thromboprophylaxis in the hospital setting5 intermittent pneumatic compression devices...

Guideline 733FM.5 1 of 55 Uncontrolled if printed

733FM.5 THROMBOPROPHYLAXIS IN THE HOSPITAL SETTING: REDUCING THE RISK OF HOSPITAL ACQUIRED DEEP VEIN THROMBOSIS OR

PULMONARY EMBOLISM

1. Thromboprophylaxis in the Hospital Setting: Reducing the Risk of Deep Vein Thrombosis and Pulmonary Embolism ....................................................................................... 3 1.1 Glossary/Definitions ...................................................................................................... 3 1.2 Introduction ................................................................................................................... 4 1.3 Purpose ........................................................................................................................ 4 1.4 Scope ........................................................................................................................... 4 1.5 Role and Responsibilities .............................................................................................. 5 1.6 Risk Assessment .......................................................................................................... 5

1.6.1 Individual assessment ................................................................................................ 5 1.6.2 Re-assessment .......................................................................................................... 7

1.7 Patient Information ........................................................................................................ 8 1.7.1 Patient information on admission ................................................................................ 8 1.7.2 Patient information on discharge ................................................................................ 8

2. Methods of VTE Prophylaxis ...................................................................................... 9 2.1 General Recommendations to Reduce the Risk of VTE ................................................ 9 2.2 Mechanical VTE Prophylaxis ........................................................................................ 9

2.2.1 Anti-embolism stockings (AES)................................................................................. 10 2.2.2 Intermittent pneumatic compression (IPC) devices ................................................... 11 2.2.3 Inferior vena cava (IVC) filters .................................................................................. 11

2.3 Pharmacological Prophylaxis - Dalteparin ................................................................... 12 2.3.1 Special treatment groups .......................................................................................... 12 2.3.2 Cautions and contraindications ................................................................................. 12 2.3.3 Adverse effects ......................................................................................................... 13 2.3.4 Monitoring ................................................................................................................ 13 2.3.5 FBC monitoring for patients at risk of HITT ............................................................... 13

2.4 Pharmacological Prophylaxis – Rivaroxaban .............................................................. 14 2.5 Special Clinical Situations ........................................................................................... 14

2.5.1 Renal impairment including dialysis and anticoagulant dosing .................................. 14 2.5.2 Spinals, epidurals and deep peripheral nerve blocks ................................................ 14 2.5.3 Patients taking antiplatelet agents or anticoagulants on admission or needing them for

treatment .................................................................................................................. 15

3. Thromboprophylaxis in Surgical Patients .............................................................. 15 3.1 Specific Advice – Peri-operative Period ...................................................................... 16

3.1.1 Timing of dalteparin in peri-operative period ............................................................. 16 3.1.2 Progesterone only preparations (POP) ..................................................................... 16 3.1.3 Combined oral contraceptives (COC) ....................................................................... 16 3.1.4 Hormone replacement therapy (HRT) ....................................................................... 16 3.1.5 Antiplatelet therapy ................................................................................................... 17

4. Patients Admitted to Critical Care ........................................................................... 17

5. Specialist Surgery .................................................................................................... 17 5.1 Day Case Surgery ...................................................................................................... 17 5.2 Bariatric and Other Surgery in Patients at Extremes of Body Weight .......................... 18 5.3 Ophthalmic Surgery .................................................................................................... 18 5.4 Oral and Maxillofacial Surgery .................................................................................... 18 5.5 ENT Surgery ............................................................................................................... 18 5.6 Breast Surgery ............................................................................................................ 19 5.7 Major Cancer Surgery in the Abdomen or Pelvis ......................................................... 19 5.8 Vascular Surgery ........................................................................................................ 19 5.9 Varicose Vein Surgery ................................................................................................ 20 5.10 Cranial Injury and/or Surgery ...................................................................................... 20


5.11 Spinal Injury and/or Surgery........................................................................................ 20 5.12 Spinal Cord Injury Patients ......................................................................................... 21

5.12.1 Acute spinal cord injury patients (within 3 months post injury) ................................ 22 5.12.2 Spinal cord injury patients (post 3 months after injury, patients undergoing

rehabilitation) ......................................................................................................... 22 5.12.3 Re-admission of chronic spinal cord injury patients ................................................ 22

5.13 Upper Limb Surgery .................................................................................................... 23 5.14 Fragility Fractures of the Pelvis, Hip and Proximal Femur ........................................... 23 5.15 Elective Hip Arthroplasty Surgery ............................................................................... 23 5.16 Elective Knee Arthroplasty Surgery: ............................................................................ 24 5.17 Non-arthroplasty Orthopaedic Knee Surgery - includes Knee Arthroscopy ................. 24 5.18 Lower Limb Amputation .............................................................................................. 24 5.19 Lower Limb Immobilisation/Casts ............................................................................... 24 5.20 Foot and Ankle Orthopaedic Surgery .......................................................................... 25

6. Duration of Thromboprophylaxis and Discharge ................................................... 25

7. Thromboprophylaxis in Medical Patients ............................................................... 27 7.1 General Medical Admissions....................................................................................... 27 7.2 Acute Stroke ............................................................................................................... 28 7.3 Acute Coronary Syndromes (ACS) ............................................................................. 28 7.4 Palliative Care ............................................................................................................ 29

8. Patients being Nursed in Paediatric Areas of BHT, including: Ward 3, PDU, St Francis, Theatres and Ward 7 (WH) ........................................................................................... 29 8.1 Patient and Family Education ..................................................................................... 29 8.2 General Measures to Prevent VTE ............................................................................. 29 8.3 Pharmacological Thromboprophylaxis Dosing in Paediatric Patients .......................... 30 8.4 Mechanical Thromboprophylaxis ................................................................................ 30 8.5 Special Considerations of this Patient Group .............................................................. 30

8.5.1 Paediatric surgical patients ........................................................................................ 30 8.5.2 Paediatric oncology patients ...................................................................................... 30 8.5.3 Paediatric palliative care patients ............................................................................... 30 8.5.4 Paediatric patients with a spinal cord injury (SCI) ...................................................... 30

9. Community Hospitals ............................................................................................... 32

10. References and Further Reading ............................................................................. 33

Appendix 1: VTE Risk Assessment for Medical and Surgical Patients ......................................... 36 Appendix 2: Patient Information Leaflet - Blood Clots (Reducing the Risks) ................................. 37 Appendix 3: VTE Prevention Exercises ........................................................................................ 38 Appendix 4: Patient Information Leaflet - How to Inject Dalteparin at Home ................................. 38 Appendix 5: Antiembolism Stockings (AES) Flowchart ................................................................. 40 Appendix 6: Mechanical Thromboprophylaxis Care Record Sheet ............................................... 41 Appendix 7: Intermittent Pneumatic Compression Devices (IPC) Flowchart ................................. 43 Appendix 8: VTE Prevention Flowchart in Surgical Inpatients ...................................................... 44 Appendix 9: VTE Prophylaxis in Trauma and Orthopaedic Spinal Patients Requiring Conservative

or Surgical Management .......................................................................................... 45 Appendix 10: VTE Prevention Flowchart in Medical Inpatients ..................................................... 46 Appendix 11: VTE Prevention in Patients with Acute Stroke ........................................................ 47 Appendix 12: Approved List of Day Case Procedures where VTE Risk Assessment can be done by

Cohort rather than an Individual Risk Assessment ................................................. 48 Appendix 13: VTE Risk Assessment for Patients Being Nursed within Paediatric Areas .............. 48 Appendix 14: VTE Risk Assessment for Day Case Surgery Patients Aged 16 and Above ........... 50 Appendix 15: VTE Prevention Flowchart in Spinal Cord Injury Inpatients ..................................... 52 Appendix 16: How to Administer Dalteparin to Minimise Bruising ................................................. 53 Appendix 17: VTE Risk Assessment for Ambulatory Patients aged ≥16 with Temporary Lower Limb

Immobilisation using TRIP(Cast) Score .................................................................. 54


List of Tables

Table No

Title Page

No

1 VTE risk assessment: Admission related risk factors for VTE 6

2 Risk assessment: Bleeding and contraindications to pharmacological VTE prophylaxis 6

3 VTE risk assessment matrix 8

4 AES contraindications 10

5 Intermittent pneumatic compression devices contraindications 11

6 Suggested dalteparin prophylactic dosing regimens for patients based on body weight 12

7 Suggested FBC monitoring for patients receiving heparin 13

8 Extended thromboprophylaxis for gynaecology patients 26

9 Extended thromboprophylaxis for orthopaedic surgery 26

10 Examples of major cancer surgery requiring extended thromboprophylaxis for 28 days post-op

27

11 Examples of complex non-cancer surgical patients requiring extended thromboprophylaxis for 14 to 28 days post-op

27

12 Dalteparin dosing in Paediatrics 30

1. Thromboprophylaxis in the Hospital Setting: Reducing the Risk of Deep Vein Thrombosis and Pulmonary Embolism

1.1 Glossary/Definitions

The following acronyms are used within the document:

AES Anti-embolism stockings BHT Buckinghamshire Healthcare NHS Trust BMI Body mass index COC Combined oral contraceptive CRS Care records service DOACs Direct oral anticoagulants DSU Day surgery unit DVT Deep vein thrombosis HAT Hospital acquired thrombosis HITT Heparin induced thrombocytopenia with thrombosis HRT Hormone replacement therapy ICP Integrated care pathway IPC Intermittent pneumatic compression device IVC Inferior vena cava filter LMWH Low molecular weight heparin NICE National Institute for Health and Care Excellence PE Pulmonary embolism SC Subcutaneous SCI Spinal cord injury SPC Summary of product characteristics UFH Unfractionated heparin VTE Venous thromboembolism VTEC Venous thromboembolism committee


1.2 Introduction

Hospital-acquired DVT and PE, collectively known as VTE, accounts for thousands of deaths annually in the NHS, and fatal pulmonary embolism remains a common cause of in-hospital mortality. HAT accounts for 50 – 60% of all VTE seen.

There is a substantial evidence base which is not detailed in the text but can be found in the accompanying References.

Almost all hospitalised patients have at least one risk factor for VTE (see Table 1) and approximately 40% have three or more risk factors. Without VTE prophylaxis, the incidence of hospital acquired DVT is approximately 10 to 40% among medical and general surgical patients and 40 to 60% following major orthopaedic surgery. In up to a third of these patients, thrombus involves proximal veins and is therefore more likely to be symptomatic and result in PE. Approximately 10% of hospital deaths are associated with PE and PE is the second commonest leading direct cause of maternal (pregnancy associated) death in the UK.

For hospitals there is a cost associated with diagnosing and treating these thrombotic episodes which may also prolong the patient’s length of stay. For patients there is the inconvenience and risk of the associated anticoagulant therapy, the increased risk of recurrent VTE and the risk of chronic post thrombotic syndrome and pulmonary hypertension.

VTE prophylaxis is highly effective at preventing symptomatic VTE and fatal PE. It includes mechanical methods (AES and IPC) and pharmacological treatments (such as heparin and other anticoagulant drugs). This is associated with little or no increase in the rates of clinically important bleeding. 1.3 Purpose

This guideline is about reducing the risk of VTE in patients admitted to hospital or attending the hospital for a day case surgical procedure. For all women who are pregnant women and in the puerperium see Trust Guideline 646FM Venous Thromboembolism (VTE) in Maternity.

It details current recommendations for VTE prophylaxis for different risk groups, taking into account current surgical practice within the Trust.

It highlights the importance of risk assessment for VTE for all patients being admitted to hospital and provides direction regarding the most suitable prophylaxis strategy for each person at risk.

For guidance on the diagnosis and management of DVT please see Trust Guideline 249 Assessment of Deep Vein Thrombosis (DVT) in the Ambulatory Setting and Anticoagulation Management of DVT and Pulmonary Embolism (PE) In Adults (aged 16 and over) and for PE see Trust guidelines 9AFM Acute PE and 9BFM Massive PE. 1.4 Scope

This document sets out the processes to follow for assessing the risk of VTE in patients who require hospital admission or attending the hospital for a day case surgical procedure and the prescribing of standard thromboprophylactic measures. This document does not include guidelines for bridging between pharmacological thromboprophylactic agents or treatment guidelines for VTE.

The advice in this guideline covers the care and treatment that should be offered to all patients. This includes those admitted to a hospital bed for day-case medical or surgical procedures, with the exceptions listed in Appendix 12. For all women who are pregnant women and in the puerperium see Trust Guideline 646FM Venous Thromboembolism (VTE) in Maternity.

The guidance is primarily based on the NICE NG89 recommendations which refers to those aged 16 and over and does not cover those patients under 16 years.

Guidance for those below the age of 16 is based on recommendations provided by The Association of Paediatric Anaesthetists of Great Britain and Ireland with the specifics detailed in Section 8, with links to other sections of the guideline. Where recommendations were not provided in the paediatric guideline, guidance from NICE NG89 has been applied to under 16s and should be used (with caution) in this patient group.

http://www.bucksformulary.nhs.uk/docs/Guideline_646FM.pdf

http://swanlive/sites/default/files/guideline_249.pdf



http://www.bucksformulary.nhs.uk/docs/Guideline_9aFM.pdf

http://www.bucksformulary.nhs.uk/docs/Guideline_9bFM.pdf



This guideline does not cover the care and treatment that should be offered to:

people attending outpatient clinic appointments

older people who are cared for at home or in residential care homes

people who are immobile and are cared for at home or in residential care homes

people who are admitted to hospital because they have a diagnosis or signs and symptoms of DVT or PE.

