European guidelines on perioperative venous thromboembolism prophylaxis

In the current issue of the European Journal of Anaesthesiology, the European Society of Anaesthesiology (ESA), together with other European societies, is publishing original and user-friendly guidelines on the prevention of venous thromboembolism (VTE) in anaesthesia and intensive care. There are many justifications for the development of these new European Guidelines, such as The steadily decreasing global postoperative VTE risk.1–4 The ongoing debate about the indications of VTE prophylaxis for fast-track procedures and day surgery.2,4,5 The questioned efficacy of elastic compression stockings in obese and elderly patients. The continued recommendation of aspirin despite the availability of new agents.6,7 The increasing need for objective definitions for major/massive bleeding. The American College of Chest Physicians (ACCP) guidelines 2008 (8th edition)8 and 2012 (9th edition)9 are still considered by many to be the 'Holy Bible', despite conflicting statements, different scope of topics, lack of incorporation of recently published important articles and last but not least lack of coverage of several topics of interest to anaesthesiologists.8,10 Thus, there is ample room for a challenging European perspective. As a consequence of the above, a Task Force was set up in 2015 with seven ESA representatives and eight representatives from invited societies: European Society of Intensive Care Medicine, European Association of Urology, European Digestive Surgery, European Board of Colleges of Obstetrics and Gynaecology, European Knee Society, European Hip Society, International Society on Thrombosis and Haemostasis and Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA). The driving incentive was to articulate an original, clinical and helpful European guideline, and not merely to implement or to extrapolate from either the North American ones (ACCP)10 or the National Institute for Health and Clinical Excellence guidelines.11 After extended discussions, the number of clinical questions (chapters) was limited to 12 taking into account the benefit/risk ratios (efficacy/safety). We chose not to start from scratch and 'reinvent the wheel', since one member of the leading Task Force was part of the previous ACCP guidelines. ACCP was informed. However, we decided to add several clinical topics which had not been fully addressed in the 2012 ACCP guideline. The Population, Intervention, Comparator, Outcome structured approach was used systematically. Each clinical question focused on perioperative prophylaxis, starting with a short rationale and ending up with a graded recommendation. It was mandatory to address the clinical relevance, the population of interest, the types of prophylaxis, the impact of duration, the assessment of benefits and harms and last, but not least, if possible to provide a cost–benefit assessment. The guidelines are presented in 12 separate articles (chapters), each edited by members of the ESA VTE Task Force. VTE prophylaxis is discussed in nine clinical settings. The usefulness of controversial treatments is discussed in three additional chapters. The clinical settings of interest were Surgery in the obese patient12 Surgery during pregnancy and the immediate post-partum period13 Surgery in the elderly14 Day surgery and fast-track surgery15 Intensive care16 Cardiovascular and thoracic surgery17 Neurosurgery18 Chronic treatments with anti-platelet agents19 Patients with pre-existing coagulation disorders, and after severe perioperative bleeding.20 The controversial treatments were Mechanical prophylaxis21 Aspirin22 Inferior vena cava filters.23 A synopsis of all recommendations can be found in an Executive Summary.24 Literature search and grading After extended evaluation and discussions, the ESA Task Force came to the conclusion that the latest search strategy designed and used by the 2012 ACCP guideline Task Force was in accordance with the best available recommendations and considered comprehensive, evidence-based, robust and thorough. Thus, we were convinced that we would add very little to the level of evidence by carrying out identical search strategies for the same time period and for similar clinical questions. As a consequence, we adopted a modified search strategy which merely updated the search findings of the 2012 ACCP guideline for the clinical questions that were of similar character. However, for those clinical questions that were not covered by the ACCP or other recently published guidelines with the same level of scientific robustness, we carried out separate search strategies covering citations of relevance published during the last 10 years with the exception of landmark studies published prior to this deadline. Our search strategy was not confined to randomised controlled trials, but also included observational studies to assess other