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Deep vein thrombosis occurs in over 20% of patients having major surgery and over 40% of patients having major orthopaedic surgery. The postoperative risk of pulmonary embolism can be as high as 5% in the highest risk groups. However, many patients are probably not currently receiving adequate prophylactic measures.1 2 This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) on how to reduce the risk of venous thromboembolism in inpatients having surgery.3
NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*).
Assess patients for the following risk factors, and inform all patients of the risks of venous thromboembolism and the effectiveness of prophylaxis.
Some clinicians hold strong views about the overall benefits of reducing the risk of deep vein thrombosis or pulmonary embolism with drugs that increase the risk of bleeding. The balance of risks cannot be quantified from clinical experience, and moreover, a recent adverse experience tends to affect objective consideration.4 The highly valued concept of clinical judgment conflicts with recognition that adherence to an evidence based guideline may be safer for doctors as well as for patients.
NICE has developed tools to help organisations implement the guidance (see www.nice.org.uk/page.aspx?o=tools).
This latest guideline presents the most comprehensive and up to date systematic review and analysis of the evidence on methods to reduce the risk of venous thromboembolism. It is the first guideline of its type to consider the cost effectiveness of the various options for prophylaxis.
The guideline was developed according to NICE guideline methodology (see www.nice.org.uk/page.aspx?o=114219) by the National Collaborating Centre for Acute Care. The collaborating centre convened a development group of clinicians and patient representatives to oversee the work and help to develop the recommendations.
The group conducted an extensive systematic review of the literature, assessed the quality of the literature, and used a combined meta-analysis approach to compare the effectiveness of the various methods of prophylaxis. An economic model was developed to ascertain the most cost effective strategies.
The guideline went through an external consultation with stakeholders. The development group assessed the comments, re-analysed the data where necessary, and modified the guideline.
NICE has produced four different versions of the guideline: a full version; a quick reference guide; a version known as the “NICE guideline” that summarises the recommendations; and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk/CG046) or the National Collaborating Centre for Acute Care's website (www.rcseng.ac.uk/surgical_research_units/nccac/).
The guideline will be updated as needed. Information about the progress of any update will be posted on the NICE website (www.nice.org.uk/CG046). NICE hopes to audit the uptake of the guideline and provide the data in any future update.
The guideline recommends that future research be carried out to determine accurate current estimates of the risk of venous thromboembolism, whether low molecular weight heparin should be started before or after surgery, and the effectiveness of combining different methods of mechanical prophylaxis.
The guideline development group comprises Nigel Acheson, Ricky Autar, Colin Baigent, Kim Carter, Simon Carter, Philippa Davies, Enrico De Nigris, David Farrell, Saoussen Ftouh, David Goldhill, Jennifer Hill, Peter Katz, John Luckit, Robin Offord, Arash Rashidian, Carlos Sharpin, Adam Thomas, Tom Treasure, David Wonderling.
Competing interests: None declared.
Funding: The National Collaborating Centre for Acute Care was commissioned and funded by National Institute for Health and Clinical Excellence to write this summary.