Seven studies reported the effect of the combination of pharmacological and mechanical prophylaxis compared with pharmacological prophylaxis alone on the risk of mortality.36,60,62,68,104,105,107 Ten studies reported the effect on the development of symptomatic PEs,60,62,68,70,105,107,109-111,117 and 6 studies reported the effect on any PE.36,104,108,112,116,117 Three studies reported data on symptomatic proximal DVTs,62,70,112 and 8 studies reported data on any proximal DVT.62,70,104,108,112-114 Three studies reported data on symptomatic distal DVTs,70,105,112 and 7 studies reported on any distal DVT.68,105,108,109,112-114 Six studies reported the effect of combination pharmacological and mechanical prophylaxis compared with pharmacological prophylaxis alone on the risk of major bleeding,60,62,68,104,109,112 and 2 studies reported the effect on the risk of reoperation.107,117. 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. Pharmacological prophylaxis vs no pharmacological prophylaxis, 19. A recent large RCT supports our recommendation that ASA or anticoagulants be used for VTE prophylaxis following total hip or knee arthroplasty. The EtD framework is available online at https://guidelines.gradepro.org/profile/05201A35-BCDA-9EFA-98CB-892C0AB72944. An international multicentre trial, Dihydroergotamine-heparin prophylaxis of postoperative deep vein thrombosis. Several recent guidelines comment on VTE prophylaxis after total hip or knee arthroplasty. Pharmacological prophylaxis may be warranted in a higher-risk subgroup of patients, such as those experiencing prolonged immobility following surgery. The panel used the GRADEpro Guideline Development Tool (www.gradepro.org) and SurveyMonkey (www.surveymonkey.com) to brainstorm and then prioritize the questions described in Table 1. The EtD framework is available online at https://guidelines.gradepro.org/profile/9160FAA2-4F98-A3AA-9816-64DF796ABBC7. This corresponds to a benefit of 4 fewer (1-7 fewer) deaths per 1000 patients. Our search for RCTs and observational studies identified 1 additional study that fulfilled the inclusion criteria.153 Additionally, we identified 1 systematic review of RCTs and observational studies that was published after our initial literature search, which did not include any new study not already included in our meta-analysis.154 We also identified 1 RCT published in July 2019, evaluating the use of IVC filters for patients experiencing trauma.155 Although we did not update the meta-analysis, the trial results were assessed by the panel as consistent with the recommendation. Pharmacological prophylaxis probably reduces mortality slightly following major gynecological surgery (RR, 0.75; 95% CI, 0.61-0.93; low certainty in the evidence of effects). Question: Should mechanical prophylaxis vs no prophylaxis be used for patients undergoing major surgery? LMWH prophylaxis appears to result in little or no difference in mortality compared with UFH prophylaxis (RR, 1.03; 95% CI, 0.89-1.18; low certainty in the evidence of effects), corresponding to 1 more (2 fewer to 3 more) deaths per 1000 patients. The International Initiative on Thrombosis and Cancer is an independent academic working group aimed at establishing a global consensus for the treatment and prophylaxis of VTE in patients with cancer. and P.D. We rated the overall certainty in the evidence of effects as moderate based on the lowest certainty in the evidence for the critical outcomes, downgrading for imprecision. Members of the VTE Guideline Coordination Panel reviewed the disclosures and judged which interests were conflicts and should be managed. The guideline panel suggests using DOACs rather than LMWH for patients undergoing total hip or knee arthroplasty. 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. For patients undergoing total hip arthroplasty or total knee arthroplasty, if a DOAC is not used, the ASH guideline panel suggests using LMWH rather than UFH (strong recommendation based on moderate certainty in the evidence of effects ⊕⊕⊕◯). Clinical documentation of low molecular weight heparin. Remark: Patients with other risk factors for VTE (eg, history of VTE, thrombophilia, or malignancy) may benefit from pharmacological prophylaxis. The panel judged the desirable effects of pharmacological prophylaxis for patients undergoing TURP as trivial and the undesirable effects as small in magnitude. were the chair and vice chair of the panel and led the panel meeting; and all authors approved the content. Combined prophylaxis likely results in a small increased risk for major bleeding (RR, 2.23; 95% CI, 1.09-4.57; moderate certainty in the evidence of effects). Health equity would probably be increased as a consequence of the use of ASA. Depending on the baseline risk, assumed to be 0.8% or 1.1% based on a large observational study,73 this benefit likely corresponds to 5 fewer (1-7 fewer) per 1000 patients in a lower-risk population to 7 fewer (1-10 fewer) per 1000 patients in a higher-risk population. There was probably no impact on equity, because both LMWH and UFH were thought to be acceptable and feasible to implement. The panel suggested that, for patients experiencing major trauma who are judged to be at low to moderate risk for bleeding, LMWH or UFH may be used for pharmacological VTE prophylaxis based on low certainty in the evidence. Efficacy and tolerance of Fraxiparine in prevention of deep vein thrombosis in general surgery with spinal anesthesia (subarachnoidal and peridural) [in Italian], Low-molecular-weight heparin and unfractionated heparin in prophylaxis against deep vein thrombosis in critically ill patients undergoing major surgery, Low molecular weight heparin and prevention of postoperative thrombosis in abdominal surgery, Low rate of venous thromboembolism after craniotomy for brain tumor using multimodality prophylaxis, Antithrombotic prophylaxis in patients undergoing laparoscopic cholecystectomy, Incidence and risk factors for symptomatic venous thromboembolism following cholecystectomy, The effect of low-dose heparin on blood loss at abdominal hysterectomy, Fixed minidose warfarin: a new approach to prophylaxis against venous thrombosis after major surgery, Surgical haemorrhage in patients given subcutaneous heparin as prophylaxis against thromboembolism, The effects of low-dose heparin treatment on patients undergoing transvesical prostatectomy, Prevention of postoperative deep-vein thrombosis by low-dose heparin in urological surgery. It further judged that there was possibly important uncertainty or variability in how much people value the main outcomes. A pilot study, Comparison of the use of a foot pump with the use of low-molecular-weight heparin for the prevention of deep-vein thrombosis after total hip replacement. Based on an overall moderate certainty in the evidence of effects, the panel judged the balance of effects to probably favor the use of DOACs over LMWH. We are very uncertain about the effects on symptomatic proximal DVTs and symptomatic distal DVTs. Five studies reported the effect of pneumatic compression prophylaxis compared with graduated compression stockings prophylaxis on risk of mortality.94,96,97,101,102 Eight studies reported the effect on the development of symptomatic PEs,37,95,96,97,98,99,102,103 and 4 studies reported the effect on any PE.94,100,101,103 One study reported data on symptomatic proximal and symptomatic distal DVTs,98 whereas 6 studies reported on any proximal DVT,37,94,96,98-100 and 5 studies reported on any distal DVT.37,94,96,98,100. For patients undergoing hip fracture repair, the ASH guideline panel suggests using pharmacological prophylaxis over no pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). We found no interaction for any of the outcomes. Given the very low baseline risks of VTE following this procedure and the increasing use of alternative modalities to treat lower urinary tract symptoms attributed to benign prostatic hyperplasia,373 further RCTs conducted on patients undergoing TURP do not appear to be a major priority. Determinants and time course of the postthrombotic syndrome after acute deep venous thrombosis. This document may also serve as the basis for adaptation by local, regional, or national guideline panels. For patients undergoing major neurosurgical procedures, the ASH guideline panel suggests against using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). 122, National Institute for Health and Care Excellence, Venous Thromboembolism in Over 16s: Reducing the Risk of Hospital-Acquired Deep Vein Thrombosis or Pulmonary Embolism. 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