Prophylaxis for Venous Thromboembolism (VTE) in Adult Non-Pregnant Patients

CLINICAL GUIDELINE CG10193-2 Prophylaxis for Venous Thromboembolism (VTE) in Adult Non-Pregnant Patients. For use in (clinical areas): All clinical...
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CLINICAL GUIDELINE

CG10193-2

Prophylaxis for Venous Thromboembolism (VTE) in Adult Non-Pregnant Patients. For use in (clinical areas):

All clinical areas

For use by (staff groups):

All staff

For use for (patients):

Adult non-pregnant patients

Document owner:

Dr Levy

Status:

Approved

Purpose of the Guideline The purpose of this guideline is to ensure that the hospital is compliant with “Venous thromboembolism: reducing the risk”( NICE clinical guideline 92). Contents Reducing the risk of VTE in patients admitted as an Emergency Admission Reducing the risk of VTE in patients aadmitted with a Stroke Reducing the risk of VTE in patients admitted for Elective Surgery VTE prophylaxis in the Pregnant Patient The Oral Contraception Pill and VTE prophylaxis Reducing the risk of VTE in patients admitted for Day Surgery Hospital Discharge Arrangements Indications and Contra-Indications of Mechanical VTE prophylaxis Indications and Contra-Indications of Pharmacological VTE prophylaxis Indications for Temporary Inferior Vena Cava Filter

page 1 page 2 page 2 page 3 page 3 page 3 page 4 page 6 page 7 page 9

Appendix 1. The WSH Mandatory VTE assessment form Appendix 2. Prophylactic Tinzaparin Dose Chart Appendix 3 Monitoring of low molecular weight heparin (LMWH) Tinzaparin

page 10 page 11 page 12

Recommendations and procedures Reducing the risk of venous thromboembolism in patients admitted as an Emergency Admission. As well as instigating the general advice for reducing the risk of VTE (see Box 1), all patients admitted should be assessed using the Trust's assessment sheet (appendix 1) at the time of admission for risk factors for developing VTE (see box 2). In view of the nature of acute hospital admissions, it is highly likely that the patient will have at least one of the risk factors for VTE such as: • • •

acute surgical admission with inflammatory or intra-abdominal condition expected significant reduction in mobility dehydration

Source: Status: Approved

Issue date: 3rd Feb 2012 Valid until: 3rd Feb 2014

Page 1 of 13

West Suffolk Hospitals NHS Trust

• •

CG10193-2 Trust Guidelines Template

Obesity (body mass index [BMI] over 30 kg/m2) One or more significant medical co-morbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions)

If the patient does have 1 or more risk factor for VTE, appropriate mechanical and pharmacological VTE prophylaxis should be offered provided there are no contraindications as stated in Boxes 3,4,5. A patient information leaflet should be handed to either the patient or the relative. This should be documented in the notes . There are 3 main methods of VTE prophylaxis. These are 1. Mechanical VTE prophylaxis 2. Pharmacological VTE prophylaxis 3. Temporary Inferior Vena Cava Filter A reassessment should be made and documented 24 hours after admission, and, if and when there is a clinical change in the patient’s risk factors. Reducing the risk of venous thromboembolism in patients admitted with a stroke Patients admitted with a stroke need to be managed differently and the VTE assessment and prophylaxis is summarised below. • Do not offer anti-embolism stockings to patients who are admitted for stroke for the first 14 days except under stroke consultant direction. • Do not offer chemical VTE prophylaxis to patients who are admitted for stroke for the first 14days except under stroke consultant direction • Re-assess at day 14 as patient is now able to have usual AES and chemical prophylaxis provided no contra-indications. Reducing the risk of venous thromboembolism in patients admitted for Elective Surgery/procedures In pre-operative assessment the patient should be risk assessed using the Trust’s mandatory VTE risk assessment form (appendix 1) and a management plan defined, having first ensured there are no contra-indications to that plan. The plan should be discussed with each patient and they should be given the patient information leaflet on reducing the risk of venous thromboembolism. This needs to be documented in the preassessment proforma. Further advice if needed is available from the haematology department. The following cohorts of patients are deemed to be at low risk of VTE and have been agreed by the SHA medical director not to require VTE risk assessment: •

Patients undergoing procedures under local anaesthesia



Patients undergoing endoscopies



Patients admitted to oncology day unit



Patients admitted to medical day treatment centre



Other cohorts as agreed by Medical Director

Source: Status: Approved

Issue date: 3rd Feb 2012 Valid until: 3rd Feb 2014

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West Suffolk Hospitals NHS Trust