1.5 Role and Responsibilities

The VTE roles and responsibilities of each staff member are detailed in the BHT Policy 145: Thromboprophylaxis in Adults (VTE Trust Policy). The role of the medical support worker is detailed in a separate Standard Operating Procedure: The Role of the Medical Support Worker in VTE Prevention in Patients aged 16 and over (VTE SOP 1). 1.6 Risk Assessment

1.6.1 Individual assessment

All patients should be risk assessed for VTE by the admitting doctor as soon as possible after admission to hospital and thromboprophylaxis administered within 14 hours of admission. The VTE risk assessment tool on page 4 of the inpatient prescription chart (Appendix 1) should be completed.

See Table 3 for department specific variances to this guidance. For patients being nursed in the paediatric areas, read Section 8 in addition to this section.

Medical staff completing the risk assessment must ensure that all applicable VTE risk factors and contraindications to thromboprophylaxis are ticked on the chart in order to weigh up the risk of VTE vs risk of bleeding with pharmacological prophylaxis.

All methods of thromboprophylaxis whether pharmacological or mechanical must be prescribed by the relevant medical team e.g. admitting medical team, responsible medical/surgical team, and attending anaesthetist.

Appendix 12 identifies cohorts of patients for whom individual VTE risk assessment is agreed as unnecessary as patients share similar characteristics and are at low risk of VTE according to the NICE guidance.

Cohorted patients are only planned day case admissions meeting specific criteria as outlined in Appendix 12. If in doubt please complete a VTE risk assessment and seek advice from senior staff/VTE nurse/lead.

The risk assessment should include:

Involvement of the patient in their own risk assessment, if they are able to.

A decision about the patient’s mobility status: Does the patient have significantly reduced mobility?

The patient’s individual pre-disposing factors for VTE and the risk associated with their current illness or procedure (see Table 1). Additional risk factors may be added to the list.

An assessment of any predisposing bleeding risk, together with the bleeding risk associated with their current illness or procedure (see Table 2).

Significantly reduced mobility

Patient is bed bound, unable to walk unaided or likely to spend a substantial proportion of their day in bed or in a chair (NICE, 2018).

http://swanlive/sites/default/files/thromboprophylaxis_in_adults_policy_vte_bht_pol_145_v3_1_final_rvw_11-20.pdf


http://swanlive/sites/default/files/vte_sop_1_msw_role_in_vte_prevention.pdf



Table 1: VTE risk assessment: Admission related risk factors for VTE

Medical patients Surgical patients and patients with trauma

If mobility significantly reduced for ≥3 days or

If expected to have ongoing reduced mobility relative to normal state plus any VTE risk factor.

If total anaesthetic + surgical time >90 minutes or

If surgery involves pelvis or lower limb and total anaesthetic + surgical time >60 minutes or

If acute surgical admission with inflammatory or intra-abdominal condition or

If expected to have significant reduction in mobility or

If any VTE risk factor present (see below)

VTE Risk Assessment: Patient Related VTE risk factors

Active cancer or cancer treatment

Age >60 years

Critical care admission

Dehydration

Known thrombophilia

Obesity (BMI >30 formula: [weight(kg) / height(cm) / height (cm)] x 10,000)

One or more significant medical comorbidities (e.g. heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions)

Personal history or first degree relative with a history of VTE

Use of HRT

Use of oestrogen-containing contraceptive therapy

Varicose veins with phlebitis

Examples of additional risk factors: smoking, intravenous drug use, acute delirium

Table 2: Risk assessment: Bleeding and contraindications to pharmacological VTE prophylaxis

Assess all patients for risk of bleeding and contraindications before offering pharmacological VTE prophylaxis. Consider not offering pharmacological VTE prophylaxis to patients with any of the risk factors for bleeding and contraindications shown in Table 2 below after discussing it with the consultant haematologist on-call, if the risk of bleeding outweighs the risk of VTE.

Regard patients as being at risk of bleeding or having a contraindication to pharmacological thromboprophylaxis if they have any of the following:

Course of action

Active bleeding Seek advice

Anticoagulants: therapeutic doses of UFH or LMWH, warfarin with INR >2, or direct oral anticoagulants

Seek advice

Inherited or acquired bleeding disorders (such as haemophilia or liver failure) Seek advice

Acute stroke See guideline

Platelet count <50 x 109/l Seek advice

Creatinine clearance <30 ml/min (refer to this guideline for dose adjustments) See guideline

Hypertension (≥230/120 mmHg) Seek advice

Neurosurgery, spinal surgery or eye surgery or other procedure with high bleeding risk Seek advice

Heparin allergy or history of heparin induced thrombocytopenia See guideline

Lumbar puncture, epidural catheter in situ or spinal anaesthesia performed within the last 4 hours or expected within next 12 hours

See guideline

The risk factors described on the VTE risk assessment tool may not be exhaustive.

Clinicians should consider additional risks for individual patients and offer thromboprophylaxis as appropriate.

Document variation from guidance in patient notes.


Individual patient factors will always determine action taken in relation to thromboprophylaxis.

Date and sign the risk assessment form and prescribe thromboprophylaxis as appropriate.

If the outcome of VTE Risk Assessment is to withhold pharmacological VTE prophylaxis due to an increased risk of bleeding, the general recommendations and mechanical thromboprophylaxis should still be offered to the patient according to Sections 2.1 and 2.2 (if not contraindicated) and the VTE and bleeding risk assessed daily to allow immediate start of the pharmacological VTE prophylaxis as soon as the bleeding risk decreases.

1.6.2 Re-assessment (See Table 3 below)

For all medical, surgical and trauma patients, the VTE risk assessment should be repeated:

On the day after admission, or at consultant review, whichever is sooner

Whenever the clinical situation changes

After a maximum of 7 days (if still an inpatient and did not have a re-assessment by then)

When the prescription charts are re-written

On discharge

The VTE re-assessment should include:

A check that the prescribed VTE prophylaxis is being administered (signed for) and used correctly

Identifying any adverse events resulting from VTE prophylaxis

A correction of the thromboprophylaxis prescription, if deemed necessary by VTE re-assessment

If the outcome of VTE Risk Assessment is to use pharmacological VTE prophylaxis, start this as soon as possible and within 14 hours of admission.

Any doctor can prescribe thromboprophylaxis. Any withholding of thromboprophylaxis must be following discussion with the consultant and documented on the clinical notes. If the patient is at increased risk of VTE but also at increased risk of bleeding, or is bleeding, or have a contraindication discuss with the haematologist before deciding to withhold thromboprophylaxis. Ensure the discussion is well documented in the patient notes and the decision explained to the patient.

Pharmacological thromboprophylaxis can be given at any time, although is often prescribed and administered on many wards at 6pm.

Clinicians can prescribe this for an earlier time if a delay is considered to increase the risk of VTE.


Table 3: VTE risk assessment matrix

1.7 Patient Information

NICE NG89 recommends that patients receive, on admission and on discharge from hospital, verbal and written information regarding their VTE risk and how to reduce it.

Patients should be given the BHT information leaflet “Blood Clots: Reducing the Risks” (Appendix 2) as soon as is practicable in the emergency setting and either at the pre-admission clinic (when there is one) or immediately following admission for elective admissions. The admitting/discharging nurse and doctor are responsible for ensuring that the patient has received the above mentioned leaflet on admission and that they have it on discharge and this should be clearly documented on the clinical notes in both instances.

Some patients, despite not being admitted to hospital, can be at high risk of VTE too. In our Trust, this applies to ambulatory patients receiving chemotherapy and ambulatory patients undergoing temporary immobilisation of the lower limb. The VTE team aims to provide VTE information to all patients at risk and is currently developing patient information leaflets tailored to these two high risk groups, which should be available to order by the departments in due course. 1.7.1 Patient information on admission

Ensure all patients understand the reason for having a risk assessment for VTE and bleeding.

Patients admitted to hospital who are at increased risk of VTE should receive (and/or family members or carers) verbal and written information on the following, before offering VTE prophylaxis:

Their personal risk factors and possible consequences of VTE

The importance of VTE prophylaxis and its possible side effects

The correct use of VTE prophylaxis

How they can reduce their risk of VTE (see Section 2)

1.7.2 Patient information on discharge

As part of the discharge plan, give patients (and/or family members or carers) verbal and written information on:

The signs and symptoms of DVT and PE

VTE Assessment

Patient Group

Correct VTE form

On admission

Day after admission

When clinical condition changes

After 7 days Drug chart re-

written

Discharge

All medical, surgical and

trauma patients

VTE Risk Assessment on

Drug Chart Appendix 1

Yes Yes Yes Yes Yes

Yes

Day surgery * If patient is admitted to

hospital, use the VTE Risk Assessment on Drug

Chart

VTE Risk assessment in

day case booklet Appendix 14

Yes Yes

(if admitted) Yes

(if admitted) Yes

(if admitted) Yes

(if admitted) Yes

(if admitted)

ITU



Yes Daily

Management Sheet

When thrombo-

prophylaxis prescription

changes

Daily Management

Sheet Yes Yes

Community hospitals



Yes No Yes Yes Yes

Yes

Paediatric Patients

VTE Risk Assessment for Patients Being Nursed in the

Paediatric Areas Appendix 13

Yes Yes Yes Yes Yes Yes

Ambulatory Lower Limb

Immobilisation

VTE Risk Assessment

TRIP(cast) Score Appendix 17

Yes When first

seen

Review in clinic

Yes n/a n/a n/a


How patients can reduce their risk of VTE (see Section 2)

The importance of seeking help if DVT or PE is suspected

Give patients discharged with VTE pharmacological prophylaxis (and/or family members or carers) verbal and written information on:

Which arrangements you made (if necessary) to ensure someone will administer the injection

The importance of using VTE prophylaxis correctly (including the correct administration and disposal of sharps) and for the recommended duration

The signs and symptoms of adverse events related to VTE prophylaxis

The importance of seeking help and who to contact if they have problems using VTE prophylaxis

The Trust leaflet: ‘How to inject Dalteparin at home, a patient guide’ (Appendix 4)

Ensure that patients who are discharged with anti-embolism stockings:

Understand the benefits of wearing them and the importance of wearing them correctly

Understand the need to remove them daily for hygiene purposes

Are able to remove and replace them, or have someone available who will be able to do this for them

Know what to look for - for example, skin marking, blistering

Know who to contact if there is a problem

Know when to stop wearing them 2. Methods of VTE Prophylaxis

2.1 General Recommendations to Reduce the Risk of VTE

Do not allow patients to become dehydrated unless clinically indicated

Encourage patients to mobilise as soon as they are able to and as much as possible

Encourage patients to perform the VTE prevention exercises hourly as instructed by the nurse or physiotherapist, if their condition allows (Appendix 3):

Ankle rolls Feet dorsi/plantar flexion Heel raises Gluteus squeezes Quadriceps squeezes Deep breathing

2.2 Mechanical VTE Prophylaxis

Mechanical thromboprophylaxis helps reduce venous stasis and vessel distension. This also carries a risk of complications if used when contraindicated (see Table 4 and Table 5). For this reason it must be prescribed by the doctor.

Always assess for contraindications for mechanical thromboprophylaxis before offering it to any patient (see Table 4 and Table 5) and make sure that your findings are documented on the VTE risk assessment.

Note: Patients admitted with acute stroke should be offered IPC alone (see Appendix 11).

All surgical patients deemed to be at risk of VTE on their VTE risk assessment should be offered mechanical thromboprophylaxis: AES and/or IPC. Continue until the patient does not have significantly reduced mobility. NICE sets the specific type and duration of mechanical thromboprophylaxis per surgical specialty (Appendix 4).

Medical patients deemed to be at risk of VTE on their VTE risk assessment should only be offered mechanical thromboprophylaxis if they are at very high risk of VTE or if pharmacological VTE prophylaxis is contraindicated, i.e. withheld due to an increased risk of bleeding. If that is the case, offer AES and/or IPC. Continue until the patient does not have significantly reduced mobility.


2.2.1 Anti-embolism stockings (AES)

A guidance flowchart on the AES usage can be found in Appendix 5.

These should preferably be knee length, as thigh length is associated with more complications and lack of compliance. They should produce a calf pressure of 14 – 15 mmHg. You can use them on one or both legs, alone or in combination with the IPC and with pharmacological VTE prophylaxis. See Table 4 for contraindications to AES.

Table 4: AES contraindications

Massive leg oedema

Heart failure

Suspected/proven peripheral arterial disease or peripheral arterial bypass surgery

Sensory impairment

Acute stroke (use IPC only)

Skin - fragile, damaged, ulcerated, recent grafts

Known allergy to material of manufacture

Having a body weight under 40 kg is suggested to reduce the effectiveness of stockings and could lead to complications if the patient’s leg size and shape prevent achieving a good fit. Currently, paediatric sizes are not available.

AES are not indicated for the treatment of a known DVT and should not be confused with Class II or III graduated compression stockings.

AES should be fitted and patients shown how to use them by staff trained in their use. Ensure patients understand that this will reduce their risk of developing VTE.

Foot pulses should be detected by healthcare professionals trained in the technique before AES are fitted. If arterial disease is suspected, seek expert opinion before fitting AES. Use caution and clinical judgement when applying AES over venous ulcers or wounds.

Ensure that patients who need AES have both of their legs measured, that the Mechanical Thromboprophylaxis Care Record Sheet is completed (Appendix 6) including a record of the exact leg measurements and that the correct size is provided.

The legs should be re-measured post major surgery, lower limb surgery or any other surgery or condition which could cause an increase or reduction in leg oedema. Otherwise, re-measure after 7 days and on discharge (if discharged with AES).

When applying AES, the heel pocket should stay over the heel and the top of the stocking should fall on the knee bend, not rolling down or folded.

AES should be worn 24 hours a day. They have to be removed daily for no longer than 30 minutes for hygiene purposes and to inspect skin condition three times a day. In patients with a significant reduction in mobility, poor skin integrity or any sensory loss, inspect the skin more often, particularly over the heels and bony prominences.

