benefit uniformly from chemical prophylaxis, so before adminis-
tering medications to prevent clotting, consider a patient's specif-
ic VTE risk. It's not unreasonable to send patients with a very high
risk for clotting home on chemical prophylaxis, but that's a clini-
cal decision that needs to be made on a case-by-case basis, as no
data-driven guideline exists.
The effectiveness and safety profiles of both subcutaneous
unfractionated heparin and enoxaparin sodium has been extensive-
ly studied over the past 20 to 30 years; these injectable medications
are the most reliable, but may be uncomfortable for patients.
Researchers are studying the prophylaxis potential of several novel
oral anticoagulants (NOACs), which have been shown in some
studies to have a favorable safety profile in inpatients. NOACs do
not require monitoring and are oral, as opposed to injected. Their
effectiveness and safety profile specific to VTE prophylaxis is still
being defined, and published data specific to the ambulatory
patient population is limited, at best. Currently, in my opinion,
unfractionated heparin or enoxaparin is the best choice based on a
predictable effectiveness and safety profile.
Precision medicine
Three-fourths of surgical patients might be receiving anti-clotting
medications they don't need, according to research my colleagues
and I recently published in the Annals of Surgery
(osmag.net/UFjyF3). The meta-analysis found that chemical pro-
phylaxis is beneficial only for patients with Caprini scores of 7 or
higher. Conversely, the risk-benefit relationship of chemoprophy-
laxis for patients with Caprini scores of 6 or lower was either
unclear or unfavorable. While these findings were largely based on
data from inpatient surgical patients, the results are certainly rele-
9 6 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • S E P T E M B E R 2 0 1 7
