VTE Prophylaxis for Cardiac Surgery patients - Reducing the risk of venous thromboembolism

Publication: 01/08/2010  --
Last review: 18/07/2017  
Next review: 01/07/2020  
Clinical Guideline
CURRENT 
ID: 2037 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

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.

Venous Thromboembolism Guidelines for Cardiac Surgery Patients

Background
Risk Assessment
Treatment/Management

Background

NICE clinical guideline 92; Venous thromboembolism: reducing the risk was issued in January 2010, updated June 2015. 

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Risk Assessment

Leeds Teaching Hospitals risk assessment tool is used to stratify the risk of VTE for each patient.

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Treatment / Management

Clinical algorithm

On admission to hospital all patients should be risk assessed and identified for risk of VTE and risk of bleeding using the Leeds Teaching Hospitals risk assessment tool. This should be completed electronically via PPM+ whenever possible. If electronic completion is not possible, a paper risk assessment form should be completed. If thromboprophylaxis is indicated it should then be prescribed appropriately.

VTE risk assessment should be repeated 24 - 48 hours after admission and whenever the patients clinical condition changes.

VTE Risk Factors

  • Active cancer or cancer treatment
  • Age over 60 years
  • Dehydration
  • Known thrombophilias
  • Obesity (BMI >30kg/m2)
  • One or more significant medical comorbidities (eg. Heart disease; metabolic, endocrine or respiratory pathologies; acute infectious disease, 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
  • Critical Care admission
  • Total anaesthetic + surgical time > 90 minutes
  • Significantly reduced mobility for 3 days or more

Anti-Embolism Stockings (AES)
All patients should be fitted with anti-embolism stockings on admission and should continue to wear them until they are discharged (unless they are contraindicated).

On the Cardiac Intensive Care Unit on the first postoperative day, those patients with saphenous vein harvest should have their dressings removed, the wound inspected, and AES applied (unless contraindicated) before transfer from the unit. This link is to the Trust guideline on anti-embolic stockings including assessment of contra-indications and appropriateness

Low Molecular Weight Heparins (LMWH)
The LMWH of choice at Leeds Teaching Hospitals NHS Trust is tinzaparin. Patients with creatinine clearance<20mL/min should receive enoxaparin

All cardiac surgery patients should receive prophylactic LMWH (tinzaparin/enoxaparin)unless they have a risk factor for bleeding:

  • Active bleeding
  • Acquired bleeding disorders (such as acute liver failure)
  • Concurrent use of anticoagulants eg. Warfarin with therapeutic INR
  • Acute stroke
  • Thrombocytopenia (platelets < 75 x 109 / L)
  • Uncontrolled systolic hypertension (230/120mmHg or higher)
  • Untreated inherited bleeding disorders eg. Haemophilia

Prescribing guidelines
Complete the Leeds Teaching Hospitals VTE risk assessment tool for every patient admitted for cardiac surgery, then prescribe:

Male: Creatinine Clearance = 1.23 x (140-age) x weight(kg) / Serum creatinine(micromoles/litre)
Female: Creatinine Clearance = 1.04 x (140-age) x weight(kg) / Serum creatinine(micromoles/litre)

Both products are of porcine origin. If patients refuse LMWH based on religious or other grounds the synthetic product fondaparinux may be used 2.5mg s/c injection once a day if creatinine clearance > 50ml/min or 1.5mg s/c injection if creatinine clearance 20-50ml/min. Do not use if the patient has a latex allergy.

Discontinuing treatment
The VTE risk assessment should be repeated 24 - 48 hours after admission and whenever the clinical situation changes. Treatment with LMWH should be discontinued:

  1. if any of the above bleeding risks arise
  2. when the patient has been fully mobile for >24 hours

Long-stay patients
Pre-operative should commence tinzaparin and AES as indicated if immobile; The last dose of tinzaparin should be given 12 hours prior to surgery

Monitoring for Heparin-Induced Thrombocytopenia (HIT)
The risk of heparin-induced thrombocytopenia is higher is patients undergoing cardiac surgery.  The following monitoring is recommended:

  • All patients started on any type of heparin should have a baseline platelet count performed
  • For patients who have received heparin of any form in the previous 100 days a platelet count at 24 hours is advised
  • For patients who have had cardiac bypass surgery, platelets should be monitored every 2-4 days from day 4-14 while they remain on any form of heparin
  • All patients on unfractionated heparin require platelet counts every 2-4 days from day 4-14 of heparin therapy

If cardiac surgery patients are discharged from hospital on LMWH, the need for repeat platelet counts as above should be communicated on the eDAN for the GP to follow-up.

If HIT is suspected, please refer to the Guideline on Diagnosis and Management of HIT; this is based on national guidance from the British Committee for Standards in Haematology November 2012.

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Provenance

Record: 2037
Objective:

Aims
Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital for cardiac surgery

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

Clinical condition:

Venous thromboembolism prophylaxis

Target patient group: Patients admitted for cardiac surgery
Target professional group(s): Secondary Care Doctors
Pharmacists
Secondary Care Nurses
Adapted from:

Evidence base

NICE clinical guideline 92

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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.