Monitor the use of AES and offer assistance if they are not being worn correctly.

Inform the doctor and discontinue the use of AES if there is marking, blistering or discolouration of the skin. If suitable, offer an IPC foot cuff as an alternative.

Ensure that patients who are discharged with AES have them prescribed in the ‘to take out’ (TTOs) to make the GP aware. Patients should be given 2 pairs of AES to take home. Before discharging the patient with AES, ensure that the patient is able to remove and replace them daily, or have someone available who will do this for them. Advise them to keep wearing the AES until they no longer have reduced mobility compared to their usual state. Unlicensed use: For patients prescribed AES to reduce oedema and/or aid haemodynamic stability during mobilisation, the correct procedure detailed in this section should still be followed, a mechanical prophylaxis care record sheet completed and AES should be prescribed by a doctor on the PRN side of the prescription chart (only if they are not already prescribed for VTE prophylaxis).


If the AES are being used only for the purpose of reducing oedema and/or aid haemodynamic stability, staff should mark the AES with a black soft-tip marker pen on the top of the foot with a locally agreed symbol, with patient consent. This helps staff know if the AES should or should not be removed when the patient returns to bed. For VTE prevention the AES should be worn continuously, for reducing oedema and/or aid haemodynamic stability the AES are only worn during the period that the patient is out of bed. 2.2.2 Intermittent pneumatic compression (IPC) devices

A guidance flowchart on the IPC usage can be found in Appendix 7.

Do not offer intermittent pneumatic compression devices to patients with contraindications stated in Table 5.

Table 5: Intermittent pneumatic compression devices contraindications

Massive leg oedema

Heart failure

Suspected/proven peripheral arterial disease or peripheral arterial bypass surgery

Skin - fragile, damaged, ulcerated, recent grafts

Known allergy to material of manufacture

Suspected or confirmed acute DVT or PE

Presence of malignancy in legs

The patients prescribed IPC should also have a Mechanical Thromboprophylaxis Care Record completed (Appendix 6).

The sleeves available are: Foot cuffs, leg sleeves and thigh sleeves. Foot cuffs should be considered when the patient presents local contraindications on the legs (e.g. wound). Leg sleeves should be used as standard choice and thigh sleeves for patients with acute stroke or at very high risk of VTE (e.g. ICU, spinal).

The foot cuff aircell should be placed at the bottom of the foot, whereas the leg and thigh sleeves’ aircells can be placed anywhere around the leg providing the tubing is pointing down.

Explain the use of the pump to the patient. Careful explanation will increase patient compliance and reduce the risk of complaints relating to the noise the machine makes.

They should be used throughout the immobilisation period including pre, intra and post operatively, with minimal interruptions. Use them for 24 hours both when in bed and when sitting in a chair, removing daily for no longer than 30 minutes for hygiene purposes and to inspect skin condition.

Discontinue when the patient is fully mobile or is discharged. 2.2.3 Inferior vena cava (IVC) filters

Inferior vena cava (IVC) filters are usually used in patients at extremely high risk of VTE who cannot receive anticoagulation.

A mesh is inserted in the vena cava under radiological guidance to catch potential DVTs travelling in the venous circulation before they reach the lungs, hence it only prevents PE and not DVTs. Only a temporary form of IVC should be inserted and a plan for removal should be made at the time of insertion. Removal can take place when the temporary contraindication to anticoagulation is no longer present, ideally within 4 weeks. The longer a filter remains in situ, the more difficult it is to remove.

IVC filters key points:

IVC filters should only be considered following discussion with a haematologist.

IVC filters are not indicated in unselected patients with VTE who will receive anticoagulation.

They may be considered in selected patients with PE, despite therapeutic anticoagulation.

Alternative treatment options, such as long‐term high‐intensity vitamin K antagonist therapy (INR target 3.5) or LMWH therapy, should be generally considered prior to IVC filter


placement, particularly in patients with thrombophilic disorders (e.g. antiphospholipid antibody syndrome) or cancer.

They should be considered in the pre-operative patient who developed VTE within the last 4 weeks (particularly within 2 weeks) in whom anticoagulation must be interrupted.

IVC filters may be considered in pregnant patients who have contraindications to anticoagulation and develop extensive VTE within 2 weeks of delivery.

Following insertion of an IVC filter: The patient should receive weight based thromboprophylaxis as soon as possible as long as the risk of bleeding is low. This should be discussed with Haematology. A plan should be put in place for escalation to therapeutic anticoagulation as soon as it is safe to do so. Complications: IVC filters are not without complications, and for this reason there must be careful consideration prior to their insertion. If an IVC filter is inserted, the patient must be closely monitored for the following complications:

Complications related to their insertion: Such as bleeding, misplacement, pneumothorax.

Post-insertion complications: Such as infection or insertion site thrombosis.

Late complications: Recurrent DVT, IVC thrombosis, post-thrombotic syndrome, IVC penetration, filter migration

2.3 Pharmacological Prophylaxis - Dalteparin

Dalteparin is the LMWH of choice for pharmacological prophylaxis. Given as a subcutaneous (SC) injection, the dose is dependent on the patient’s body weight.

The licensed dose of dalteparin for medical patients is 5000 units once daily. However there is evidence to suggest dosing based on weight (see Table 6 below) may provide more effective prophylaxis and should be considered in patients at the extremes of bodyweight (unlicensed).

Table 6: Suggested dalteparin prophylactic dosing regimens for patients based on body weight as per recommendations from HAT Committee of UKCPA (unlicensed)

Weight Dose of dalteparin subcutaneous

injection - unlicensed

150 kg or more 7,500 units twice daily

100 - 149 kg 5,000 units twice daily

50 - 99 kg 5,000 units daily

49 kg or less 2,500 units daily

2.3.1 Special treatment groups

Elderly - dalteparin has been used safely in elderly patients and does not require dose adjustment. Pregnancy - see Trust Guideline 646FM Venous Thromboembolism (VTE) in Maternity. Renal impairment – see Section 2.4. Extremes of weight – see Section 2.3 (above) Paediatrics – see Section 8 2.3.2 Cautions and contraindications

See Summary of Product Characteristics (SPC) for dalteparin available at www.medicines.org.uk.


http://www.medicines.org.uk/


2.3.3 Adverse effects

Most common adverse effects relate to the blood and lymphatic system and include reversible thrombocytopenia (type I and type II) and haemorrhage. Dalteparin can also cause transient elevation of liver transaminases (AST and ALT).

Patients can experience subcutaneous haematoma at the injection site. See Appendix 16 on best practice on how to administer dalteparin to reduce bruising.

For full list of adverse effects please consult the BNF, BNFc or Summary of Product Characteristics (SPC) for dalteparin available at www.medicines.org.uk. 2.3.4 Monitoring

For inpatients, platelet counts should be checked before initiation of dalteparin and then, as a minimum, as described in Table 7. Note that the patient’s clinical condition may require regular full blood count (FBC) monitoring. Seek advice from a haematologist in patients developing thrombocytopenia on dalteparin.

If the platelet count is normal at discharge, further monitoring of FBC is not required in the absence of clinical indication.

Heparin anti-Xa levels (citrate sample to send to haematology) are not routinely required for patients on dalteparin. These may occasionally be helpful in patients at increased risk of bleeding, very underweight patients, patients with BMI >40 or those who are pregnant. Always discuss with a haematologist before requesting these tests.

LMWH can also induce hyperkalaemia due to inhibition of aldosterone secretion. For inpatients, potassium levels must therefore also be checked before initiation and at least fortnightly, particularly in those patients with chronic renal failure, diabetes mellitus, acidosis, or those patients on potassium sparing medications. If the potassium level is normal at discharge, further monitoring of potassium is not required in the absence of clinical indication. 2.3.5 FBC monitoring for patients at risk of HITT

A small number of patients receiving heparin develop an antibody to heparin which results in a fall in the platelet count (HITT). Paradoxically, this increases the risk of both arterial and venous thromboembolism (because the heparin/antibody complex activates platelets). The risk is highest with UFH, but can occur with LMWH too, albeit rarely. Please see Table 7 for guidance on FBC monitoring for patients receiving LMWH and UFH. Table 7: Suggested FBC monitoring for patients receiving heparin (based on BCSH 2012)

Day 0 Day 2 Day 5 Day 8 Day 11 Day 14

Assessments FBC, U&E, LFT, weight

FBC FBC FBC FBC FBC

Prophylactic or therapeutic dose LMWH in post-operative, obstetric or medical patients

Yes - - - - -

Prophylactic or therapeutic dose UFH in all patients Post-operative cardiopulmonary bypass patients receiving any heparin preparation

Yes - Yes Yes Yes Yes, continue monitoring every 4 days until heparin stopped

Post-operative patients receiving any heparin preparation, who may have received UFH or LMWH within 100 days

Yes Yes - - - -

Patients on therapeutic dose LMWH who have creatinine clearance of less than 30 ml/min or whose clinical status changes significantly may accumulate heparin. In these situations seek advice from a pharmacist.

If the platelet count falls by 30% or more, and/or the patient develops new thrombosis or skin allergy between days 4 and 14 of LMWH administration, HITT should be considered and the on-call haematologist consulted.

https://bnf.nice.org.uk/

https://bnfc.nice.org.uk/



2.4 Pharmacological Prophylaxis – Rivaroxaban

Rivaroxaban is a direct oral anticoagulant (DOAC) and has been recommended in NICE guideline NG89 for thromboprophylaxis for patients who have undergone hip or knee replacement surgery. The standard dose of rivaroxaban for use as thromboprophylaxis is 10 mg orally, daily, starting 6 to 10 hours post-operatively. See SPC (available at www.medicines.org.uk).

Rivaroxaban may be considered in patients who are unable to tolerate subcutaneous injections or unable to self/peer-administer at home following lower limb immobilisation and day case surgical procedures when all other options have been exhausted. Its use for such indications is UNLICENSED.

Please note DOACs are also not licensed in those aged 18 or below and should be avoided.

2.5 Special Clinical Situations

2.5.1 Renal impairment including dialysis and anticoagulant dosing

UFH is rarely used for thromboprophylaxis. The usual dose of UFH for thromboprophylaxis is 5,000 units SC twice daily.

If needed, reduce the dose of LMWH and UFH for patients with renal impairment. Base the decision on multidisciplinary or senior opinion.

Dalteparin is renally excreted. At prophylactic dose, modification is not required in the presence of a GFR greater than 20 ml/min. If the GFR is less than 20 ml/min, dose adjustment may not be required if short term use is expected (less than 10 days) but this is based on limited data. For longer term use dalteparin accumulation can be measured by a heparin anti-Xa level. A peak level (4 hours post dose) and trough level immediately pre dose should be measured. For thromboprophylaxis, a peak level should be around 0.3 u/ml, and a trough level should be undetectable.

Arbitrary dose reduction may result in sub-optimal provision of prophylaxis and may put the patient at increased risk of hospital acquired VTE. However a dose reduction should be considered in those patients in whom accumulation is detected by heparin anti-Xa assay.

Note: eGFR is a reasonable guide to GFR in most patients. In patients at extremes of body weight a GFR should be calculated using the Cockcroft-Gault formula (and ideal body weight).

There is very little data with regard to use of prophylactic dalteparin and dosing regimens in dialysis patients. Dialysis patients are overall at increased risk of both thrombosis and bleeding. Renal consultants at Oxford University Hospitals advise that inpatients at risk of thrombosis should be prescribed standard dose of dalteparin unless contraindicated (in addition to routine anticoagulant for prevention of clotting in extracorporeal circuit). If there is particular concern with regard to bleeding risk then this should be discussed with the renal consultant and reduced dose considered on an individual basis, with documentation of this decision. 2.5.2 Spinals, epidurals and deep peripheral nerve blocks

The use of anticoagulants increases the risk of spinal and epidural haematoma which can result in spinal cord compression. This is a risk both at the time of insertion and at the time of epidural catheter removal.

Insertion of a spinal or epidural catheter should be delayed until >12 hours after a prophylactic dose of LMWH. Subsequent doses should be delayed if a haemorrhagic aspirate (bloody tap) is encountered during initial spinal needle placement.

Prophylactic dose LMWH administration should be delayed for >4 hours after spinal needle or epidural catheter removal and should not be sooner than 12 hours after the previous dose.

The same precautions should be taken with deep peripheral nerve blocks.

Spinal or epidural should be delayed for >24 hours after a prophylactic dose of fondaparinux and its administration should be delayed for >12 hours after spinal needle or epidural catheter removal.



2.5.3 Patients taking antiplatelet agents or anticoagulants on admission or needing them for treatment

Do not regard aspirin or other antiplatelet agents as adequate prophylaxis for VTE. Consider offering additional VTE prophylaxis to patients who are having antiplatelet agents to treat other conditions and who are assessed to be at increased risk of VTE by VTE risk assessment. Take into account the risk of bleeding and comorbidities such as arterial thrombosis.

If the risk of VTE outweighs the risk of bleeding, consider offering LMWH if the risk of bleeding outweighs the risk of VTE, offer other methods of VTE prophylaxis (see Sections 2.1 and 2.2).

Do not offer additional pharmacological prophylaxis for VTE to patients who are taking vitamin K antagonists (e.g. warfarin) and who are within their therapeutic range (INR >2), providing anticoagulant therapy is continued. If you need to discontinue the vitamin K antagonist or INR is <2 ensure you offer them additional pharmacological thromboprophylaxis such as dalteparin. Do not offer additional pharmacological thromboprophylaxis to patients who are having therapeutic (treatment dose) anticoagulant therapy (e.g. UFH, LMWH, warfarin or DOACs). Do not give additional LMWH to patients on DOACs even if they have ‘sub therapeutic INRs’ as coagulation tests are significantly unreliable on DOACs.

