50 – What are the indications for seeking a thrombosis specialist or a hematology consult for VTE prevention, in patients undergoing elective orthopaedic procedures?

Daniel Caldeira.

Response/Recommendation: In the absence of reliable evidence, it is the opinion of this workgroup that patients with known or suspected bleeding or coagulation disorder, creatinine clearance<30 mL/min, active hepatobiliary disease, with significant anemia or thrombocytopenia or patients requiring continuous use of antiplatelet and/or anticoagulant might benefit from a thrombosis specialist or a hematology consult in the absence of an antithrombotic strategy established by the surgeon and/or the specialist usually follows the patient.

Strength of Recommendation: Consensus.

Rationale: Randomized controlled trials (RCT) have been performed to establish the efficacy and safety of thrombophylatic strategies in patients undergoing orthopaedic procedures and the main strategies are currently well studied¹.  However, RCT excludes some patients for whom the thrombophylatic strategies might not be well established and individualization is required.  Currently there are not any robust data about the indications for a thrombosis specialist or a hematology consult and its impact on thrombosis and/or haemorrhage after surgery.  Therefore, it is the opinion of this guideline workgroup that patients excluded from most of the contemporary trial, namely, those with known or suspected bleeding or coagulation disorder, creatinine clearance<30 mL/min, active hepatobiliary disease, with significant anemia or thrombocytopenia or patients requiring continuous use of antiplatelet and/or anticoagulant might benefit from seeking a thrombosis specialist or a hematology consult in the absence of antithrombotic strategy established by the surgeon and/or the specialist usually follows the patient.

References:

1.         Gómez-Outes A, Terleira-Fernández AI, Suárez-Gea ML, Vargas-Castrillón E. Dabigatran, rivaroxaban, or apixaban versus enoxaparin for thromboprophylaxis after total hip or knee replacement: systematic review, meta-analysis, and indirect treatment comparisons. BMJ. 2012;344:e3675. doi:10.1136/bmj.e3675