The panel judged that combined pharmacological and mechanical prophylaxis would be most beneficial for patients considered at very high risk for VTE following major surgery. The risks of reoperation may be similar with LMWH and UFH (RR, 0.79; 95% CI, 0.57-1.08; low certainty in the evidence of effects), corresponding to 1 fewer (0-2 fewer) event based on a baseline risk of 0.4%.380. Pharmacological prophylaxis results in little or no difference in reoperation (RR, 0.75; 95% CI, 0.21-2.77; low certainty in the evidence of effects). Available evidence from RCTs did not allow the panel to quantitate whether there was an incremental risk for HIT associated with the use of pharmacological UFH or LMWH prophylaxis beyond that of heparin administered during the procedure itself or whether there was a relatively greater incremental risk for HIT in the cardiac surgery setting with postoperative UFH prophylaxis than with LMWH. Once bleeding is stabilized and the patient is no longer considered at high risk for major bleeding, the use of pharmacological prophylaxis should be reconsidered. Anticoagulants should stop after 3 months of therapy in patients with an acute, proximal deep venous thrombosis (DVT) provoked by surgery rather than shorter or longer treatment courses (Grade 1B). For patients undergoing major gynecological surgery, the ASH guideline panel suggests using LMWH or UFH (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). DOACs may require dose reduction or avoidance in patients with renal dysfunction, and should be avoided in pregnancy. They further indicate a preference for LMWH over the other listed agents, with the exception of ASA. These adaptations should be based on the associated EtD framework.416 The Agency for Healthcare Research and Quality in the United States provides a guide for implementing effective quality improvement in this patient population.417. Pharmacological prophylaxis probably results in no difference in reoperations (RR, 2.01; 95% CI, 0.29-14.05; low certainty in the evidence of effects), corresponding to 1 more (1 fewer to 19 more) per 1000 patients. The guideline panel determined that potential undesirable effects of pharmacological prophylaxis, in particular major bleeding, outweighed its potential benefit for patients undergoing laparoscopic cholecystectomy. We identified 1 systematic review of RCTs addressing this research question.30 We identified only 4 studies374,376,377,379 overall that were conducted with patients undergoing major gynecological surgery. Prophylaxis with LMWH vs UFH probably does not affect major bleeding (RR, 0.97; 95% CI, 0.78-1.20; moderate certainty in the evidence of effects). Decision aids may be useful in helping patients to make decisions consistent with their individual risks, values, and preferences. The guideline panel suggests against pharmacological prophylaxis for patients undergoing TURP. It has been estimated to cause >50 000 deaths per annum in the United States alone.7 The importance of preventative measures to minimize the risk of VTE following major surgery has been recognized for decades; however, even with the use of prophylaxis, surgery accounts for ∼25% of VTEs observed in communities.8, Although most surgical procedures carry some risk for VTE, this risk varies considerably across surgical procures and among individual patients undergoing surgery. Furthermore, it is recognized that the risk of HIT in other settings has been shown to be higher with the use of UFH vs LMWH. When DVT is confirmed, anticoagulation is indicated to control symptoms, prevent progression and reduce the risk of postâthrombotic syndrome and pulmonary embolism. Six studies186-191 reported the effect of early vs late postsurgical antithrombotic administration on the risk of mortality and on the risk of development of any PEs. Patients hospitalized for major trauma were included whether they underwent surgery or not. Based upon the very low baseline risk for patients undergoing TURP, this would correspond to 0 fewer symptomatic events per 1000 higher-risk patients. Determinants and time course of the postthrombotic syndrome after acute deep venous thrombosis. accepted. Patients with other risk factors for VTE (eg, history of VTE, thrombophilia, or malignancy) may benefit from pharmacological prophylaxis. As such, they completed a disclosure of interest form, which was reviewed by ASH and is available as Supplements 2 and 3. 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