For advice on how to manage warfarin or the new oral anticoagulants prior to surgery, see Guidelines 83FM Peri-operative Bridging of Warfarin Therapy in Adult Patients undergoing Elective Surgery or Invasive Procedures and Guidance for Management of Overdose, Bleeding and Emergency/Elective Surgery - 34FM Dabigatran and 240FM Rivaroxaban and Apixaban. 3. Thromboprophylaxis in Surgical Patients

In Appendix 8, a flowchart explains VTE prevention in surgical patients.

High VTE risk surgery is defined as: hip or knee arthroplasty, hip fracture surgery, major trauma, spinal cord injury and any surgery in patients with other significant or multiple risk factors (e.g. cancer, BMI >30, reduced mobility compared to baseline). Patients with personal history of VTE should be prescribed 6 weeks of pharmacological and mechanical thromboprophylaxis post-surgery.

Any surgery performed in patients with significant or multiple risk factors such as, but not limited to, active cancer and/or cancer treatment, BMI >30, significantly reduced mobility compared to baseline: Patient will be at high risk of VTE and should receive

thromboprophylaxis, providing the VTE risk outweighs the bleeding risk.

Any surgery performed in patients with previous history of VTE and not already taking long term anticoagulation: Prescribe 6 weeks of pharmacological and mechanical thromboprophylaxis, or follow local guidance for extended thromboprophylaxis, whichever is the longest option providing the VTE risk outweighs the bleeding risk.

Example 1: Total hip replacement should receive 28 days of thromboprophylaxis, however if the patient had previous VTE they will receive 6 weeks (the longest option) of thromboprophylaxis, if not already on long term anticoagulation.

Example 2: Ankle fusion with lower limb immobilised for 8 weeks should receive pharmacological thromboprophylaxis for as long as the immobilisation continues, so even if they had previous VTE they would receive 8 weeks (the longest option) of thromboprophylaxis, if not already on long term anticoagulation.

Example 3: Patient admitted for total abdominal hysterectomy for uterine cancer. Pre-admission the patient was on long term warfarin/DOAC for previous VTE: Treatment dose of dalteparin is required as inpatient, as soon as the surgical bleeding risk decreases. Local guidance for major gynae cancer surgery recommends 28 days of thromboprophylaxis but because this patient is already on long term anticoagulation this must be continued as per their personal anticoagulation plan and requires switching back to their regular pharmacological agent before discharge, following Trust policy.






3.1 Specific Advice – Peri-operative Period

3.1.1 Timing of dalteparin in peri-operative period

There are two options for dalteparin peri-operatively, as per SPC for dalteparin in high risk surgical patients: Option 1 - Suggested option if patient having surgery on same day of admission 2,500 units SC 1 - 2 hours before surgery, then 2,500 units 8 - 12 hours later, followed by a regular once daily dose based on dosing in Table 6. Option 2 Give weight based dose dalteparin SC at least 12 hours before surgery followed by 5,000 units fixed dose after surgery (6 hours post wound closure), to continue on the day after surgery with the weight-based prophylactic doses, as per Table 6, as long as there is no significant active bleeding. Emergency surgery Dalteparin should start on admission unless surgery is anticipated on the same day. If surgery is taking place on the day of admission, see Section 3.1.1 Option 1, for timing of dalteparin (above).

If surgery is delayed more than 12 hours, give dalteparin thromboprophylaxis unless contraindicated, and record the decision in the medical notes.

A 12 hour interval between the last dose of dalteparin prophylaxis and surgery is usually sufficient, unless undergoing spinal or neurosurgery, where a 24 hour interval would be recommended. Post-operatively, providing the VTE risk is high, that the bleeding risk is low and that no other contraindications exist (as per VTE risk assessment document), LMWH should be started 6 hours post-operatively (counted from the wound closure time or, if that information is not readily available, from the time of arrival in recovery or first set of observations). 3.1.2 Progesterone only preparations (POP)

There is no evidence of increased risk of VTE in the peri-operative period and these preparations should not be stopped. 3.1.3 Combined oral contraceptives (COC)

NICE suggests advising patients to consider stopping COC 4 weeks before elective surgery. After a discussion with the woman about the risks, as outlined below, if she wishes to stop COC, she should be referred back to her GP or Family Planning Clinic to arrange alternative contraception.

There is a small absolute risk of post-operative VTE in COC users (estimated to be 1% for users compared with 0.5% for non-users). The risk of VTE (including any other personal predisposing factors for VTE such as personal or family history of VTE, malignancy, obesity, severe varicose veins or prolonged bed rest) should be balanced against the consequences of an unwanted pregnancy prior to major surgery. These include the effects of surgery and anaesthesia on the pregnancy and risks associated with a subsequent termination. These risks should be discussed with the patient prior to elective surgery. A record should be made in the case notes that potential advantages and disadvantages have been discussed with the woman.

In any case (emergency or elective) where the patient is admitted and is still taking the COC it should be prescribed on the prescription chart and not be discontinued. The patient should then receive thromboprophylaxis as outlined in the thromboprophylaxis guidelines. 3.1.4 Hormone replacement therapy (HRT)

NICE suggests advising patients to consider stopping hormone replacement therapy 4 weeks before elective surgery. However, although taking HRT is likely to slightly increase the risk of post-operative VTE, this additional risk has not been well quantified. Most women on HRT are likely to have additional risk factors for VTE which in themselves necessitate use of peri-operative thromboprophylaxis.

In addition withdrawing HRT is likely to precipitate the recurrence of menopausal symptoms at an already stressful time.


In general, there appears to be no need to advise patients to discontinue HRT before surgery if there are no other personal predisposing factors for VTE e.g. personal or family history of VTE, malignancy, obesity, severe varicose veins or prolonged bed-rest. If there are predisposing risk factors, it may be prudent to review the need for HRT as the risks may exceed the benefits. Any patient wishing to stop HRT should be referred back to her GP. HRT should be withdrawn slowly to minimise recurrence and exacerbation of menopausal symptoms.

The possible increased risk should be explained to the patient and the decision documented. Patients deciding to continue with HRT or in any case (emergency or elective) where the patient is admitted and is still taking HRT, their medication should be prescribed on the prescription chart and thromboprophylaxis provided as outlined in the thromboprophylaxis guidelines. 3.1.5 Antiplatelet therapy

Assess the risks and benefits of stopping pre-existing established antiplatelet therapy one week before surgery (see Section 2.5.3).

Consider regional anaesthesia for individual patients in addition to other methods of VTE prophylaxis, as it carries a lower risk of VTE than general anaesthesia. Take into account the patient’s preferences, their suitability for regional anaesthesia and any other planned method of VTE prophylaxis. If regional anaesthesia is used, plan the timing of pharmacological prophylaxis to minimise the risk of epidural haematoma (see Section 2.5.2).

See Sections 2.3 to 2.5 for guidance on dosing in special clinical situations. 4. Patients Admitted to Critical Care

Assess all patients admitted to the Critical Care Unit for risk of VTE and bleeding (See Table 3).

Reassess VTE and bleeding risk daily for patients in Critical Care Units (see Table 3).

Assess VTE and bleeding risk more than once a day in patients admitted to the Critical Care Unit if the person’s condition is changing rapidly (see Table 3).

Provide LMWH to patients admitted to the critical care unit if pharmacological VTE prophylaxis is not contraindicated. For patients with renal impairment see Section 2.5.1.

Consider mechanical VTE prophylaxis for patients admitted to the critical care unit based on their condition or procedure as per Appendices 5 and 7. If using mechanical VTE prophylaxis for patients admitted to the critical care unit, start it on admission and continue until the person no longer has reduced mobility relative to their normal or anticipated mobility. 5. Specialist Surgery

5.1 Day Case Surgery

Recommendations outlined for subspecialist surgery in this guideline will apply to day case surgery.

Patients undergoing day case surgical procedures should have their VTE risk assessed using the DSU VTE risk assessment tool (Appendix 14) and prescribed thromboprophylaxis according to the scoring table.

The VTE team developed a list of day case surgical procedures that do not require the full completion of an individual VTE risk assessment providing the patient does not have personal history of VTE. It is considered that those patients belong to a low risk group, or cohort (Appendix 12).

The surgeon can overrule the low risk cohort i.e. decide to complete a full VTE risk assessment for a patient that, according to Appendix 12, normally would not require one.

Likewise, the surgeon can overrule the scoring table thromboprophylaxis recommendations. However, it is advisable to seek Haematology advice and to produce clear documentation of the rationale for that decision on the box “Doctor overrule score” in the DSU VTE risk assessment tool (Appendix 14).


Any surgery performed in patients with previous history of VTE and not already taking long term anticoagulation: prescribe 6 weeks of pharmacological thromboprophylaxis, or follow local guidance (see Section 6) for extended thromboprophylaxis, whichever is the longest option, providing the VTE risk outweighs the bleeding risk.

5.2 Bariatric and Other Surgery in Patients at Extremes of Body Weight:

See also Section 5.1 for further advice on Day Case Surgery.

Start mechanical thromboprophylaxis on admission, continue until the patient no longer has significantly reduced mobility relative to their normal or anticipated mobility.

See Sections 2.3 and 2.5.1 for anticoagulant dosing in extremes of body weight and renal impairment. Offer LMWH or fondaparinux sodium for a minimum of 7 days for patients whose risk of VTE outweighs their risk of bleeding. The dose of the anticoagulant must be adjusted according to the patient’s weight and renal function.

Any surgery performed in patients with previous history of VTE and not already taking long term anticoagulation: Prescribe 6 weeks of pharmacological and mechanical thromboprophylaxis, or follow local guidance (see Section 6) for extended thromboprophylaxis, whichever is the longest option, providing the VTE risk outweighs the bleeding risk.

5.3 Ophthalmic Surgery:

See Section 5.1 for advice on Day Case Surgery.

5.4 Oral and Maxillofacial Surgery:


Consider pharmacological VTE prophylaxis with LMWH for a minimum of 7 days for patients undergoing oral or maxillofacial surgery whose risk of VTE outweighs their risk of bleeding.

Consider AES and IPC starting on admission for patients undergoing oral or maxillofacial surgery who are at increased risk of VTE and high risk of bleeding. Continue until the patient no longer has significantly reduced mobility relative to their normal or anticipated mobility.


5.5 ENT Surgery:


Consider pharmacological VTE prophylaxis with LMWH for a minimum of 7 days for patients undergoing ear, nose and throat (ENT) surgery whose risk of VTE outweighs their risk of bleeding.

Consider AES and IPC starting on admission for patients undergoing ENT surgery who are at increased risk of VTE and high risk of bleeding. Continue until the patient no longer has significantly reduced mobility relative to their normal or anticipated mobility.



5.6 Breast Surgery:


According to the Consensus Guideline on Venous Thromboembolism Prophylaxis for Patients Undergoing Breast Operations from the American Society of Breast Surgeons, decisions regarding VTE prophylaxis should be individualised, taking into consideration procedure type and duration, anaesthesia type, patient history of prior VTE or hypercoagulability condition, and the risk of bleeding complications.

Mastectomy with immediate reconstruction, especially autologous reconstruction are high VTE risk procedures.

Other risk factors for VTE in these patients are similar to those of any other patient: age >65, obesity, operative time with general anaesthesia >3 hours, increased length of hospital stay, recent surgery within 30 days before the breast operation and a cancer diagnosis.

Ambulatory patients undergoing breast operations with local or regional anaesthesia generally do not require any specific prophylaxis for VTE. Most patients undergoing breast operations with general anaesthesia and no reconstruction will have a low risk of VTE with IPC and early ambulation. The VTE team suggests that you follow the Day Case VTE Risk Assessment guidance (Section 5.1) and use your clinical judgement when applying the relevant specialty consensus guidelines.

Pharmacological thromboprophylaxis according to Sections 2.3, 2.4 and 2.5 may be considered in the following cases:

General anaesthesia >3 hours

Patients with multiple risk factors as noted above

Patients who are not at high risk for bleeding complications

Mastectomy with immediate reconstruction

Pharmacological thromboprophylaxis is recommended for all patients undergoing mastectomy with immediate autologous reconstruction unless there is a specific medical contraindication

The risk of unplanned re-operations for haematoma or any bleeding complication ranges from 2% - 6% and depends on procedure type. The evidence is insufficient to determine if there is a significant increase in patients receiving pharmacological thromboprophylaxis.


5.7 Major Cancer Surgery in the Abdomen or Pelvis:

Requires pharmacological prophylaxis for 28 days (see Tables 8 and 10).

Start mechanical thromboprophylaxis on admission with AES and IPC and continue it until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility.

Any surgery performed in patients with previous history of VTE and not already taking long term anticoagulation: prescribe 6 weeks of pharmacological and mechanical thromboprophylaxis, or follow local guidance (see Section 6) for extended thromboprophylaxis, whichever is the longest option, providing the VTE risk outweighs the bleeding risk.

5.8 Vascular Surgery:


Consider pharmacological VTE prophylaxis with LMWH for patients who are undergoing open vascular surgery or major endovascular procedures, including endovascular aneurysm repair whose risk of VTE outweighs their risk of bleeding.

Consider mechanical VTE prophylaxis with AES and IPC on admission for patients who are undergoing open vascular surgery or major endovascular procedures, including endovascular aneurysm repair, if pharmacological prophylaxis is contraindicated. Continue

https://associationofbreastsurgery.org.uk/media/64238/z-vte_statement.pdf

https://associationofbreastsurgery.org.uk/media/64238/z-vte_statement.pdf


until the patient no longer has significantly reduced mobility relative to their normal or anticipated mobility.


