Thromboprophylaxis in the Hospital Setting

1 Guideline 1 of 58 Uncontrolled if printed 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 Glossary/Definitions .. 3 Introduction .. 4 Purpose .. 4 Scope .. 4 Role and Responsibilities .. 5 Risk Assessment .. 5 Individual 5 Re-assessment .. 7 Patient Information .. 8 Patient information on admission .. 8 Patient information on discharge.

2 8 2. Methods of VTE Prophylaxis .. 9 general Recommendations to Reduce the Risk of VTE .. 9 Mechanical VTE Prophylaxis .. 9 Anti-embolism stockings (AES) .. 10 Intermittent pneumatic compression (IPC) devices .. 11 Inferior vena cava (IVC) filters .. 11 Pharmacological Prophylaxis - Dalteparin .. 12 Special treatment groups .. 12 Cautions and contraindications .. 12 Adverse effects .. 12 Monitoring .. 13 FBC monitoring for patients at risk of HITT .. 13 Pharmacological Prophylaxis Rivaroxaban .. 13 Special Clinical Situations.

3 14 Renal impairment including dialysis and anticoagulant dosing .. 14 Spinals, epidurals and deep peripheral nerve blocks .. 14 Patients taking antiplatelet agents or anticoagulants on admission or needing them for treatment .. 14 3. Thromboprophylaxis in Surgical Patients .. 15 Specific Advice Peri-operative Period .. 15 Timing of dalteparin in peri-operative period .. 15 Progesterone only preparations (POP) .. 16 Combined oral contraceptives (COC) .. 16 Hormone replacement therapy (HRT) .. 16 Antiplatelet therapy.

4 17 4. Patients Admitted to Critical Care .. 17 5. Specialist Surgery .. 17 Day Case Surgery .. 17 Bariatric and Other Surgery in Patients at Extremes of Body Weight .. 17 Ophthalmic Surgery .. 18 Oral and Maxillofacial Surgery .. 18 ENT Surgery .. 18 Breast Surgery .. 18 Major Cancer Surgery in the Abdomen or Pelvis .. 19 Vascular Surgery .. 19 Varicose Vein Surgery .. 19 Cranial Injury and/or Surgery .. 20 Spinal Injury and/or 20 Spinal Cord Injury Patients .. 21 Acute spinal cord injury patients (within 3 months post injury).

5 21 Guideline 2 of 58 Uncontrolled if printed New spinal cord injury patients (post 3 months after injury, patients undergoing rehabilitation) .. 22 Re-admission of chronic spinal cord injury patients .. 22 Day case surgery in spinal cord injury patients .. 22 Urology Surgery .. 23 Upper Limb Surgery .. 23 Fragility Fractures of the Pelvis, Hip and Proximal Femur .. 24 Elective Hip Arthroplasty Surgery .. 24 Elective Knee Arthroplasty 24 Non-arthroplasty Orthopaedic Knee Surgery - includes Knee Arthroscopy.

6 25 Lower Limb Amputation .. 25 Lower Limb Immobilisation/Casts .. 25 Foot and Ankle Orthopaedic Surgery .. 25 6. Duration of Thromboprophylaxis and Discharge .. 26 7. Thromboprophylaxis in Medical Patients .. 29 general Medical 29 Acute Stroke .. 29 Acute Coronary Syndromes (ACS) .. 30 Palliative Care .. 30 8. Patients being Nursed in Paediatric Areas of BHT, including: Ward 3, PDU, St Francis, Theatres and Ward 7 (WH) .. 30 Patient and Family Education .. 31 general Measures to Prevent VTE .. 31 Pharmacological Thromboprophylaxis Dosing in Paediatric Patients.

7 31 Mechanical Thromboprophylaxis .. 31 Special Considerations of this Patient Group .. 31 Paediatric surgical patients .. 31 Paediatric oncology patients .. 31 Paediatric palliative care patients .. 31 Paediatric patients with a spinal cord injury (SCI) .. 32 9. Community .. 33 References and Further Reading .. 34 Appendix 1: VTE Risk Assessment for Medical and Surgical Patients .. 37 Appendix 2: Patient Information Leaflet - Blood Clots (Reducing the Risks) .. 38 Appendix 3: VTE Prevention Exercises .. 39 Appendix 4: Patient Information Leaflet - How to Inject Dalteparin at 40 Appendix 5: Antiembolism Stockings (AES) Flowchart.

8 41 Appendix 6: Mechanical Thromboprophylaxis Care Record Sheet .. 42 Appendix 7: Intermittent Pneumatic Compression Devices (IPC) Flowchart .. 44 Appendix 8: VTE Prevention Flowchart in Surgical Inpatients .. 45 Appendix 9: VTE Prophylaxis in Trauma and Orthopaedic Spinal Patients Requiring Conservative or Surgical Management .. 46 Appendix 10: VTE Prevention Flowchart in Medical Inpatients .. 47 Appendix 11: VTE Prevention in Patients with Acute Stroke .. 48 Appendix 12: VTE Cohort Protocol for Day Case Surgery Only.

9 49 Appendix 13: VTE Risk Assessment for Patients Being Nursed within Paediatric Areas .. 50 Appendix 14: VTE Risk Assessment for Day Case Surgery Patients Aged 16 and Above .. 51 Appendix 15: VTE Prevention Flowchart in Spinal Cord Injury 53 Appendix 16: How to Administer Dalteparin to Minimise Bruising .. 54 Appendix 17: VTE Risk Assessment for Ambulatory Patients aged 16 with Temporary Lower Limb Immobilisation using TRIP(Cast) Score .. 55 Appendix 18: VTE Community Care Plan .. 57 Guideline 3 of 58 Uncontrolled if printed List of Tables Table No Title Page No 1 VTE risk assessment: Admission related risk factors for VTE 6 2 Risk assessment.

10 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 27 9 Extended Thromboprophylaxis for orthopaedic surgery 27 10 Examples of major cancer surgery requiring extended Thromboprophylaxis for 28 days post-op 28 11 Examples of complex non-cancer surgical patients requiring extended Thromboprophylaxis for 14 to 28 days post-op 28 12 Dalteparin dosing in Paediatrics 31 A VTE protocol for urology surgery 23 B Extended Thromboprophylaxis for urology surgery 28 1.