VTE Prophylaxis for General Medical Patients All Ages - Reducing the Risk of Venous Thromboembolism

Publication: 01/08/2010  --
Last review: 15/02/2019  
Next review: 14/02/2022  
Clinical Guideline
CURRENT 
ID: 2030 
Approved By: Thrombosis Steering Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

VTE Prophylaxis for General Medical Patients All Ages

 

Background

NICE clinical guideline 92; Venous thromboembolism: reducing the risk was issued in January 2010.  NICE clinical guideline NG89 Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism was issued in March 2018

Risk Assessment

Leeds Teaching Hospitals risk assessment tool on PPM+ used …Yes  

Treatment/Management

All patients should be risk assessed for VTE and bleeding risk on admission or by the time of first consultant review. This should be repeated at consultant review and whenever the clinical situation changes.
If a patient requires thromboprophylaxis tinzaparin is the low molecular weight heparin (LMWH) of choice and should be started within 14 hours of admission.
Usual dose 4500 units s/c once a day.
Patients < 50kg or > 100kg see table below. This is based on the recommendation of 50units/kg but adapted so that part syringes are not used.
Ensure weight is recorded on the patient’s electronic record.

Weight Band/kg

Dose of tinzaparin in units

Pre-filled Syringes to Use

< 50

2500

1 x 2500*

 

50 - 99

4500**

1 x 4500

 

100 - 109

5000

2 x 2500

 

110 - 129

6000

1 x 2500

1 x 3500

130 - 149

7000

2 x 3500

150 - 169

8000

1 x 3500

1 x 4500

170 - 189

9000

2 x 4500

190 - 199

50 units/kg, rounded up to the nearest 1000 units

Give dose from 20 000 units/ml syringes (10,000, 12,000, 14,000, 16,000 or 18,000 unit syringes)

       > 200

50 units/kg, rounded up to the nearest 1000 units
and seek haematology advice

Give dose from 20 000 units/ml syringes (10,000, 12,000, 14,000, 16,000 or 18,000 unit syringes)

*   The lowest strength tinzaparin syringe is 2500 units so this is the smallest dose available.
**Patients with creatinine clearance 20-30mls/minute at the lower end of the weight range consider using 3500 units daily

Patients with creatinine clearance < 20mls/minute use enoxaparin 20mg sc once a day. See advice below for patients at extremes of weight but with creatinine clearance < 20ml/minute

Weight band

Dose of enoxaparin

< 40 kg

20 mg daily with caution - consider Factor Xa levels

40 - 100 kg

20 mg daily

101- 150 kg

40 mg daily

> 150 kg

60 mg daily

NICE states “to offer pharmacological VTE prophylaxis for a minimum of 7 days to acutely ill medical patients whose risk of VTE outweighs their risk of bleeding.” Patients should be assessed at discharge and those with a high risk of VTE and on-going risk factors can be considered for extended prophylaxis as per NICE but it was not felt by the CSU or TSG to be required for all patients.

All heparins are porcine based. If patients do not want a porcine based product consider fondaparinux 2.5mg s/c once a day reduced to 1.5mg s/c once a day if CrCl 20-50ml/min) Contra-indicated if CrCl < 20ml/min
  
Falls risk: If the patient is at risk of falls consider their risk and VTE risk and document decision regarding prophylaxis. Ensure this is regularly reviewed at consultant review and documented.

Patients on anti-platelets: Review bleeding risk and VTE risk. Patients with an increased VTE risk but low bleeding risk should be offered thromboprophylaxis. Patients with an increased VTE risk but high bleeding risk should be reviewed by a senior doctor and should have regular review. They could be considered for mechanical prophylaxis as per NICE 2018

Patients on warfarin with subtherapeutic INR, consider prophylactic or treatment dose LMWH depending on reason for anticoagulation. Recent DVT/PE/stroke or known metal valve use treatment dose LMWH. Ensure the INR is monitored regularly and stop LMWH once INR in range.

Patients on DOACs (direct oral antcioagulants), apixaban, dabigatran, edoxaban, rivaroxaban, should not receive pharmacological prophylaxis unless they are not able to take their oral anticoagulant.

Patient Information
All patients should be given verbal and written information on admission of their risk of VTE, what will happen, side effects and how they can reduce the risk. On discharge they should be given verbal and written information on signs and symptoms of VTE and what to do should they occur and how to use their thromboprophylaxis if required on discharge. Leaflet LN004075 contains this information and is available to order from the print unit

Information for Discharge
Notify the patient's GP if they have been discharged with pharmacological and/or mechanical VTE prophylaxis to be used at home.
Patients who are being discharged to medically optimised wards should have their VTE prophylaxis reviewed prior to discharge and the decision documented

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Provenance

Record: 2030
Objective:

Aims
Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital to a medical admissions ward (including elderly admissions).

Objectives
To provide evidence-based recommendations for appropriate venous thromboembolism (VTE) risk assessment and management of patients admitted to hospital 

Clinical condition:

VTE thromboprophylaxis for patients admitted to a medical admissions ward.

Target patient group: Medical patients incl elderly
Target professional group(s): Secondary Care Doctors
Pharmacists
Secondary Care Nurses
Adapted from:

Evidence base

NICE clinical guideline CG92 (full guidelines and quick reference) - Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital.

NICE clinical guideline NG89 (full guidelines and quick reference) Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism 

Approved By

Thrombosis Steering Group

Document history

LHP version 1.0

Related information

Not supplied

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