relevant outcomes such as safety, harms and cost-effectiveness. We adhered to ESA standards for creation of guidelines25 and, as a consequence, the GRADE system for rating clinical guidelines was the cornerstone of the applied process.26 Furthermore, we incorporated the CAPRINI risk score as the risk assessment tool for the occurrence of VTE.27 Finally, The Appraisal of Guidelines for Research & Evaluation (AGREE) instrument was used to address the issue of variability and to evaluate the process of our guideline development and the quality of reporting.28 Writing the questions (rationale and recommendations) The Guidelines Task Force nominated a pool of advisory experts each of whom were asked to be in charge of one chapter. In general, two or three experts were responsible for each of the pre-defined topics. Each European society proposed up to four experts to participate in creation of these guidelines. The nomination process was further adjusted by the ESA to reflect a balanced distribution of experts. Finally, a total of 32 experts were chosen by the Task Force. These European guidelines on VTE prophylaxis provide not only an updated comprehensive assessment of the available evidence for our defined clinical questions, but represent also the first European multidisciplinary document concerning perioperative VTE to reflect the clinical perspectives pertinent to our physicians and our reality. These recommendations adhere to ESA and internationally acknowledged methodological standards and we hope to be able to disseminate our recommendations successfully to various national societies and ideally facilitate a rapid implementation of our recommendations into clinical practice. We plan to carry out future updates of these guidelines as recommended by the ESA. Acknowledgements relating to this article Assistance with the Editorial: none. Financial support and sponsorship: two meetings of the VTE Guidelines Task Force (Brussels and Berlin) were covered by the ESA for the ESA members. Conflict of interest: honoraria from Aspen, Bayer, BMS, Daiichi, Medtronics, Pfizer, Portola, Roche, Sanofi, Siemens and Stago (CMS). Comment from the Editor: this Editorial was checked by the editors but was not sent for external peer review. CMS is an associate editor of the European Journal of Anaesthesiology. Members of the ESA VTE Guidelines Task Force Arash Afsharia (European Society of Anaesthesiology), Walter Agenob (International Society on Thrombosis and Haemostasis), Aamer Ahmedc (European Society of Anaesthesiology), Jacques Duranteaud (European Society of Intensive Care Medicine), David Faraonie (European Society of Anaesthesiology), Sibylle Kozek-Langeneckerf (European Society of Anaesthesiology), Juan Llaug (European Society of Anaesthesiology), Jacky Nizardh (European Board of Colleges of Obstetrics and Gynaecology), Karin Plassi (European Association of Urology), Maurizio Solcaj (European Society of Anaesthesiology), Jakob Stensballek (Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis), Emmanuel Thienpontl (European Knee Society), Eleftherios Tsiridism (European Hip Society), Linas Venclauskasn (European Digestive Surgery) and Charles Marc Samamao (European Society of Anaesthesiology). aDepartment of Anaesthesia, Mother and Children's centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. bDepartment of Clinical and Experimental Medicine, University of Insubria, Varese, Italy. cDepartment of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK. dDepartment of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris-Sud, Assistance Publique–Hôpitaux de Paris, Université Paris-Sud, Hôpital de Bicêtre, UMRS 942, Le Kremlin-Bicêtre, France. eDepartment of Anaesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. fSigmund Freud Private University and Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna, Vienna, Austria. gDepartment of Anaesthesiology and Critical Care, University Hospital Clinic, University of València, Valencia, Spain. hDepartment of Obstetrics and Gynecology, Groupe hospitalier Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris, Paris, France. iEuropean Association of Urology, Guidelines Office, Arnhem, The Netherlands. jEuropean Society of Anaesthesiology, Brussels, Belgium. kDepartment of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University Hospital, Copenhagen & Section for Transfusion Medicine, Capitol Region Blood Bank, Copenhagen University Hospital, Copenhagen, Denmark. lOrthopaedic Surgery, University Hospital Saint Luc, Brussels, Belgium. mOrthopaedic Surgery, Aristotle University Medical School, Thessaloniki, Greece and Imperial College London Medical School, London, UK. nDepartment of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania. oDepartment of Anaesthesia and Intensive Care, Cochin University Hospital, Assistance Publique–Hôpitaux de Paris, Université Paris Descartes, Paris, France.