Guideline for the Prevention of Venous Thromboembolism ...

1 Medication Services Queensland Guideline for the Prevention of Venous Thromboembolism (VTE) in Adult Hospitalised Patients December 2018 2 Guideline for the Prevention of Venous T hromboembolism (VT E) in adult hospitalised patients. Published by the State of Queensland (Queensland Health), December 2018 This document is licensed under a Creative Commons Attribution Australia licence. To view a copy of this licence, visit State of Queensland (Queensland Health) 2018 You are free to copy, communicate and adapt the work, as long as yo u attribute the State of Queensland (Queensland Health). For more information co ntact: Medication Safety Medication Services Queensland, Department of Health, GPO Box 48, Brisbane QLD 4001, email Medicatio , p ho ne (07) 3708 5306.

2 An electronic version of this document is available at Disc la imer: The content presented in this publication is distributed by the Queensland Government as an information source only. The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publicatio n. The State of Queensland disclaims all responsibility and all liability (including witho ut limitation for liability in negligence) for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reaso n reliance was placed o n such information.

3 3 Contents Co nte nts .. 3 5 Int ro duc tio n .. 6 Purpo se .. 6 Scope .. 6 Related documents .. 7 Key definitions and abbreviations .. 8 Guideline 10 General recommendations for VTE preventio n in all stages of care .. 11 1. Steps invo lved in VTE Prevention .. 11 Assess all patients to identify need for VTE risk assessment .. 11 Conduct advance-planning for planned hospitalisation patients .. 12 Undertake VTE risk 12 VTE risk assessment .. 12 VTE risk factors .. 13 Patients on therapeutic anticoagulation .. 14 Specific patient groups at increased VTE 14 Assess contraindications to prophylaxis .. 14 Contraindications to mechanical VTE prophylaxis .. 15 Contraindications to pharmacological VTE prophylaxis.

4 15 Special co nsiderations with pharmacological VTE prophylaxis .. 16 Conduct baseline tests for heparin-based VTE prophylaxis .. 16 Renal functio n estimation .. 17 Develop VTE Prevention Plan and initiate VTE prophylaxis .. 17 Pharmacological Prophylaxis .. 18 Options for pharmacological VTE prophylaxis .. 18 Standard dosing and timing .. 19 Neuraxial puncture or catheter insertion and removal .. 20 Surgical patients on therapeutic 21 Dose adjustment for prophylaxis in specific patients .. 22 Mechanical prophylaxis .. 23 Types of mechanical prophylaxis .. 23 Timing of imitation and duration of mechanical prophylaxis .. 24 Factors to consider on initiation of mechanical 24 Inferior Vena Cava (IVC) filters.

5 24 Monitor, reassess and update VTE preventio n plan .. 25 General VTE prophylaxis monitoring .. 25 Pharmacological VTE prophylaxis 25 Mechanical VTE prophylaxis monitoring .. 26 Reassess for risks of VTE and bleeding .. 26 Update VTE preventio n 26 Write discharge plan and ensure transfer of care .. 27 2 VTE prophylaxis Guideline for individual patient cohorts .. 28 Medical and Mental Health Patients .. 28 Acute Stro 29 4 Critically ill patients .. 30 Medical cancer inpatients .. 31 Acutely ill medical 32 Mental health patients .. 33 Surgical and orthopaedic patients .. 34 General and abdominal-pelvic 35 Major abdominal-pelvic surgery for cancer.

6 36 Total hip arthroplasty and Total knee arthroplasty .. 37 Fragility fractures of the pelvis, hip and pro ximal 38 Ambulatory patients with isolated lower limb immobilisation .. 39 Other orthopaedic procedures .. 40 Major trauma .. 41 Craniotomy .. 42 Cardiac surgery .. 43 Vascular surgery .. 44 Thoracic surgery .. 45 Elective spinal surgery .. 46 Bariatric surgery .. 47 Appendices .. 48 Appendix 1: Patient and/or carer engagement .. 48 Patient-centred care and shared decision 48 General VTE information and education .. 48 Ensure appropriate documentatio n .. 48 Appendix 2: Advance-planning for planned hospitalisation patients .. 49 Patients on estrogen-co ntai ni ng medica tio n.

7 49 Patients on other medicatio ns that increase the risk of VTE .. 49 Anaesthesia and VTE risk .. 49 Patients already receiving 49 Patients on regular antiplatelet agents .. 50 Appendix 3: Padua VTE Risk Assessment 51 Appendix 4: Caprini VTE Risk Assessment 52 References .. 54 57 Business Area Contact .. 57 Approval and Implementation .. 57 5 Tables Table 1: Risk assessment models used by the statewide VTE Risk Assessment Tool .. 13 Table 2: Pharmacological VTE prophylaxis 18 Table 3: LAM restrictions relating to pharmacological VTE prophylaxis 18 Table 4: Standard prophylactic doses in medical 19 Table 5: Standard prophylactic doses and timing of prophylaxis in surgical patients.

8 19 Table 6: Standard prophylactic doses and timing of DOAC for THR/TKR surgery .. 20 Table 7: Timing of anticoagulants and neuraxial puncture or catheter insertio n/removal .. 21 Table 8: Heparin-based VTE prophylaxis dose adjustments for patients with renal impairment .. 22 Table 9: DOAC VTE prophylaxis dose adjustments for THR/TKR patients with renal impairment .. 22 Table 10: Recommendations for dose adjustment of LMWH in patients that are obese .. 23 Table 11: VTE prophylaxis in acute stroke medical patients .. 29 Table 12: VTE prophylaxis in critically ill medical patients .. 30 Table 13: VTE prophylaxis in medical cancer inpatients .. 31 Table 14: VTE prophylaxis in acutely ill medical patients.

9 32 Table 15: VTE prophylaxis in mental health patients .. 33 Table 16: VTE prophylaxis in general and abdominal-pelvic surgery (non-cancer) patients . 35 Table 17: VTE prophylaxis in major abdominal-pelvic surgery for cancer 36 Table 18: VTE prophylaxis in total hip arthroplasty and total knee arthroplasty .. 37 Table 19: VTE prophylaxis in fragility fractures of the pelvis, hip and pro ximal femur .. 38 Table 20: VTE prophylaxis in ambulatory patients with isolated lower limb immobilisation .. 39 Table 21: VTE prophylaxis in other orthopaedic procedures .. 40 Table 22: VTE prophylaxis in major trauma surgical 41 Table 23: VTE prophylaxis in craniotomy .. 42 Table 24: VTE prophylaxis in cardiac 43 Table 25: VTE prophylaxis in vascular surgery.

10 44 Table 26: VTE prophylaxis in thoracic 45 Table 27: VTE prophylaxis in elective spinal surgery .. 46 Table 28: VTE prophylaxis in bariatric surgery .. 47 6 Introduction Veno us Thromboembolism (VTE), a disease which encompasses deep vein thrombosis (DVT) and pulmo nary embolism (PE) is a major health-care problem, resulting in significant mortality and morbidity, and expenditure in healthcare reso urces. PE re mai ns o ne o f the leading causes of preventable in-hospital deaths.(1) The Prevention of VTE, or VTE prophylaxis, is an important patient safety strategy in hospital settings where patients are at risk of developing VTE.(2) Purpose This Guideline provides recommendations regarding best practice for the Prevention of VTE in adults admitted to Queensland Health facilities and those discharged from the emergency departments of Queensland public hospitals.