5.9 Varicose Vein Surgery:


VTE prophylaxis is generally not needed for patients undergoing varicose vein surgery where: Total anaesthesia time is less than 90 minutes and the patient is at low risk of VTE. Consider pharmacological VTE prophylaxis with LMWH, starting 6 hours after surgery and continuing for 7 days for patients undergoing varicose vein surgery if total anaesthesia time is more than 90 minutes or the patient’s risk of VTE outweighs their risk of bleeding.

Consider mechanical VTE prophylaxis with AES, on admission, for patients undergoing varicose vein surgery who are at increased risk of VTE and if pharmacological prophylaxis is contraindicated. If using AES for patients undergoing varicose vein surgery, continue until the patient no longer has significantly reduced mobility relative to their normal or anticipated mobility.


5.10 Cranial Injury and/or Surgery:

Offer mechanical thromboprophylaxis to patients presenting with a head injury, with or without the need for surgical treatment, from admission and continue it for 30 days or until the patient is mobile or discharged, whichever is sooner.

Consider adding pre-operative LMWH, giving the last dose no less than 24 hours before surgery and 24 - 48 hours after surgery for patients undergoing cranial surgery whose risk of VTE outweighs their risk of bleeding, continuing until discharge. If there is a need to start it earlier than 24 hours post-operatively, that decision should be made by the consultant after discussion with the multidisciplinary team.

Do not offer pharmacological VTE prophylaxis to patients with ruptured cranial vascular malformations (e.g. brain aneurysms) or with intracranial haemorrhage (spontaneous or traumatic) and until the lesion has been secured or the condition has stabilised.


5.11 Spinal Injury and/or Surgery (Appendix 9):

Offer mechanical thromboprophylaxis to patients with a spinal injury and/or elective spinal surgery from admission and continue it for 30 days or until the patient is mobile or discharged, whichever is sooner.

Patients should be informed of that risk, balanced with the risk of getting a VTE. They require increased monitoring of the legs to ensure correct fit and to check for skin marks. The monitoring frequency should be decided based on clinical judgement, bearing in mind the baseline for all the patients is 3x a day. Patient and family education on how to use

The risk of pressure damage to the skin caused by AES in this particular patient group is high due to the sensory impairment and these devices should be used with caution. See Section 2.2.


mechanical thromboprophylaxis correctly is paramount for all patients in general but in particular for spinal injury patients.

AES should preferably be knee length, as the thigh length is associated with more complications and lack of compliance.

Consider LMWH for patients whose risk of VTE outweighs their risk of bleeding, taking into account individual patient and surgical factors (major or complex surgery) and according to clinical judgement. Consider offering LMWH 24 hours after admission if the surgery is not planned for the next 24 - 48 hours, if the VTE risk outweighs the risk of bleeding.

If LMWH is required to start earlier than 24 hours post-operatively, that decision should be made by the consultant after discussion with the multidisciplinary team, otherwise it should be started 24 - 48 hours post-operatively according to clinical judgement and continued for 30 days or until the patient is mobile or discharged, whichever is sooner.

For patients prescribed AES to aid haemodynamic stability during mobilisation, the correct procedure detailed in Section 2.2.1 should still be followed (i.e. a mechanical prophylaxis care record sheet completed, correct leg measurements and everything else detailed on Section 2.2.1).


5.12 Spinal Cord Injury Patients

See Appendix 15 for the VTE prevention flowchart in spinal cord injury patients.

VTE remains a significant cause of morbidity and mortality in individuals with spinal cord injuries (SCI). The incidence of DVT has been reported to range between 9% to 100% during the acute stage of SCI, with most occurring in the first two - three weeks post-injury. This can sometimes lead to a PE which remains a common cause of death.

In addition to the VTE risk factors specified in Table 1, there are additional factors associated with increased rates of VTE in SCI patients:

Paraplegia vs tetraplegia (paraplegia has greater incidence of VTE)

Complete vs incomplete injuries (motor complete injuries have greater VTE risk)

Concomitant lower-extremity fractures

Time from injury (highest risk in acute care phase of SCI)

Previous VTE confers a six-fold greater risk

Absent or delayed thromboprophylaxis (starting prophylaxis within 2 weeks of injury is strongly associated with reduced risk of VTE)

All patients admitted to hospital should be given verbal and written information about their risk of VTE and how to prevent it. See Section 1.7 for full requirements.

See Section 2.1 for the general recommendations on how to prevent VTE, which also apply to SCI patients.

Mechanical Thromboprophylaxis: Safety Considerations

Patients should be informed of the risk of skin damage explained above, balanced with their risk of getting a VTE. Patient and family education on how to use mechanical thromboprophylaxis correctly is paramount on this patient group.

The SCI patient fitted with AES will require increased monitoring of the legs’ skin condition to ensure correct fit and to check for skin marks. The monitoring frequency should be decided based on clinical judgement, bearing in mind the baseline for all the patients is three times a day.

The risk of pressure damage to the skin caused by AES on this particular patient group is high due to the sensory impairment and these devices should be used with caution and according to Section 2.2.


For patients prescribed AES to reduce oedema and/or aid haemodynamic stability during mobilisation, the correct procedure detailed in Section 2.2.1 should still be followed, a mechanical prophylaxis care record sheet completed and AES should be prescribed by a doctor on the PRN side of the prescription chart (only if they are not already prescribed for VTE prophylaxis).

If the AES are being used only for the purpose of reducing oedema and/or aid haemodynamic stability, staff should mark the AES with a black soft-tip marker pen on the top of the foot with a locally agreed symbol, with patient consent. This helps staff know if the AES should or should not be removed when the patient returns to bed. For VTE prevention the stockings should be worn continuously, for reducing oedema and/ or aid haemodynamic stability the stockings are only worn during the period that the patient is out of bed. 5.12.1 Acute spinal cord injury patients (within 3 months post injury)

Thigh length AES should be applied for 3 months post injury when not contraindicated by a lower extremity injury.

Aim to start anticoagulation within 72hrs after injury unless there is active bleeding or a high risk of bleeding. If active bleeding or high risk of bleeding, use IPC together with thigh length AES until anticoagulation is started.

If anticoagulation is delayed, a daily assessment of the bleeding risk must be performed and documented in accordance to Section 1.6 and pharmacological thromboprophylaxis started as soon as the bleeding risk decreases.

Start dalteparin SC once daily at weight-based dose for 3 months post-injury (see Sections 2.3 and 2.5.1 for dosing in renal impairment or extremes of bodyweight).

Consider changing to a DOAC after 2 months (unlicensed use).

Consider changing to a DOAC, if patient is on weekend leave (unlicensed use).

Use a gastro-protective i.e. ranitidine 150 mg BD. 5.12.2 Spinal cord injury patients (post 3 months after injury, patients undergoing rehabilitation)

Start dalteparin SC using weight-based dosing (see Table 6 in Section 2.3 and 2.5.1 for dosing information depending on weight and renal function) or consider a DOAC (unlicensed use) for up to 6 months post injury, then reassess the need to continue prophylaxis on an individual basis.

Continue until discharge if additional VTE risk factors i.e. increased age, obesity, cancer, previous DVT, lower extremity fractures, are present.

5.12.3 Re-admission of chronic spinal cord injury patients

Annual risk for DVT amongst chronic SCI group is 1.1% for 1 to 6 years post injury. Risk for PE is 0.3%.

Start dalteparin SC using weight-based dosing (see Table 6 in Section 2.3 and 2.5.1 for dosing information depending on weight and renal function) if patients are:

1. On bed rest for 3 or more days 2. Undergoing major surgical procedures or have a medical illness 3. Patients undergoing a surgical procedure performed as a day case should be VTE

risk assessed using the VTE risk assessment proforma and guidance found in Appendices 12 and 14)

IPC and AES should be offered according to Section 2.2 and Appendices 5, 6 and 7.

Once patients start to mobilise for more than 4 hours or they are back to their baseline mobilisation (whichever is shorter) the VTE prophylaxis can be stopped.

Additional notes:

Oral vitamin K antagonists such as warfarin are not recommended as VTE prophylaxis in SCI.

We recommend against the use of low-dose or adjusted-dose unfractionated heparin in the prevention of VTE in SCI (unless LMWH is not available or contraindicated).

Aspirin is not an option.

Inferior vena cava filters are not recommended as prophylaxis.

Routine screening for DVT is not recommended.

D-Dimer testing is not recommended.


All VTE risk assessment documentation will be recorded on IMS (NSIC electronic recording system) and in accordance to Section 1.6.


5.13 Upper Limb Surgery:


For hand and wrist surgery on ambulatory patients, the VTE team suggests that you follow the Day Case VTE Risk Assessment guidance (Section 5.1) and use your clinical judgement when applying the relevant specialty consensus guidelines (British Society for Surgery of the Hand guidelines on VTE).

For elbow and shoulder surgery inpatients follow this guideline and for ambulatory patients follow Section 5.1 of this guideline using your clinical judgement when applying the relevant specialty consensus guidelines (VTE Guidelines for Shoulder and Elbow Surgery, The consensus views of the British Elbow and Shoulder Society).

The patient may be deemed to be at high risk of VTE if any of the following personal risk factors are present: active cancer, or cancer treatment, inherited thrombophilia, personal history of VTE, pregnancy and 6 weeks postpartum, severe dehydration and admission to critical care.

We would advise that these consensus guidelines are used in conjunction with the main Trust guidelines and the day case VTE risk assessment.

Any patients who are admitted to hospital should receive thromboprophylaxis with LMWH and contrary to the consensus guidelines, the VTE team would advise that patients with reduced mobility for 3 days or more, BMI >30, use of COCP, HRT and tamoxifen should be considered as significant risk particularly if undergoing open surgery or surgery with total anaesthetic time >90 min.


5.14 Fragility Fractures of the Pelvis, Hip and Proximal Femur:

Offer VTE prophylaxis for 28 days to patients with fragility fractures of the pelvis, hip or proximal femur if the risk of VTE outweighs the risk of bleeding (see Table 9).

Commence dalteparin 6 hours after surgery unless there is an increased risk of bleeding.

Give pre-operative pharmacological thromboprophylaxis for patients with fragility fractures of the pelvis, hip or proximal femur unless surgery is planned in less than 12 hours. Give the LMWH dose no less than 12 hours before surgery.

Consider IPC only for patients with fragility fractures of the pelvis, hip or proximal femur at the time of admission. Continue until the patient no longer has significantly reduced mobility relative to their normal or anticipated mobility.


5.15 Elective Hip Arthroplasty Surgery:

Offer VTE prophylaxis to patients undergoing elective hip replacement surgery whose risk of VTE outweighs their risk of bleeding. Choose either:

- Weight-based dalteparin SC for 28 days combined with AES (until discharge) or - Rivaroxaban 10 mg orally daily for 28 days (see Table 9)

https://www.bssh.ac.uk/professionals/vte_guidelines.aspx


http://www.bess.org.uk/media/VTE_Guidelines_updated_Feb_2013.doc

http://www.bess.org.uk/media/VTE_Guidelines_updated_Feb_2013.doc


Consider AES until discharge from hospital if pharmacological thromboprophylaxis is contraindicated


5.16 Elective Knee Arthroplasty Surgery:

Offer VTE prophylaxis to patients undergoing elective knee replacement surgery whose VTE risk outweighs their risk of bleeding. Choose either:

- Weight-based dalteparin for 14 days combined with AES ( until discharge) or - Rivaroxaban 10 mg orally daily for 14 days (see Table 9)

Offer IPC when pharmacological thromboprophylaxis is contraindicated. Continue until the patient is mobile.


5.17 Non-arthroplasty Orthopaedic Knee Surgery - includes Knee Arthroscopy:


VTE prophylaxis is generally not needed for patients undergoing arthroscopic knee surgery where total anaesthesia time is less than 90 minutes and the patient is at low risk of VTE.

Consider LMWH 6 hours after surgery for 14 days for patients undergoing arthroscopic knee surgery if:

- Total anaesthesia time is more than 90 minutes or - The patient’s risk of VTE outweighs their risk of bleeding

Consider VTE prophylaxis for patients undergoing other knee surgery (for example, osteotomy or fracture surgery) whose risk of VTE outweighs their risk of bleeding


5.18 Lower Limb Amputation:

Consider using IPC device on the contralateral leg starting on admission continuing it until the patient no longer has significantly reduced mobility relative to their anticipated mobility.

Consider LMWH from admission. Continue thromboprophylaxis until patient no longer has significantly reduced mobility relative to their anticipated mobility.


5.19 Lower Limb Immobilisation/Casts:

See separate pathway for the “VTE risk assessment for ambulatory patients with temporary lower limb immobilisation using Trip(cast)score” (Appendix 17).

Consider mechanical (on contralateral leg) and pharmacological thromboprophylaxis for patients with plaster casts, aircast boots or otherwise having a lower limb immobilised (e.g. arthrodesis) from admission for as long as immobilisation continues, however consider


stopping it if it extends for longer than 42 days, except for Achilles tendon rupture, which is 56 days.


5.20 Foot and Ankle Orthopaedic Surgery:


Consider pharmacological VTE prophylaxis for patients undergoing foot or ankle surgery if any of the following applies:

Requires immobilisation (for example, arthrodesis or arthroplasty)

When total anaesthesia time is more than 90 minutes

The patient’s risk of VTE outweighs their risk of bleeding

If VTE prophylaxis is commenced consider stopping this after an immobilisation period of 42 days, except for Achilles tendon rupture, which is 56 days. See Table 9 for the recommended duration of thromboprophylaxis after foot and ankle surgery.


6. Duration of Thromboprophylaxis and Discharge

Prior to discharge, carefully consider the need for thromboprophylaxis on discharge. This will require reassessment of VTE risk.

Any surgery performed in patients with previous history of VTE and not already taking long term anticoagulation: Prescribe 6 weeks of pharmacological and mechanical thromboprophylaxis, or follow local guidance (see below) for extended thromboprophylaxis, whichever is the longest option, providing the VTE risk outweighs the bleeding risk.

