What to Know About Deep Vein Thrombosis Prophylaxis

Risk of DVT in Otolaryngology Procedures

According to Dr. Cramer’s 2017 study, “Risk of Venous Thromboembolism Among Otolaryngology Patients vs. General Surgery and Plastic Surgery Patients” (JAMA Otolaryngol Head Neck Surg. 2018;144:9-17), most patients undergoing otolaryngology procedures are at low risk of VTE.  This indicates guidelines for a low-risk population could be adapted to otolaryngology, while patients undergoing high-risk otolaryngology procedures should be considered for more aggressive VTE prophylaxis.

I think a lot of DVT and VTE risk is all about patients ambulating. —John Cramer, MD

Dr. Cramer said otolaryngology is generally a low-risk field for VTE because otolaryngology patients ambulate more. “I think a lot of DVT and VTE risk is all about patients ambulating,” he said.

While otolaryngology may be an order of magnitude less for DVT and VTE as compared with general surgery, neurosurgery, or other fields, Dr. Cramer said the risk is still potentially significant for some subpopulations.

“Even though our patients are at lower risk, our patients in the subpopulation we operate on that have high Caprini scores are definitely at risk for DVT and PE,” Dr. Cramer said. “And for those patients, the number one intervention we can do to prevent death after surgery is appropriate DVT and PE prophylaxis.”

According to Dr. Kahue, evidence shows that the ear, nose, and throat procedures that carry the highest risk are those that involve head and neck cancer, multiple-day hospitalizations after surgery, and significant reconstruction, including free flaps and regional flaps.

The Problem with Sequential Compression Devices

Dr. Kahue said most hospitals require that at the time of general anesthesia induction, all surgical patients have sequential compression devices (SCDs), which  squeeze the ankle, mid-calf, and upper calf. “Even if you’re going home the same day from surgery, they should be placed at the time when someone’s going to sleep,” she said, “and they should be on after surgery.”

For inpatient procedures, many people find the devices annoying and opt out of wearing them after surgery, she said. “I think people don’t understand how important they are “so the compliance rate with SCD use is actually quite low,” she said. Dr. Kahue added that nurses do not enforce compliance, as they are often busy with many other tasks.

But patients who aren’t ambulating should be wearing the devices nearly constantly. “In theory, even if someone is walking around during the day, they really should still have them on when in bed overnight,” she said. “And essentially everyone that is admitted to the hospital should be on prophylactic heparin or low-molecular-weight heparin, like Lovenox, typically for the duration of their hospitalization.”