Do you use heparin or fractionated heparin? What kind of fractionated heparin do you prefer? What is your favorite dosing scheme (time of starting and finishing)? How often do you see hemorrhages with heparin? Do you have some contraindications for heparin (for example, melanoma brain metastasis or minimal amount of blood clots in postoperative cavity on 1st post op brain CT)? Do you always use stockings? What length of stockings (knee, thigh) do you prefer? Do you use pneumatic intermittent compression devices?
I think the best prophylaxis is molecular low-weight heparin (like nadroparin ) for the first two months after surgery (6000 IU/d) and then you can use indefinitely defibrotide bidaily. It is a really safe and reliable drug that efficaciously protects the patient even during chemotherapy .
For an evidence-based information, I suggest you to have a look at the guidelines published in 2012 in Chest:
Prevention of VTE in Nonorthopedic Surgical Patients
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Michael K. Gould, MD, FCCP; David A. Garcia, MD; Sherry M. Wren, MD; Paul J. Karanicolas, MD, PhD; Juan I. Arcelus, MD, PhD; John A. Heit, MD; and Charles M. Samama, MD, PhD, FCCP
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT e227S-e277S
I'm not involved in brain surgery. For spinal surgery, tumors are considered surgery at moderate risk. Intermittent compression pumps is recommended. In addition, fractionated heparin is useful reducing venous thrombosis and embolisms. Our preference is using calf and thigh stockings from immediate preoperative, one dose of enoxaparin 4000UI, 12 hours before surgery, next dose (4000UI/day) after cessation of bleeding risk (24 to 72 hours after surgery, continuing to 35th postop day). Stockings kept till the patient is ambulating normally. Currently intermittent compression (though indicated) is not available at our institution.
Hope you find useful this information.
This is the link to Chest, here you can download the paper
http://journal.publications.chestnet.org/data/Journals/CHEST/23443/112296.pdf
Dear Fabio and Pedro, in surgical neurooncology (unlike in general neurosurgery) we have no such simple recomendations and every clinic has it's own rules (it was the reason why I asked this question - but only you answered - thank you for your answers!).
After completing a thorough evidence-based review through Oct 20012, for intradural intracranial surgery, our department agreed to use mechanical compression devices pre-, peri-, and post-operatively and to start SQ heparin at prophylactic dose 24 hours after surgery if post-op neuroimaging failed to reveal a significant intracerebral hemorrhage (minimal blood in a tumor resection cavity OK). We have had no problems with this protocol since its institution >6 months ago, and our VTE rate has already dropped.
Patients undergoing major neurosurgical procedures require routine prophylaxis for VTE.
Two double-blind, randomized, venography-based studies compared graduated compression stockings alone or a combination of graduated elastic stockings and LMWH started postoperatively in neurosurgical patients. In both studies in patients receiving the combined prophylaxis have better results. Therefore, prophylaxis with the combination of LMWH and graduated compression stockings is more efficacious than prophylaxis with the stockings alone. (Ref:Nurmohamed MT, van Riel AM, Henkens CM, et al. Low molecular weight heparin and compression stockings in the prevention of venous thromboembolism in neurosurgery. Thromb Haemost. 1996; 75: 233–238 & Agnelli G, Piovella F, Buoncristiani P, et al. Enoxaparin plus compression stockings compared with compression stockings alone in the prevention of venous thromboembolism after elective neurosurgery. N Engl J Med. 1998; 339: 80–85. )
Full anticoagulation may begin
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