford Hospital Evidence-based Practice Center under Contract No. 290-2007-10067-I). Rockville, MD: Agency for Healthcare Research and Quality; March 2012. AHRQ Publication No. 12-EHC020-EF. Available at www.effectivehealthcare.ahrq.gov/thrombo.cfm.
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