Surgical patients with high risk of VTE include those with significant VTE risk factors, such as active cancer or cancer treatment, those with BMI >30 and patients with ongoing significantly reduced mobility. The VTE team recommends that you continue offering mechanical and pharmacological prophylaxis for such patients whilst their risk of VTE remains high.

Ensure you encourage the patient to continue the general measures to reduce the risk and give them appropriate verbal and written information about VTE as per Sections 1.7.2 and 2.1.

Patients being discharged on LMWH should have their weight recorded on the discharge prescription. The full course should be prescribed and dispensed as TTO medicine on discharge and the patient’s GP should be informed. Before discharge, the patient should be provided with a pocket size sharp box and taught how to self-administer the injection, or a family member or carer, and given the Trust leaflet ‘How to inject Dalteparin at home, a patient guide’ (order code WZZ2214). If no one can administer the injection every day, arrangements should be made for post-discharge injection administration with the patient’s GP before discharge.

If the patient falls into any of the categories shown in Tables 8, 9, 10 and 11 below or remains at risk of VTE on discharge as explained in this section, extended pharmacological thromboprophylaxis is advised. See Tables 8 and 9 for duration. Where the duration is unclear, discuss with the on-call haematologist.

https://www.buckshealthcare.nhs.uk/Downloads/Patient-leaflets-general/Dalteparin%20leaflet%20277919-WZZ2214.pdf


Table 9: Extended thromboprophylaxis for orthopaedic surgery

Indication

Medication (for dalteparin* dose – see Table 6 in Section

2.3 and 2.5.1 for dosing in renal impairment and

extremes of bodyweight)

Duration*

(post-procedure)

Knee replacement surgery (total/bilateral/revision/

unicompartmental)

Dalteparin* SC or Rivaroxaban 10 mg orally OD (if

unable to self-inject on discharge)

14 days

Subtract the days of post-op Dalteparin

given in hospital from

the total number of injections prescribed

on discharge

Hip replacement surgery (total/bilateral/revision/re-surfacing)

Dalteparin* SC or Rivaroxaban 10 mg orally OD (if

unable to self-inject on discharge)

28 days

Surgery for # neck of femur (NOF) (hemiarthroplasty/dynamic hip screw

(DHS)/intra-medullary hip screw (IMHS)) Dalteparin* SC 28 days

Fragility fractures of the pelvis, hip and proximal femur

Dalteparin* SC 28 days

Ankle and hindfoot or midfoot fusion

Ankle fractures (plaster/boot/ conservatively/surgically managed)


Tendoachilles ruptures (conservatively or surgically managed)


*Any surgery performed in patients with previous history of VTE and not already taking long term anticoagulation: Prescribe 6 weeks of pharmacological and mechanical thromboprophylaxis, or follow local guidance for extended thromboprophylaxis, whichever is the longest option, providing the VTE risk outweighs the bleeding risk.

Table 8: Extended thromboprophylaxis for gynaecology patients

Indication

Medication (for Dalteparin* dose – see Table 6 in Section

2.3 and 2.5.1 for dosing in renal impairment and extremes of

bodyweight)

Duration* (post-procedure, unless otherwise requested by

surgeon)

Non cancer (benign)

Pelvic surgery with total anaesthetic + surgical time >60 minutes


Subtract the days of post-op

dalteparin given in hospital from the total number of

injections prescribed on

discharge.

Surgery for vulvar cancer Dalteparin* SC 7 days

Cancer major

Laparotomy for ovarian, cervical, uterine cancer

Laparoscopic surgery for ovarian, cervical, uterine cancer or complex atypical hyperplasia of the endometrium (see Table 10 for more examples of major cancer surgery)

Dalteparin* SC 28

days



7. Thromboprophylaxis in Medical Patients

7.1 General Medical Admissions

In Appendix 10, a flowchart explains VTE prevention in medical patients. For patients admitted with acute stroke, see Appendix 11.

Offer pharmacological thromboprophylaxis alone based on the VTE risk assessment within 14 hours of admission to the acutely ill medical patient whose risk of VTE outweighs their risk of bleeding. Combine with mechanical thromboprophylaxis if the patient is at very high risk of VTE (see Section 1.6). Offer mechanical thromboprophylaxis alone if the patient is not suitable for pharmacological thromboprophylaxis (even if the pharmacological thromboprophylaxis is withheld for a limited time only). You can offer AES and IPC. Remember that if the patient has localised contraindications for AES you can still assess their suitability to have IPC leg sleeves or foot cuffs (see Section 2.2).

NICE NG89 states: “Offer pharmacological VTE prophylaxis for a minimum of 7 days to acutely ill medical patients whose risk of VTE outweighs their risk of bleeding.”

Table 10: Examples of major cancer surgery requiring extended thromboprophylaxis for 28 days post-op*

Adrenalectomy

Colectomy (right, left, subtotal, anterior resection, abdominoperineal resection

Hartmann’s procedure

Cystectomy

Gastrectomy

Total and subtotal (NOT laparoscopic gastrointestinal stromal tumour (GIST) resection)

Hepatectomy

Laparoscopic or open radical nephrectomy (for renal cell carcinoma)

Lymph node dissection (check with consultant)

Nephroureterectomy

Oesophagectomy

Nephrectomy (partial, radical or simple)

Radical prostatectomy

Splenectomy


Table 11: Examples of complex non-cancer surgical patients requiring extended thromboprophylaxis for 14 to 28 days post-op* (discuss with haematology)*

Significant VTE risk factors (see Section 6 for examples)

Suspected malignancy awaiting histology results

Complex non-cancer surgery

Prolonged general anaesthesia

Significant blood loss requiring blood transfusion



Given the lack of robust evidence for this NICE recommendation, Kings Thrombosis Exemplar Centre along with a number of other Exemplar Centres in the UK including Oxford is not adopting this recommendation.

BHT will also not implement the routine provision of thromboprophylaxis on discharge however there are certain situations when patients may benefit from it:

Previous history of VTE: Consider 6 weeks of pharmacological thromboprophylaxis after discussion with haematology if patient not already taking long term anticoagulation

Patients with significantly reduced mobility (e.g. lower limb immobilisation)

Active cancer or cancer treatment

Clinical judgement

If in doubt discuss with the on-call haematologist

7.2 Acute Stroke

The Stroke ICP should be followed (Appendix 11).

In Appendix 11, a flowchart explains VTE prevention in acute stroke patients. Recent stroke has been associated with an increased risk of developing VTE. Do not offer AES for VTE prophylaxis to patients who are admitted for stroke.

For patients diagnosed with acute stroke offer IPC (see Section 2.2.2 for contraindications). If using it continue for 30 days or until the patient is mobile or is discharged, whichever is sooner.

Explain to the patient and their family members or carers that IPC reduces the risk of DVT and may increase their chances of survival however it will not help them recover from the stroke, and there may be an associated increased risk of surviving with severe disability.

Provide “Blood Clots: Reducing the risks” leaflet (Appendix 2) and provide patient education according to Section 1.7.

Pharmacological thromboprophylaxis: from admission to up to 7 to 14 days post stroke

Dalteparin should not normally be prescribed for patients with acute ischemic stroke during the first 7 to 14 days after stroke. However, after senior review it may be used in selected patients at very high risk or at high risk of VTE.

Consider VTE prophylaxis with LMWH for patients if:

A diagnosis of haemorrhagic stroke has been excluded and

The risk of bleeding (haemorrhagic transformation of stroke or bleeding into another site) is assessed to be low, and who have one or more of:

major restriction of mobility, e.g. complete leg paresis

previous history of VTE

dehydration

comorbidities (such as malignant disease) The decision to use LMWH in these patients should be made in consultation with the stroke team and carefully documented.

Pharmacological thromboprophylaxis: Ongoing after day 14

Dalteparin should be prescribed from day 14 in patients with non-haemorrhagic stroke with ongoing reduced mobility. For patients with known haemorrhagic transformation of cerebral infarction or intracerebral haemorrhage, it should be a consultant decision to use dalteparin.

Continue LMWH until the patient’s mobility is no longer increasing. 7.3 Acute Coronary Syndromes (ACS)

Be aware that patients receiving anticoagulants such as fondaparinux as part of their treatment for an ACS do not usually need VTE prophylaxis.

Patients no longer on anticoagulants for ACS should be prescribed appropriate pharmacological and mechanical thromboprophylaxis regimen based on the VTE risk assessment and after senior medical review.


Antiplatelet agents are not sufficient for thromboprophylaxis.

Patients remaining in hospital for some time after completion of their management for ACS remain at risk of VTE and require further regular assessment. These patients should be considered for further VTE prophylaxis if the anticoagulant therapy is interrupted. 7.4 Palliative Care

Note that the scope of the NICE NG89 extends to hospitals only. Hospice care is out of the scope of this guideline so formal risk assessment using Trust proforma is not required. However it is good clinical practice to risk assess these patients as part of their overall care and this should be documented in the case notes.

Consider offering VTE prophylaxis to patients in palliative care who have potentially reversible acute pathology. Take into account temporary increases in thrombotic risk factors, risk of bleeding, likely life expectancy and the views of the patient (and/or family or carers). Review VTE prophylaxis decisions daily taking into account the views of the patient (and/or family or carers) and the multidisciplinary team. Do not routinely offer VTE prophylaxis to patients admitted for terminal care or those commenced on an end-of-life care pathway or in the last days of life. 8. Patients being Nursed in Paediatric Areas of BHT, including: Ward 3, PDU, St Francis, Theatres and Ward 7 (WH)

Every child (of any age) must have a VTE risk assessment completed by the admitting medical staff following the recommendations that are specified in Section 1.6.

Even though the incidence of VTE in children is lower than in adults, some children are at an increased risk if:

The child weighs greater than 40 kg

The child is 13 years old or more

The child has reduced mobility for 3 days or more

Any surgical patients with a total anaesthetic + surgical time >90 minutes (or if pelvis or lower limb total time >60 minutes)

Has a spinal cord injury

Has a history of a thrombus

Children should be VTE risk assessed using the VTE Risk Assessment for Patients Being Nursed within Paediatric Areas (Appendix 13). The VTE risk assessment must be completed on admission, day after admission, whenever the clinical situation changes, every 7 days (if still an inpatient and did not have a re-assessment by then) and on discharge (Section 1.6.). 8.1 Patient and Family Education

Read Section 1.7 throughout to know more about educating children and their families on VTE prevention in hospital and after discharge. 8.2 General Measures to Prevent VTE

See Section 2.1 to know what children can do in general to prevent VTE, including the VTE prevention exercises. This should be part of their educational session on VTE.

Guidance for those below the age of 16 is based on recommendations provided by The Association of Paediatric Anaesthetists of Great Britain and Ireland, detailed in Section 8, with links to other sections of the guideline when relevant. Where recommendations were not provided in the paediatric guideline, guidance from NICE NG89 has been applied to under 16s and should be used (even if with caution) in this patient group.


8.3 Pharmacological Thromboprophylaxis Dosing in Paediatric Patients

If a child is prescribed prophylactic dalteparin by SC injection, doses in the BNFc should be followed. See Table 12 below.

Table 12: Dalteparin dosing in Paediatrics

Child’s Age Dalteparin dose

Neonate 100 units/kg SC once daily

Child 1 month – 11 years 100 units/kg SC once daily

Child 12 – 17 years Depends on kidney function and body weight

Follow weight-based dosing on Table 6 in Section 2.3 and see Section 2.5.1 for renal adjusted dosing

Monitoring of patients on dalteparin should follow guidance in Section 2.3.5. 8.4 Mechanical Thromboprophylaxis

Any patient offered mechanical thromboprophylaxis should have it prescribed on the prescription chart and a mechanical thromboprophylaxis care plan chart started. The recommendations for the usage of mechanical thromboprophylaxis are specified in Section 2.2, Appendices 5 and 7 and must be followed. 8.5 Special Considerations of this Patient Group

8.5.1 Paediatric surgical patients

Surgical patients are at risk of VTE and should be adequately hydrated and early mobilisation should be encouraged.

Any surgical patients (13 years and over and who weigh more than 40 kg) with a total anaesthetic + surgical time >90 minutes (or if pelvis or lower limb total time >60 minutes) should be prescribed AES and IPC peri-operatively.

If there are additional risk factors, LMWH should be considered if the bleeding risk is low. 8.5.2 Paediatric oncology patients

Children with cancer whether or not they are receiving treatment for cancer, are at increased risk of VTE, however, it is not always appropriate to use LMWH in all patients. These children should be considered for LMWH on an individual basis, as LMWH prophylaxis may not be appropriate for all.

Unless contraindicated, children aged 13 years or older who weigh greater than 40 kg and who have significantly reduced mobility for 3 days or more should be prescribed mechanical thromboprophylaxis and considered for LMWH if there are any additional VTE risk factors. 8.5.3 Paediatric palliative care patients

If a child is receiving end of life care do not routinely offer VTE prophylaxis. 8.5.4 Paediatric patients with a spinal cord injury (SCI)

DVT is uncommon in children who acquire a SCI between birth and pre-puberty. Although this group of patients is at risk of VTE, it is not always appropriate to use mechanical and/or pharmacological thromboprophylaxis.

All patients admitted to hospital should be given verbal and written information about their risk of VTE and how to prevent it. See Section 1.7 for full requirements. See Section 2.1 for the general recommendations on how to prevent VTE, which also apply to paediatric SCI patients.



Mechanical Thromboprophylaxis: Safety Considerations

Children of all ages receive mechanical prophylaxis with AES and/or IPC for 3 months post injury, if proper sizing and fit can be achieved.

Patients should be informed of the risk of skin damage explained above, balanced with their risk of getting a VTE. Patient and family education on how to use mechanical thromboprophylaxis correctly is paramount in this patient group.

