vte prophylaxis prescribing guideline summary · vte prophylaxis prescribing - guideline summary...

Anticoagulation Related Bleeding - Guideline Summary

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VTE PROPHYLAXIS PRESCRIBING - GUIDELINE SUMMARY Click here for the full RCHT Thrombosis Prevention and Anticoagulation Policy

Click on the appropriate link below:

o RISK ASSESSMENT FOR ALL PATIENTS ADMITTED TO HOSPITAL

o GIVING INFORMATION AND PLANNING FOR DISCHARGE

o GUIDANCE FOR MECHANICAL PROPHYLAXIS (STOCKINGS)

Prophylaxis Recommendations by specialty (select option)

o ACUTE CORONARY SYNDROME

o ACUTE STROKE

o CANCER AND PALLIATIVE CARE

o CRITICAL CARE PATIENTS o ORTHOPAEDIC SURGICAL PATIENTS

o NON-BARIATRIC ABDOMINAL SURGERY

o BARIATRIC ABDOMINAL SURGERY

o ORAL / MAXILLO-FACIAL AND ENT SURGERY

o VASCULAR SURGERY PATIENTS

o PREGNANT WOMEN INCLUDING BIRTH, MISCARRIAGE OR TERMINATION OF PREGNANCY IN THE PAST 6 WEEKS

o FURTHER SUPPORTING INFORMATION FOR PROPHYLAXIS MANAGEMENT

http://doclibrary-rcht-intranet.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/AnticoagulationAndThrombosis/ThrombosisPreventionAndAnticoagulationPolicy.pdf

VTE prophylaxis prescribing - Guideline Summary Nov 19

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RISK ASSESSING PATIENTS >16 YEARS ADMITTED TO HOSPITAL

CLICK HERE TO RETURN TO OPTIONS FOR SPECIFIC PROPHYLAXIS ACTIONS FOR INDIVIDUAL PATIENT GROUPS

Review and re-assess patient whenever their clinical condition changes

If using pharmacological prophylaxis start it as soon as possible and within 14 hours

of admission

Balance the risk of VTE against the risk of bleeding when deciding whether to offer pharmacological prophylaxis to patients

Use VTE risk assessment tool within EPMA

Assessment should be completed as soon as possible after admission or by time of

initial consultant review

Assess all patients to identify the risk of Venous Thrombo-Embolism and bleeding


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GIVING INFORMATION AND PLANNING FOR DISCHARGE

At discharge provide patients at risk (or their carers) appropriate verbal and written information on re:

- Signs and symptoms of VTE and how to seek help if VTE is suspected

- Reducing risk of VTE by keeping mobile and hydrated

Be aware Heparins are of animal origin - advise patients and if necessary discuss alternatives

Before prescribing prophylaxis provide patients at risk (or their carers) appropriate verbal and written

information before providing prophylaxis on:

- risks and consequences of VTE

- importance of prophylaxis and side effects

- Correct use of prophylaxis (ie AE stockings)

- how patients can reduce their risk of VTE

On admission ensure people understand the reason for having a risk assessment for VTE and

bleeding


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GUIDANCE FOR MECHANICAL PROPHYLAXIS (STOCKINGS)

DO NOT offer Anti-embolism stockings to patients with known contra-indications (ie peripheral vascular disease / neuropathy / stroke / severe leg oedema / major limb deformity / allergy to stocking material)

Patients who require Anti-Embolism stockings should have their legs measured and be provided with the correct size

Stockings should be fitted and patients shown how to use then by staff trained in their use

Post-operative patients and patients with oedema should have their legs regularly re-measured and stockings re-fitted as required

If arterial disease is suspected seek expert opinion before fitting stockings

Patients should be encouraged to wear stockings day and night until they no longer have reduced mobility

Stockings should be removed at least daily for skin inspection and hygiene reasons or more frequently where there is recorded sensory loss or poor skin integrity

STOP using the stockings if patients experience marking, blistering or discolouration of the skin – if needed offer intermittent pneumatic compression as an alternative

In cases where patients are declining stockings they should be counselled as to their risks of developing VTE. If patients continue to decline then the prescription for stockings should be discontinued and the patients choice recorded in the notes and/or on EPMA

Prescriptions for stockings should be discontinued once the patient has regained their normal level of mobility. Continuing the use of stocking post-discharge is generally not recommended and should only occur at request of consultant in charge of the patient’s care


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ACUTE CORONARY SYNDOMES

ACUTE STROKE PATIENTS

People receiving anticoagulant drugs as part of their treatment for an acute coronary syndrome do not usually need additional VTE prophylaxis -

Review current ACS treatment first

When using intermittent pneumatic compression for people who are admitted with acute stroke,

provide it for 30 days or until the person is mobile or discharged, whichever is sooner

Explain to the person with acute stroke that IPC:

- reduces risk of DVT & may increase chances of survival

- will not help them recover from stroke, & there may be an increased risk of surviving with severe disability.

