Diagnosis
- Assess all patients on admission for increased VTE risk: reduced mobility for > 3 days
- OR reduced mobility and:
- Active cancer or cancer treatment
- Age over 60 years
- Critical care admission
- Dehydration, hence do not allow patients to become dehydrated
- Known thrombophilias
- Obesity (body mass index [BMI] over 30 kg/m2)
- One or more significant medical comorbidities (for example: 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 hormone replacement therapy OR oestrogen-containing contraceptive therapy
- Varicose veins with phlebitis
OR acute surgical admission or total surgery (+ anaesthesia) time> 90 mins
Do not offer VTE prophylaxis if any of the following bleed risks:
- Active bleeding
- Acquired bleeding disorders (such as acute liver failure)
- Concurrent use of anticoagulants known to increase the risk of bleeding (such as warfarin with international normalised ratio [INR] higher than 2)
- Lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hours
- Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours
- Acute stroke
- Thrombocytopenia (platelets less than 75 x 109/l)
- Uncontrolled hypertension (230/120 mmHg or higher)
- Untreated inherited bleeding disorders (such as haemophilia and von Willebrand’s disease)
Investigation
- n/a
Management
Mechanical VTE Prophylaxis
(choice based on clinical condition, patient preference)
- Anti-embolism stocking (TEDS): measured to fit limb, to produce calf pressure of 14-15 mm Hg, and ensure wear day and night till mobility increased
- Do not offer TEDS in Peripheral Artery Disease, previous by-pass grafting, peripheral neuropathy, skin condition, cardiac failure, leg or pulmonary oedema, and discontinue if patient experiences pain or discomfort
- If compression stocking not appropriate offer Foot impulse device OR Intermittent pneumatic compression, and encourage to use as much as possible
Pharmacological Prophylaxis
- Based on local practices and clinical condition (i.e. renal function), noting Anti-platelet therapy not adequate prophylaxis:
- General medical patients: choose any of the following
- LMWH heparin
- Fondapariux
- Unfractionated heparin (if eGFR < 30)
- Commence as soon as possible after risk assessment
Patients with stroke
- Consider LMWH or unfractionated heparin if Haemorrhagic stroke and risk of haemorrhagic transformation of stroke ruled out, and immobility, dehydration or previous VTE
- Do not offer compression stockings
(See CG192)[02-CG192] for more specific details regarding each medical and surgical patient
General medical considerations:
- Do not routinely offer VTE prophylaxis to palliative patients
- Do not routinely offer to cancer patients with oncological treatment who are ambulant
General surgical considerations:
- Stop OCP / HRT 4 wks before surgery
- Risk benefit of stopping anti-platelet 7 days before surgery
- Regional anaesthesia has lower risk of VTE vs GA, though plan timing wrt minimising risk of epidural haematoma
- If local anaesthetic and no reduced immobility, do not routinely offer VTE prophylaxis
- Most surgery: start mechanical prophylaxis at admission and pharmacological treatment with patients with a low risk of bleeding, unless orthopaedic surgery in which case for all patients unless contra-indicated
- Do not offer VTE prophylaxis in acute traumatic or non-traumatic haemorrhage, or ruptured spinal / cranial vascular malformation, until lesion has been secured
Pregnancy and up to 6 wks post partum:
consider LMWH (or unfractionated) in the following:
- Significantly reduced mobility > 3 days / critical care admission
- > 35 yrs
- Obesity
- Dehydration
- Thrombophilia or previous VTE
- Pregnancy related risk factors (hyperemesis, pre-eclampsia etc)
- Co-morbidities