The SCI patient fitted with AES will require frequent monitoring of the legs’ skin condition to ensure correct fit and to check for skin marks. The monitoring frequency should be based on clinical judgement, bearing in mind the baseline for all the patients is three times a day.

For patients prescribed AES to reduce oedema and / or aid haemodynamic stability during mobilisation, the correct procedure detailed in Section 2.2.1 should still be followed, a mechanical prophylaxis care record sheet completed and AES should be prescribed by a doctor on the PRN side of the prescription chart (only if they are not already prescribed for VTE prophylaxis).

If the AES are being used only for the purpose of reducing oedema and / or aid haemodynamic stability, staff should mark the AES with a black soft-tip marker pen on the top of the foot with a locally agreed symbol, with patient consent. This helps staff know if the AES should or should not be removed when the patient returns to bed. For VTE prevention the AES should be worn continuously, for reducing oedema and / or aid haemodynamic stability the AES are only worn during the period that the patient is out of bed.

Pharmacological Thromboprophylaxis:

Pre-pubertal children need to be assessed on an individual basis to decide if thromboprophylaxis is required (e.g. if they also have cancer, obesity or lower limb fractures).

Post-pubertal children: Start dalteparin SC at a weight-base dosage for 3 months post-injury (see Table 6 in Section 2.3 and 2.5.1 for dosing in renal impairment or extremes of bodyweight).

Aim to start anticoagulation within 72hrs after injury unless there is active bleeding or high risk of bleeding. If active bleeding or high risk of bleeding, use IPC together with thigh length AES until anticoagulation is started.

If anticoagulation is delayed, a daily assessment of the bleeding risk must be performed and documented in accordance with Section 1.6 and pharmacological thromboprophylaxis started as soon as the bleeding risk decreases.

Start a gastro-protective agent together with the dalteparin being mindful of potential Clostridium difficile outbreaks.

The duration of pharmacological thromboprophylaxis is usually for 3 months, however it could be longer depending on consultant decision.

Children with Spinal Cord injury >3 Months Post Injury - Undergoing Rehabilitation

VTE prophylaxis is not recommended unless additional risk factors such as obesity, cancer, lower extremity fractures, previous DVT are present. Re-admission of Children with Chronic Spinal Cord Injury

VTE prophylaxis is not routinely recommended in pre-pubertal children. VTE prophylaxis is not recommended in post pubertal children if at baseline mobilisation. LMWH is recommended in post-pubertal children if major surgical intervention or medical illness requiring bed rest for more than 3 days.

The risk of pressure damage to the skin caused by AES in this particular patient group is high due to sensory impairment and these devices should be used with caution and according to Section 2.2.


Paediatric Patients with Chronic SCI who are Hospitalised for Medical Illnesses or Surgical Procedures

Patients should receive an individual VTE risk assessment and be prescribed appropriate thromboprophylaxis during the period of increased risk, as per VTE assessment. Additional notes:

Oral vitamin K antagonists such as Warfarin are not recommended as VTE prophylaxis in SCI

We recommend against the use of low-dose or adjusted-dose unfractionated heparin in the prevention of VTE in SCI (unless LMWH is not available or contraindicated)

Aspirin is not an option

Inferior Vena Cava filters are not recommended as prophylaxis

Routine screening for DVT is not recommended

D-Dimer testing is not recommended

All VTE risk assessment documentation will be recorded on IMS (NSIC electronic recording system) and in accordance to Section 1.6.

9. Community Hospitals

All patients admitted to community hospitals should be assessed for their risk of VTE and bleeding in concordance with Section 1.6.

Patients admitted from the community in whom there is no acute illness and no acute deterioration in mobility do not generally require routine mechanical or pharmacological thromboprophylaxis. However, their risk needs to be reassessed as per Section 1.6.

If the acute episode has resolved and the patient has returned to their baseline mobility, then it may be appropriate to discontinue pharmacological and mechanical thromboprophylaxis. Unless the patient is recovering from total hip replacement, total knee replacement, fractured neck of femur, fragility fractures of the pelvis, hip and proximal femur and major trauma, who must continue pharmacological and mechanical thromboprophylaxis as per Sections 5 and 6.


10. References and Further Reading

Document Title Document Location

British Society for Surgery of the Hand VTE Guidelines https://www.bssh.ac.uk/professionals/vte_guidelines.aspx

British Elbow and Shoulder Society – VTE guidelines for shoulder and elbow surgery (2013)

B. Nemeth et al., Clinical risk assessment model to predict venous thromboembolism risk after immobilization for lower-limb trauma, EClinicalMedicine (2020)

https://doi.org/10.1016/j.eclinm.2020.100270

Consensus Guideline on Venous Thromboembolism (VTE) Prophylaxis for Patients Undergoing Breast Operations from the American Society of Breast Surgeons

https://www.breastsurgeons.org/docs/statements/Consensus-Guideline-on-Venous-Thromboembolism-VTE-Prophylaxis-for-Patients-Undergoing-Breast-Operations.pdf

Guidance notes to accompany VTE risk assessment data collection. https://improvement.nhs.uk/resources/vte/#h2-guidance-for-vte-data-collection

Guidelines for Pharmacological and Mechanical thromboprophylaxis for venous thromboembolism

University Hospitals of Leicester NHS Trust

Guideline for the use of thromboprophylaxis in ambulatory trauma patients requiring temporary limb immobilisation: College of Emergency Medicine 2012

https://www.rcem.ac.uk/docs/College%20Guidelines/5z26.%20Thromboprophylaxis%20in%20ambulatory%20trauma%20patients%20requiring%20temporary%20limb%20immobilisation%20-%20(Flowchart)%20(Oct%202012).pdf

Guidelines on use of vena cava filters (BCSH) https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2141.2006.06226.x

Joint Formulary Committee (2019) British National Formulary. https://bnf.nice.org.uk/

Joint Formulary Committee (2019) British National Formulary for Children.


Ko RH, Thornburg CD. Venous Thromboembolism in Children with Cancer and Blood Disorders. Front Pediatr. 2017;5:12. Published 2017 Feb 6. doi:10.3389/fped.2017.00012

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5292750/

Monagle P, Chan AK, Goldenberg NA, et al. 2012. Antithrombotic therapy in neonates and children. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest;141(2 Suppl):e737S– e801S.

https://journal.chestnet.org/article/S0012-3692(12)60137-8/fulltext














https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2015/04/NHS-England-VTE-Guidance-April-2015.pdf














https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2141.2006.06226.x



https://bnf.nice.org.uk/









Document Title Document Location

NICE guideline NG89: Venous Thromboembolism in Over 16s. Reducing the risk of hospital acquired deep vein thrombosis or pulmonary embolism. March 2018

https://www.nice.org.uk/guidance/ng89

Prevention of Peri-operative Venous Thromboembolism in Paediatric Patients, The Association of Paediatric Anaesthetists of Great Britain and Ireland

https://www.apagbi.org.uk/sites/default/files/inline-files/APA%20Thromboprophylaxis%20guidelines%20final.pdf

Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest 2008;133;381S-453S William H. Geerts, David Bergqvist, Graham F. Pineo, John A. Heit, Charles M. Samama, Michael R. Lassen and Clifford W. Colwell.


Prevention of Venous Thromboembolism in Individuals with Spinal Cord Injury Clinical Practice Guideline for Health Care Providers Third Edition 2016

https://pva-cdnendpoint.azureedge.net/prod/libraries/media/pva/library/publications/cpg_thrombo_fnl.pdf

RCOG Green-top Guideline no 37, November 2015, Reducing the risk of venous thromboembolism during pregnancy and the puerperium.

www.rcog.org.uk

Tullius BP, Athale U, van Ommen CH, Chan AKC, Palumbo JS, Balagtas JMS, for the Subcommittee on Hemostasis and Malignancy and the Subcommittee on Pediatric/Neonatal Thrombosis and Hemostasis. The identification of at-risk patients and prevention of venous thromboembolism in pediatric cancer: guidance from the SSC of the ISTH. J Thromb Haemost 2018; 16: 175–80.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/jth.13895

Trust Clinical Guideline for the Prevention of Venous thromboembolism (VTE) for Adult Surgical Patients: Day Case, General Surgery, Gynaecology, Orthopaedics, Urology and Vascular

Norfolk and Norwich University Hospitals NHS Trust

Venous Thromboprophylaxis in Adult Surgical In-patients Guy’s and St Thomas’ NHS Trust

Vogel L, Betz R, Mulcahey M. 2011. Pediatric spinal cord disorders. In: Kirshblum S, Campagnolo DI, eds. Spinal Cord Medicine, 2nd ed., Philadelphia: Lippincott Williams & Wilkins:533–64.

Book

Vogel LC, Lubicky JP. 2001. Lower extremity compartment syndrome in an adolescent with a spinal cord injury. J Spinal Cord Med;24(4):278–83.

J Spinal Cord Med;24(4):278–83.
















http://www.rcog.org.uk/





See also: Guideline 9AFM Algorithm for Suspected Acute Non-massive Pulmonary Embolus (PE) Guideline 9BFM Massive Pulmonary Embolus (PE) Guideline 34FM Dabigatran: Guidance for Management of Overdose, Bleeding and

Emergency/Elective Surgery Guideline 66 COVID 19 Venous Thromboembolism Management Guideline for Patients Aged 16 or

Above Admitted onto Wards (except ICU)* Guideline 70 Anticoagulation with Intravenous Heparin* Guideline 83FM Peri-operative Bridging of Warfarin Therapy in Adult Patients undergoing Elective

Surgery or Invasive Procedures Guideline 116FM Dalteparin for Prophylactic Use in Surgery, Oncology, Haematology and Medicine Guideline 240FM Rivaroxaban and Apixaban: Guidance for Management of Overdose, Bleeding and

Emergency/Elective Surgery Guideline 249 Assessment of Deep Vein Thrombosis (DVT) in the Ambulatory Setting and

Anticoagulation Management of DVT and Pulmonary Embolism (PE) In Adults (aged 16 and over)*

Guideline 270 Management of Patients with Altered Coagulation for Spinal and Epidural Anaesthesia*

Guideline 295FM Dabigatran, Rivaroxaban Apixaban and Edoxaban for Deep Vein Thrombosis and Pulmonary Embolism

Guideline 313FM Dabigatran, Rivaroxaban, Edoxaban and Apixaban for Atrial Fibrillation Guideline 646FM Venous Thromboembolism (VTE) in Maternity COVID 19 Venous Thromboembolic Management Pathway for Critically Ill Patients on ICU* Standard Operating Procedures: CSS 13 VTE Risk Assessment Proformas in Patients Aged 16 and Over* VTE SOP 1 Medical Support Worker Role in VTE Prevention In Patients Aged 16 and Over* BHT Policy: BHT Pol 145 Prevention of Hospital Acquired Venous Thromboembolism (VTE) in Adults and

Process of Root Cause Analysis for Hospital Acquired VTE* * BHT users only

Title of Guideline Thromboprophylaxis In The Hospital Setting: Reducing The Risk of Hospital Acquired Deep Vein Thrombosis or Pulmonary Embolism

Guideline Number 733FM

Version 5

Effective Date July 2020

Review Date July 2023

Original Version Published December 2010

Approvals:

Medicine Check (Pharmacy) 20th April 2020

Clinical Guidelines Group 21st July 2020

Authors Dr Renu Riat, Consultant Haematologist Dr Atanu Dutta, Consultant Paediatrician Dr Anitha Naidoo, Consultant in Spinal Injuries Dr Matthew Burn, Stroke SDU Lead Mr Stephen Mitchell, Urology Lead Mr Raghubir Kankate, T&O Consultant Mariana Mascarenhas, VTE Prevention Specialist Nurse

SDU(s)/Department(s) responsible for updating the guideline

Haematology Paediatrics Spinal Cord Injuries Trauma and Orthopaedics

Uploaded to Intranet 30th July 2020

Buckinghamshire Healthcare NHS Trust

http://www.bucksformulary.nhs.uk/docs/Guideline_9AFM.pdf

http://www.bucksformulary.nhs.uk/docs/Guideline_9BFM.pdf



https://www.buckshealthcare.nhs.uk/Downloads/AA_COVID_19/COVID-19%20Surgery%20and%20crit%20care/200603_COVID-19%20venous%20thromboembolism%20management%20guideline%20for%20patients%20aged%2016%20or%20above%20admitted%20onto%20wards%20expect%20ICU.pdf

https://www.buckshealthcare.nhs.uk/Downloads/AA_COVID_19/COVID-19%20Surgery%20and%20crit%20care/200603_COVID-19%20venous%20thromboembolism%20management%20guideline%20for%20patients%20aged%2016%20or%20above%20admitted%20onto%20wards%20expect%20ICU.pdf


















https://www.buckshealthcare.nhs.uk/Downloads/AA_COVID_19/COVID-19_ICU/COVID19%20VTE%20pathway%20Final%20V1%2017.pdf

http://swanlive/sites/default/files/sop_for_vte_risk_assessment_proformas_-_final_july_20.pdf





Appendix 1: VTE Risk Assessment for Medical and Surgical Patients (in the inpatient prescription chart page 4)


Appendix 2: Patient Information Leaflet - Blood Clots (Reducing the Risks) (Order Code: WZZ1294) See: Blood Clots (reducing the risks) If the hyperlink fails to work the leaflet is available on the BHT public website (For Patients and Visitors/Information Leaflets under the heading ‘General’).

https://www.buckshealthcare.nhs.uk/Downloads/Patient-leaflets-general/Blood%20Clots%20-%20reducing%20the%20risks.pdf


Appendix 3: VTE Prevention Exercises

THESE EXERCISES HELP PREVENTING BLOOD CLOTS AND THEY CAN BE DONE LYING

IN BED OR SITTING ON THE CHAIR. AIM FOR 10 REPETITIONS OF EACH, EVERY HOUR.