CG10193-2 Trust Guidelines Template

For all patients the general advice for reducing the risk of VTE should be implemented (see box 1). The risk factors to enable accurate risk assessment are found in Box 2. Patients should be considered for both mechanical and chemical prophylaxis if there is one or more risk factor. The contra-indications to anti-embolic stockings (AES) are found in Box 3. The risk factors for bleeding/contra-indications to pharmacological VTE prophylaxis are found in Box 5. A reassessment should be made and documented 24 hours after admission in the risk assessment section of the drug chart, and if there is a clinical change in the patient’s risk factors. VTE prophylaxis in the Pregnant Patient Whenever a pregnant patient is admitted their risk for VTE must be assessed using the ‘Prophylaxis for Venous Thromboembolism (VTE) in Pregnant Patients’ guidelines. This applies to all pregnant patients including VTOPs; ERPCs; and pregnant patients admitted with a non-obstetric complaint. The Oral Contraception Pill and VTE prophylaxis in Elective Surgery Whether or not to stop the oral contraceptive pill (OCP) before major surgery is a controversial issue. The risk of postoperative VTE increases from 0.5% to 1% for pill users versus non-users. This small absolute excess risk in oral contraception users must be balanced against the risks of stopping the pill 4-6 weeks prior to surgery, including unwanted pregnancy, the increased risk of VTE associated with pregnancy (60 per 100,000 cf 30 per100, 000 on the OCP), the effects of surgery and anaesthesia on a pregnancy, and the risks of a subsequent termination. These risks should be communicated to the patient and, unless adequate alternative contraception can be instituted, the patient should remain on her normal oral contraception. Reducing the risk of venous thromboembolism in patients admitted for Day Surgery Patients admitted for day surgery are offered the same standard of care in reducing the risk of venous thromboembolism. Thus VTE risk assessment and prophylaxis must be performed as detailed above. The VTE risk assessment needs to occur at pre-operative assessment and checked on admission to hospital. If indicated mechanical VTE prophylaxis with AES should be commenced on day surgery unit admission. The AES will be prescribed by the operating surgeon. AES should be worn until the patient's mobility is no longer significantly reduced. Intermittent pneumatic compression devices can be used if mechanical prophylaxis is indicated and AES are contra- indicated. If Pharmacological VTE prophylaxis is indicated (box 2), and there are no contraindications (box 5) the operating surgeon should choose between either Tinzaparin or unfractionated heparin (for patients with renal failure). This should generally be given at induction, However if spinal anaesthesia has been used, it should be administered at least two hours after the spinal injection. If the patient is expected to have significantly reduced mobility after discharge, or if the patient has a previous history of VTE continue pharmacological VTE prophylaxis in the community, generally for 5–7 days.

Source: Status: Approved

Issue date: 3rd Feb 2012 Valid until: 3rd Feb 2014

Page 3 of 13

West Suffolk Hospitals NHS Trust

CG10193-2 Trust Guidelines Template

Hospital Discharge Arrangements The discharging nurse will ensure that the patient has a copy of the DVT leaflet (should have been given at Pre-operative assessment if admitted for elective surgery) and remind the patient of following: • The signs and symptoms of deep vein thrombosis and pulmonary embolism • The correct use of VTE prophylaxis at home and the signs and symptoms of adverse events related to VTE prophylaxis (if discharged with prophylaxis) • The importance of seeking help if they have any problems using the prophylaxis or if deep vein thrombosis or pulmonary embolism are suspected. The discharging nurse will document this in the notes. If the patient is discharged with VTE prophylaxis the discharging doctor needs to ensure that the patient’s GP is notified that their patient is at higher risk of VTE and has been discharged on prophylaxis.

Source: Status: Approved

Issue date: 3rd Feb 2012 Valid until: 3rd Feb 2014

Page 4 of 13

West Suffolk Hospitals NHS Trust

Box 1. 1. 2. 3. 4. 5. 6. 7.

8. 9.

