Thromboprophylaxis Guideline for Critically Ill Adult Patients ( excludes patients on planned critical care pathways )
|Publication: 01/08/2010 --|
|Last review: 28/11/2019|
|Next review: 07/11/2022|
|Approved By: Trust Clinical Guidelines Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2019|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Thromboprophylaxis Guideline for Critically Ill Adult Patients
(excludes patients on planned critical care pathways)
Hospital - associated VTE leads to about 40,000 deaths in England per year, 25,000 of which may be preventable through proper risk management and care.
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 and updated in August 2019. (1)
All patients aged 16 years and over admitted to critical care unit require a VTE risk assessment and a review of bleeding risk within 24hours of admission. This assessment should be completed on the online PPM + system (1). If electronic completion is not possible due to IT issues a paper risk assessment form should be completed. If thromboprophylaxis is indicated it should then be prescribed appropriately.
The VTE and bleeding risk for people in critical care units should be reassessed daily or more often if the person’s condition is changing rapidly (1).
Falls risk: If the patient is at risk of falls consider their risk and VTE risk. Document any decisions regarding prophylaxis and fall risk. Ensure this is regularly reviewed by the multidisciplinary team.
This guideline excludes patients on a planned pathway through critical care e.g. elective cardiac surgery, liver transplant, elective gastrointestinal surgery etc. for which there are separate guidelines to follow. See Leeds Health Pathways.
- Low Molecular Weight Heparin (LMWH) should be prescribed to all people admitted to the critical care unit except when pharmacological VTE prophylaxis is contraindicated (1). Always consider the relative risk of thrombosis compared to that for bleeding.
- The dosage of LMWH should be individualised according to actual body weight, renal function, and use of renal replacement therapy e.g. CVVHD. See details below.
- All critically ill patients will be started on mechanical VTE prophylaxis such as intermittent pneumatic compression (IPC) devices e.g. Flowtrons. These should be started at admission unless a contraindication exists to their use. Each patient should be reassessed daily until they no longer have reduced mobility relative to their normal or anticipated mobility (1).
- If there are no contraindications all patients will receive both mechanical and pharmacological thromboprophylaxis.
Contraindications to mechanical VTE prophylaxis devices
- Severe arteriosclerosis or other ischemic vascular diseases.
- Severe congestive cardiac failure or any condition where an increase of fluid to the heart may be detrimental.
- Known or suspected acute DVT, thrombophlebitis or Pulmonary Embolism (PE).
- Any local condition that the device or garment could disturb, including: gangrene, a recent skin graft, dermatitis or untreated, infected leg wounds.
Contraindications to pharmacological thromboprophylaxis
- Coagulopathy INR > 2.0. (or an INR >2.5 for patients with chronic liver disease)
- Platelet count <75 x 109/L. (or platelets <50 x 109/L for patients with chronic liver disease, or liver transplant)
- Active bleeding.
- Ischaemic or haemorrhagic stroke - discuss with neurology/stroke team.
- Traumatic Brain Injury <72hrs - discuss with neurosurgical team.
- Use with caution in patients with a recent (within 3 months) history of GI bleeding.
- Patients already receiving systemic anticoagulation. This may include some modalities of renal replacement therapy but not continuous haemodialysis using citrate anticoagulation.
Low Molecular Weight Heparin
The standard treatment for high risk patients weighing <50kg or >100kg is tinzaparin 4,500 units daily by subcutaneous injection. Other patients should receive a dose adjusted to their actual body weight.
Moderate (creatinine clearance (CrCl) 30-50mL/min) & mild renal impairment (CrCl 50-80mL/min): Although no dosage adjustments are recommended for tinzaparin in patients with moderate renal or mild renal impairment. Careful clinical monitoring is advised.
Severe renal impairment (CrCl <30mL/min):
Tinzaparin is contra-indicated in patients with severe renal impairment. Enoxaparin is the recommended medicine in this patient population.
Dosage guide for low molecular weight heparins (LMWH).
Severe renal impairment CrCl <30ml/min
Normal to Moderate renal impairment (CrCl>30ml/min) and patients receiving CVVHD
Tinzaparin 2500units OD
Tinzaparin 4,500 units OD
~ 50units/kg OD (dose banded -see eMEDs)
<100kg 20 mg OD 100-150kg 40mg OD >150kg 60mg OD
Allergy to heparins
If heparins cannot be used alternatives such as Fondaparinux or Danaparoid are available - See below for fondaparinux dosage information. The dosage of danaparoid should be discussed with a haematologist.
Heparin Induced Thrombocytopenia (HIT)
All patients started on any type of heparin should have a baseline platelet count performed, and if the received heparin of any form in the previous 100 days a further platelet count at 24 hours is advised.
If thrombocytopenia occurs and HIT is suspected please refer to the LTH Guideline on The Management of Heparin Induced Thrombocytopenia and Thrombosis
All heparins are porcine (pork) derived.
If a patient does 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). This is contra-indicated if CrCl < 20ml/min.
Patients on anti-platelets: Review bleeding risk and VTE risk. Patients with an increased VTE risk but low bleeding risk should be offered thromboprophylaxis in addition to anti-platelets. Patients with an increased VTE risk but high bleeding risk should be reviewed by a senior doctor and at regularly periods afterwards.
Patients on warfarin. If the INR is below the target range documented for the warfarin therapy, consider prophylactic or treatment dose LMWH depending on reason for anticoagulation. Recent DVT/PE/stroke history, presence of metal mechanical valve etc. should warrant the prescribing of treatment dose LMWH. Ensure the INR and activity is monitored regularly and stop LMWH once target INR in range.
Patients on Direct Oral Anticoagulants (DOACs). E.g. apixaban, dabigatran, edoxaban, rivaroxaban, should only receive pharmacological prophylaxis with LMWH when they are unable to receive their usual DOAC therapy.
|Target patient group:||Adults|
|Target professional group(s):||Secondary Care Doctors
- National Institute of Health and Care Excellence. Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. Updated August 2019. https://www.nice.org.uk/guidance/ng89
Trust Clinical Guidelines Group
LHP version 2.0
Equity and Diversity
The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.