Paddle your feet up and down and circle them around and around

Brace your knees so you can feel the muscle tighten on the front of the thigh. Hold for a count of 3 and gently relax.

ANKLES

KNEES

BOTTOM

Clench your buttock muscles together and hold for a count of 3 before

relaxing.

BREATHING

Place your hands on the side of your rib cage. Take a deep breath and feel the

ribs being pushed out to the side as you expand your lungs

Download the free app: Preventing VTE

Before you teach any of these exercises to the patient check with the nurse, doctor or physiotherapist if it is safe to do them


Appendix 4: Patient Information Leaflet - How to Inject Dalteparin at Home See: Dalteparin Injection (prefilled syringe) – How to inject Dalteparin at home, a patient guide If the hyperlink fails to work the leaflet is available on the BHT public website (For Patients and Visitors/Information Leaflets under the heading ‘General’).

https://www.buckshealthcare.nhs.uk/Downloads/Patient-leaflets-general/Dalteparin%20leaflet%20277919-WZZ2214.pdf


Appendix 5: Antiembolism Stockings (AES) Flowchart

Adapted from the VTE Prevention Team, Oxford University Hospitals

Picture 1: How to measure the legs correctly for Cardinal Health

TM stockings (old Covidien

TM)

Always use the MedtronicTM

sizing chart to identify the size. If the correct size is unavailable, do not apply and place an order on procurement.

Has your patient been risk assessed for VTE?

No Yes

VTE risk assessment must be completed within 14 hours of admission, updated on the day after admission and when the clinical condition changes, if drug chart re-written, maximum

after 7 days and on discharge

AES recommended? Recommended for all surgical patients, for medical

patients that present contraindications to pharmacological thromboprophylaxis and for medical patients at very high

risk of VTE by having significant and multiple VTE risk factors (e.g. cancer, reduced mobility, BMI>30, previous VTE)

Do not prescribe AES. Review if

clinical condition changes

Ensure AES are prescribed on the prescription chart

AES can be used alone or together with

intermittent pneumatic compression device (IPC)

Complete the Mechanical Prophylaxis Care

Record Sheet

Choose between: Knee length: less risk of complications,

increased compliance or

Thigh length: better VTE prevention but

increased risk of complications and of non-compliance

Measure the legs (Picture 1) to select the size. Always use Medtronic

TM stockings.

Patient and carer should be shown how to fit AES correctly: The heel pocket should sit on the heel, the stocking is not folded or rolled down and sits below the knee line (knee length stocking)/ below the gluteus furrow (thigh length stocking).

Remove them daily for skin checks for no longer than 30 minutes

Provide verbal and written information to the patient and their family regarding their risk of VTE and how to reduce it. Give the Trust

Leaflet: “Blood Clots: Reducing the Risk”

No Yes

Are there AES contraindications? As per Trust guideline 733FM

No Yes

Sign the prescription chart every shift after checking skin for complications:

Impaired neurovascular status, marking, blistering or discolouration. Inform the doctor if you find any of

the above

Discontinue if patient

developed complications



Appendix 6: Mechanical Thromboprophylaxis Care Record Sheet (order code WZZ 2152)


Appendix 7: Intermittent Pneumatic Compression Devices (IPC) Flowchart

Picture 1: How to measure the legs correctly for Venaflow

TM sleeves

Maximum foot circumference = 41 cm

One Size Only

Universal: calf up to 48 cm XL: calf up to 55 cm XXL: calf up to 76 cm

Maximum thigh circumference = 74 cm

One Size Only

If thigh is over 74 cm choose a calf sleeve instead

Foot cuff

Calf Sleeve

Thigh Sleeve


Complete the Mechanical Prophylaxis Care

Record Sheet

Choose between: Foot cuffs: less effective and more expensive,

only use if calf or thigh sleeves are contraindicated due to a localised condition

Calf sleeves: usual 1st choice

Thigh sleeves: for patients at very high risk of

VTE (e.g. stroke, spinal cord injury, ICU)

Foot sleeves must have the aircell at the bottom of the foot whereas calf and thigh sleeves can have

the aircell anywhere around the leg as with the tubing pointing down to the foot as in Picture 1.

Measure at the widest part of the foot, calf or thigh. Use Picture 1 to select size. Sleeves should be

applied snugly but not tight.

Start IPC from the immobilisation period (i.e. when bedbound, intra-op or spending long periods in bed or chair, including overnight) and continue until patient returns to baseline mobility. Remove them daily for skin checks for no longer than 30 minutes

Provide verbal and written information to the patient and their family regarding their risk of VTE and how to reduce it. Give the Trust


Sign the prescription chart every shift after checking skin for complications:

Impaired neurovascular status, marking, blistering or discolouration. Inform the

doctor if you find any of the

above

Discontinue if patient

developed complications or

returned to baseline mobility


No Yes

VTE risk assessment must be completed within 14 hours of admission, updated on the day after admission and when the clinical condition changes, if drug chart re-written, maximum after 7 days and on discharge

IPC recommended?

Recommended for all surgical patients, for medical patients that present contraindications to pharmacological thromboprophylaxis and for medical patients at very high

risk of VTE by having significant and multiple VTE risk factors (e.g. cancer, reduced mobility, BMI>30, previous VTE)

Do not prescribe IPC. Review if

clinical condition changes

Ensure IPC are prescribed on the prescription chart

IPC can be used alone or together with anti-embolism stockings

No Yes

Are there IPC contraindications? As per Trust guideline 733FM

No Yes



Appendix 8: VTE Prevention Flowchart in Surgical Inpatients

Offer extended thromboprophylaxis As per Trust guideline 733FM

Previous history of VTE (minimum of 6 weeks pharmacological and mechanical thrombo-prophylaxis if not already taking long term anticoagulants) or

Patients post high risk procedures (e.g. THR, Hip fracture, TKR, major abdominal cancer surgery) or

Patients with significantly reduced mobility (e.g. lower limb immobilisation) or

Active cancer or cancer treatment or Clinical judgement

If in doubt, discuss with the on-call haematologist


Prescribe and administer pharmacological thromboprophylaxis

within 14 hours of admission As per Trust guideline 733FM

Update VTE risk assessment on the day after admission, when clinical condition changes or maximum after 7 days and

on discharge

Provide verbal and written information to the patient and their family regarding their risk of

VTE and how to reduce it. Give the Trust


Continue until the patient no longer is at

risk of VTE or is discharged (see next

box)

When to offer extended (post-

discharge) mechanical and pharmacological

thromboprophylaxis?


No Yes


Is the patient at risk of VTE? (has 1 or more VTE risk factor/s identified in the VTE risk assessment?)

Continue mechanical thromboprophylaxis Seek advice from on-call haematologist

Reinforce patient education Re-assess VTE and bleeding risk daily

No Yes

Is pharmacological thromboprophylaxis contraindicated? Does the risk of bleeding outweigh the

risk of VTE? As per Trust guideline 733FM

No

Yes

Prescribe mechanical thrombo-

prophylaxis unless contraindicated As per Trust guideline 733FM

Continue until the patient is no longer at

risk of VTE

No thromboprophylaxis required. Re-assess VTE risk accordingly



Appendix 9: VTE Prophylaxis in Trauma and Orthopaedic Spinal Patients Requiring Conservative or Surgical Management

See: Guideline 5 VTE Prophylaxis in Patients with Orthopaedic Spinal Involvement (Elective and Emergency) requiring Conservative or Surgical Management – Reducing the Risk of VTE




Appendix 10: VTE Prevention Flowchart in Medical Inpatients

Is the patient at very high risk of VTE? (e.g. recent

major surgery, significantly reduced mobility, previous history of VTE, active cancer / cancer treatment, BMI>30, clinical judgement)

Yes

No


Prescribe and administer pharmacological thromboprophylaxis

within 14h of admission As per Trust guideline 733FM

Update VTE risk assessment on the day after admission, when clinical condition

changes, if drug chart is re-written or maximum after 7 days and on discharge




Continue until the patient is no longer at risk of VTE or

discharged (see next box)

When to offer extended (post-

discharge) pharmacological

thromboprophylaxis?


No Yes


Is the patient at risk of VTE? (has 1 or more VTE risk factor/s identified in the VTE risk

assessment)

No thromboprophylaxis required. Re-assess VTE risk accordingly

No Yes


risk of VTE? As per Trust guideline 733FM

No

Yes

Prescribe mechanical thromboprophylaxis unless contraindicated. Re-inforce

patient education As per Trust guideline 733FM

Continue until the patient is no longer at risk of VTE or

is discharged

If not combined with pharmacological

thromboprophylaxis, re-assess VTE and bleeding

risk daily

Offer extended thromboprophylaxis As per Trust guideline 733FM


Previous history of VTE: Consider 6 weeks of pharmacological thromboprophylaxis after discussion with haematology if patient not already taking long term anticoagulation or

Patients with significantly reduced mobility (e.g. lower limb immobilisation) or

Active cancer or cancer treatment or Clinical judgement

Has the patient had an acute

stroke within the last 30 days?

Yes See Stroke

flowchart

No



Appendix 11: VTE Prevention in Patients with Acute Stroke


Appendix 12: Approved List of Day Case Procedures where VTE Risk Assessment can be done by Cohort rather than an Individual Risk Assessment

Surgical day case procedures that normally would not need an individual VTE risk assessment, unless they have personal history of VTE:

1. Minor day surgical procedures under local , regional or conscious sedation anaesthesia of less than 90 minutes duration

2. Minor day case surgical procedures under short general anaesthesia estimated to last less

than 30 minutes (unless specified otherwise) where there is no immobilisation of the lower leg or general immobility afterward including:

Spinal/Pain team local and regional analgesia

Dermatological procedures

Ophthalmic procedures

Proctological procedures

Day case carpal tunnel release

Day case lumbar puncture

Non-cancer ear, nose and throat (ENT) surgery lasting <90 minutes

Non-cancer dental or maxillofacial procedures lasting <90 minutes

Incision and drainage of perianal abscesses 3. Day case prostate biopsy (cohort assessed as balance of risk of bleeding rather than

thrombosis) 4. Outpatient/day case cystoscopy and cystoscopic procedures

Cystoscopy, bladder biopsy, ureteroscopy

Circumcision

Vasectomy

Hydrocele repair/epididymal cyst surgery

Urolift

Testicular torsion/scrotal exploration

Simple orchidectomy

All paediatrics’ urology surgery 5. Upper and lower GI endoscopy including PEG, PIG, stents and biopsies 6. Minor day case gynaecological surgical procedures under short general anaesthesia

estimated to last less than 30 minutes:

Colposcopy/hysteroscopy

Essure sterilisations

Polypectomies

Novasure endometrial ablations

Medical termination of pregnancy (TOPs)

Surgical management of miscarriage (SMM/ERPC)

Diagnostic laparoscopy

7. Patients attending the Surgical Assessment Unit unless they need a day case surgical procedure

8. Patients attending Ambulatory Care Unit, not planned for

inpatient admission

The doctor can

overrule the

cohort and

assess the

patient

individually

based on clinical

judgement

All patients who remain in hospital after 23:59hrs (i.e. are admitted) must have a VTE risk assessment completed using the inpatient VTE risk assessment at time of

admission


Appendix 13: VTE Risk Assessment for Patients Being Nursed within Paediatric Areas (order code WZZ 2270)


Appendix 14: VTE Risk Assessment for Day Case Surgery Patients Aged 16 and Above


Appendix 15: VTE Prevention Flowchart in Spinal Cord Injury Inpatients

VTE risk assessment must be completed within 14 hours of admission, updated on the day after admission and when the clinical condition changes, maximum after 7 days, when drug chart is re-written and on

discharge.

Patients with chronic SCI who are hospitalised for medical illnesses or surgical procedures should receive thromboprophylaxis during the

period of increased risk, according to their VTE risk assessment. See Appendices 8 and 10 for flowcharts on how to prevent VTE in medical or surgical admissions on chronic SCI patients and Appendices 12 and 14 for chronic SCI patients undergoing day case surgical procedures

Prescribe and administer pharmacological thromboprophylaxis within 14 hours of admission together

with ranitidine 150 mg BD As per Trust guideline 733FM

Update VTE risk assessment on the day after admission, when clinical condition

changes, after a maximum of 7 days, when drug chart is re-written and on

discharge




Continue for at least 12 weeks after injury up to 6 months

Consider DOACs after 8 weeks and for weekend leave

As per Trust guideline 733FM

When to offer extended mechanical and pharmacological thromboprophylaxis?

Continue mechanical thromboprophylaxis Seek for the on-call haematologist advice

Re-inforce patient education Re-assess VTE and bleeding risk daily


risk of VTE? Frank intracranial bleeding, incomplete SCI with perispinal bleeding, active/risk of major

bleeding

No

Yes

Prescribe mechanical thromboprophylaxis for 12 weeks unless contraindicated. Frequent monitoring is

required to check for skin damage due to sensory impairment

Continue until the patient no longer has reduced mobility.

When to offer extended thromboprophylaxis? As per Trust guideline 733FM

Motor complete injuries Lower extremity fractures Older age Previous history VTE Active cancer or cancer treatment BMI >30 Clinical judgement



No Yes

Is the patient at risk of VTE? (has 1 or more VTE risk factor/s identified in the VTE risk assessment?)

No Yes

No thrombo-prophylaxis

required. Re-assess VTE

risk accordingly



Appendix 16: How to Administer Dalteparin to Minimise Bruising


Appendix 17: VTE Risk Assessment for Ambulatory Patients aged ≥16 with Temporary Lower Limb Immobilisation using TRIP(Cast) Score (order code WZZ 2269)

thromboprophylaxis in the hospital setting5 intermittent pneumatic compression devices...

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