Provide Intermittent pneumatic compression as VTE prophylaxis. Start within 3 days of stroke

DO NOT offer Anti-embolism stockings to patients with acute stroke


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CANCER AND PALLIATIVE CARE

VTE prophylaxis should be reviewed regularly particularly for palliative care patients

VTE Prophylaxis should be with either:

- Dalteparin 5000units once daily (eGFR >30)

- Enoxparin 20mg once daily (eGFR <30)

DO NOT offer cancer patients prophylaxis in the last days of life

Cancer patients receiving palliative care as an inpatient should be offered prophylaxis taking

into account temporary increased risks, life expectancy and views of the patient and their

family or carers

ALL Cancer patients receiving inpatient care should be offered prophylaxis.

Cancer patients receiving cancer-modifying treatments as outpatients should not be offered

routine prophylaxis if they are mobile


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PATIENTS ADMITTED TO CRITICAL CARE

If using mechanical prophylaxis start on admission to critical care and continue until the patient no longer

has reduced mobility

Consider mechanical prophylaxis for all patients who are contra-indicated to pharmacological prophylaxis

Pharmacological Prophylaxis should be provded to all patients if not contra-indicated using either:



ALL patients admitted to critical care should be assessed daily for their risks of VTE and bleeding or

more frequently if patients condition changes rapidly


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ORTHOPAEDIC SURGERY PATIENTS


o LOWER LIMB IMMOBILISATION

o FRAGILITY FRACTURES OF THE PELVIS, HIP AND PROXIMAL FEMUR

o ELECTIVE HIP REPLACEMENT o ELECTIVE KNEE REPLACEMENT o NON-ARTHROPLASTY ORTHOPAEDIC SURGERY o FOOT AND ANKLE ORTHOPAEDIC SURGERY o UPPER LIMB ORTHOPAEDIC SURGERY


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LOWER LIMB IMMOBILISATION

FRAGILITY FRACTURES OF THE PELVIS, HIP AND FEMUR

Offer pharmacological VTE prophylaxis to all patients assessed as high risk (score ≥3) using either:


- Enoxaparin 20mg once daily (eGFR <30)

Consider stopping prophylaxis if lower limb immobilisation continues beyond 42 days

Assess all patients using RCHT approved VTE risk assessment tool for patients with lower leg

immobilisation (CHA3592)

Consider intermittent pneumatic compression if pharmacological prophylaxis is contraindicated. Continue

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

Consider pre-operative prophylaxis if surgery is delayed beyond the day of admission

Offer VTE prophylaxis for one month to all patients with fragility fractures if risk of VTE is greater than risk

of bleeding using either:




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ELECTIVE HIP REPLACEMENT

Consider Anti-embolism stockings until discharge for patients who are contra-indicated to

pharmacological prophylaxis

If using LMWH this should either be:



Offer VTE prophylaxis to all patients undergoing elective hip replacement if risk of VTE is greater than risk of bleeding. Choose any one of either:

- LMWH for 10 days followed by aspirin 75mg for 28 days

- LMWH for 28 days combined with Anti-Embolism stockings until discharge

- Rivaroxaban 10mg once daily for 35 days

Prophylaxis should start 6-12hrs post surgery


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ELECTIVE KNEE REPLACEMENT

Consider Anti-embolism stockings until discharge for patients who are contra-indicated to

pharmacological prophylaxis




Offer VTE prophylaxis to all patients undergoing elective Knee replacement if risk of VTE is

greater than risk of bleeding. Choose any one of

- Aspirin 75mg for 14 days

- LMWH for 14 days combined with Anti-Embolism stockings until discharge

- Rivaroxaban 10mg once daily for 14 days

Prophylaxis should start 6-12 hrs post surgery


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NON-ARTHROPLASTY ELECTIVE KNEE SURGERY




Consider VTE prophylaxis in the following cases:

- Knee arthroplasty with anaesthesia >90 mins

- Where VTE risk outweighs risk of bleeding

- Non-arthroscopic knee surgery (ie osteotomy or fracture surgery)

Start LMWH prophylaxis 6-12 hours post surgery

VTE prophylaxis is generally not needed for patients undergoing arthroscopic knee surgery if

- Total anaesthesia time is <90 mins

- the person is low risk for VTE


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FOOT AND ANKLE SURGERY

Consider stopping if immobilisation continues beyond 42 days




Consider LMWH VTE prophylaxis for patients undergoing foot and ankle surgery :

- That requires immobilisation (ie arthrodesis)

- Where anaesthesia time is >90 mins




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UPPER LIMB ORTHOPAEDIC SURGERY




VTE prophylaxis is generally not needed for patients undergoing elective shoulder surgery

but should be offered if:

- Total general anaesthesia time is >90 mins

- Shoulder surgery will make it difficult for patient to mobilise

- Surgery is performed following non-elective (emergency) admission


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NON-BARIATRIC ABDOMINAL SURGERY