General Advice for reducing the risk of venous thromboembolism Do not allow patients to become dehydrated unless clinically indicated. Encourage patients to mobilise as soon as possible. Do not regard aspirin or other anti-platelet agents as adequate prophylaxis for VTE. Consider offering temporary inferior vena caval filters to patients who are at very high risk of VTE (such as patients with a previous VTE event or an active malignancy) and for whom mechanical and pharmacological VTE prophylaxis are contraindicated. Advise patients to consider stopping the oestrogen-containing oral contraceptives or hormone replacement therapy 4 weeks before elective surgery, provided other effective and alternative contraceptive methods are to be utilised. Assess the risks and benefits of stopping pre-existing established anti-platelet therapy 1 week before surgery. 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 patients’ preferences, their suitability for regional anaesthesia and any other planned method of VTE prophylaxis. If regional anaesthesia is used, plan the timing of pharmacological VTE prophylaxis to minimise the risk of epidural haematoma. Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients undergoing a surgical procedure with local anaesthesia by local infiltration with no limitation of mobility

Box 2 • • • • • • • • • • • • • • •

CG10193-2 Trust Guidelines Template

Risk factors for VTE Surgical procedure with a total anaesthetic and surgical time of more than 90 minutes, or 60 minutes if the surgery involves the pelvis or lower limb Acute surgical admission with inflammatory or intra-abdominal condition Expected significant reduction in mobility Active cancer or cancer treatment Age over 60 years Critical care admission Dehydration 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 Use of oestrogen-containing contraceptive therapy Varicose veins with phlebitis Pregnancy or 6/52 post-pregnancy

Source: Status: Approved

Issue date: 3rd Feb 2012 Valid until: 3rd Feb 2014

Page 5 of 13

West Suffolk Hospitals NHS Trust

CG10193-2 Trust Guidelines Template

Mechanical VTE prophylaxis This includes 1. anti-embolism stockings (thigh or knee length) 2. intermittent pneumatic compression devices Anti-Embolic stockings (AES) should be offered, prescribed and fitted to every surgical patient on admission who meets the criteria, provided there are no contra-indications. The evidence regarding the benefit of mechanical VTE prophylaxis in medical patients is extrapolated, so their use is not mandatory. But, their use should be considered in high risk medical patients. Anti-Embolic stockings (AES) should be prescribed by the medical staff. The nursing staff should record their use. If the patient does refuse to wear them, this needs to be documented in the drug chart with a ‘4’, to signify patient refusal. Contra-indications to the use of AES stockings are found in Box 3 Box 3. • • • • • • • • • •

Contra-indications to Anti-Embolic stockings (AES) Acute Stroke Suspected or proven peripheral arterial disease Peripheral arterial bypass grafting Peripheral neuropathy or other causes of sensory impairment any local conditions in which stockings may cause damage, for example fragile ‘tissue paper’ skin, dermatitis, gangrene or recent skin graft Known allergy to material of manufacture Cardiac failure Severe leg oedema or pulmonary oedema from congestive heart failure Unusual leg size or shape Major limb deformity preventing correct fit.

Use caution and clinical judgement when applying anti-embolism stockings over venous ulcers or wounds. Intermittent Pneumatic compression devices should be considered for use in theatre if there are contraindications to AES. Their use in combination with AES may be considered in patients at very high very risk of VTE (> 2 risk factors).Their use should be considered on the wards if a. is intolerant of pharmacological prophylaxis b. is immobile. Contra-indications to the use of these devices are found in Box 4 Box 4. Contraindications to Pneumatic Compression Devices Theses include: • Postoperative vein ligation • Gangrene • Recent skin graft • Severe ischemic vascular disease • Severe lower extremity edema • Extreme leg deformity • Suspected pre-existing DVT • Dermatitis, Source: Status: Approved

Issue date: 3rd Feb 2012 Valid until: 3rd Feb 2014

Page 6 of 13

West Suffolk Hospitals NHS Trust

CG10193-2 Trust Guidelines Template

Pharmacological VTE prophylaxis This includes 1. low molecular weight heparin (LMWH) i.e. Tinzaparin 2. unfractionated heparin (UFH) (for patients with renal failure). 3. oral direct thrombin inhibitors i.e. rivaroxaban for elective knee and hip replacements. These agents should be avoided if there is a significant risk of bleeding. These risk factors are found in Box 5 Box 5 Risk factors for Bleeding • • • • • • • • • •

Acute stroke (less than 2 weeks) Active bleeding Acquired bleeding disorders (such as acute liver failure) Concurrent use of anticoagulants Lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hours Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours Thrombocytopenia (platelets less than 75 x 109/l) Uncontrolled systolic hypertension (230/120 mmHg or higher) Untreated inherited bleeding disorders (such as haemophilia and von Willebrand’s disease) Cancers at risk of bleeding eg oesophageal and rectal

Use of Tinzaparin All patients who have one or more risk factors from Box 1 should be offered Tinzaparin, once a day by subcutaneous injection, for the duration of their admission as long as there are no contraindications as described in Box 5 or severe renal impairment. To achieve consistency and to allow safe epidural practice tinzaparin is routinely offered at 1800 hours In severe renal impairment (estimated glomerular filtration rate

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