Continue LMWH prophylaxis as inpatient then, based on clinical judgement, extend course as follows:

For up to 7 days

- where risk of VTE outweighs risk of bleeding

- in all patients with inflammatory bowel disease

For up to 28 days

- for all major abdominal cancer surgery

in addition to LMWH start mechanical prophylaxis on admission with either anti-embolism stockings or

intermittent pneumatic compression and continue until discharge

LMWH Prophylaxis should be with either:



ALL patients admitted for abdominal surgery (GI, gynaecological, urological) should be offered

pharmacological prophylaxis if not contra-indicated


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BARIATRIC ABDOMINAL SURGERY

Continue VTE prophylaxis (both LMWH and Anti-Embolism Stockings) for a minimum of 7 days

including beyond discharge:

in addition to LMWH start mechanical prophylaxis on admission with either anti-embolism stockings or

intermittent pneumatic compression and continue until discharge

LMWH Prophylaxis should be with either:



ALL patients admitted for bariatric abdominal surgery should be offered pharmacological

prophylaxis if not contra-indicated


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ORAL / MAXILLOFACIAL AND ENT SURGERY

Consider Anti-embolism stockings until discharge for patients who are high risk of VTE but also have high risk of bleeding or who are contra-

indicated to pharmacological prophylaxis




Consider LMWH VTE prophylaxis for ALL inpatients undergoing oral / maxillo-facial or ENT

surgery if their VTE risk outweighs risk of bleeding



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VASCULAR SURGERY PATIENTS


o OPEN VASCULAR SURGERY OR ENDOVASCULAR ANEURYSM REPAIR

o LOWER LIMB AMPUTATION

o VARICOSE VEIN SURGERY


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OPEN VASCULAR SURGERY OR ANEURYSM REPAIR

Consider Anti-embolism stockings until discharge for patients who are high risk of VTE but who

also have high risk of bleeding or who are contra-indicated to pharmacological prophylaxis




Consider LMWH VTE prophylaxis for ALL inpatients undergoing open vascular surgery or

major vascular surgery procedures



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LOWER LIMB AMPUTATION

Continue mechanical VTE prophylaxis until the person no longer has significantly reduced

mobility relative to their anticipated mobility

Consider mechanical prophylaxis with intermittent pneumatic compression on the

contra-lateral leg from admission for patients who are high risk of VTE but who are contra-

indicated to pharmacological prophylaxis




Consider LMWH VTE prophylaxis for ALL inpatients undergoing lower limb amputation

whose risk of VTE outweighs the risk of bleeding



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VARICOSE VEIN SURGERY

Consider mechanical prophylaxis with anti-embolism stockings from admission for patients

who are high risk of VTE but who are contra-indicated to pharmacological prophylaxis




Consider VTE prophylaxis in the following cases:

- total anaesthesia time >90 mins



VTE prophylaxis is generally not needed for patients undergoing varicose vein surgery if:

- total anaesthesia time is <90 mins

- the person is low risk for VTE


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PREGNANT WOMEN, BIRTH, MISCARRIAGE OR TOP

Add mechanical prophylaxis for women who are likely to be immobilised or have significantly

reduced mobility for 3 or more days after their clinical event including caesarian section

DO NOT offer VTE prophylaxis to women in active labour and discontinue any previous prescription for LMWH when labour starts




Start within 14 hours of admission in pregnancy or 4-8 hours after birth, miscarriage or TOP

Consider LMWH VTE prophylaxis for ALL women admitted to hospital who are pregnant, have

given birth or had a miscarriage or TOP in past 6 weeks whose risk of VTE outweighs bleed risk


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FURTHER SUPPORTING INFORMATION:

People using Anti-platelet agents

Patients already taking oral anticoauglation

General Care: Early mobilisation and Hydration

Extended Prophylaxis

Encourage people to mobilise as soon as possible

Do not allow people to become dehydrated unless clinically indicated.

Consider VTE prophylaxis for people who are having antiplatelet agents for other conditions and whose risk of VTE outweighs their risk of bleeding. Take into account the risk of bleeding and of comorbidities such as arterial thrombosis.

If the risk of VTE outweighs the risk of bleeding, consider pharmacological VTE prophylaxis with LMWH based on their condition or procedure.

If the risk of bleeding outweighs the risk of VTE, consider mechanical VTE prophylaxis.

Consider VTE prophylaxis for people at increased risk of VTE who are interrupting their usual oral anticoagulant therapy. If patients are taking Warfarin provide LMWH prophylaxis whenever INR is below therapeutic levels (ie INR <2.0)

Be aware that in some clinical cases there is an indication to continue Prophylaxis beyond discharge. For a full list of indications please see Appendix 9 of the Trust VTE prevention policy at: RCHTThrombosisPreventionAndAnticoagulationPolicy.pdf

http://doclibrary-rcht-intranet.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/AnticoagulationAndThrombosis/ThrombosisPreventionAndAnticoagulationPolicy.pdf