VTE Prophylaxis for Transplant Surgery ( Liver ) - Reducing the risk of venous thromboembolism

Publication: 01/09/2010  --
Last review: 09/10/2019  
Next review: 09/10/2022  
Clinical Guideline
CURRENT 
ID: 2051 
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.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Thromboprophylaxis Guidelines for Liver Transpant Surgical Patients (all recipients and living-donors)

Aims

Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital for initial liver transplant surgery.

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Objectives

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

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Background

NICE clinical guideline 92; Venous thromboembolism: reducing the risk was issued in January 2010, updated June 2015 and replaced by NICE guideline NG89 Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism in March 2018

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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

Transplant Recipients
All new liver transplant recipients will qualify for VTE risk assessment. This assessment is undertaken by the clerking doctor on admission to ward 83 ahead of surgery. The VTE risk assessment tool is available in electronic format which is accessible through PPM+.

This guideline only applies to the transplant surgical admission for the patient.

Pre-operative anticoagulation with oral anticoagulants is reversed, either by omission of anticoagulant in planned live donation or pharmacologically when a patient is called for a deceased-donor organ.

Patients will be prescribed tinzaparin 4,500 units sc once daily unless under 50kg when 2500 units should be used or over 100kg when a dose of 50 units/kg rounded to the nearest 1000 units should be used - see link.
Guidelines for dosing in extremes of body weight
http://nww.lhp.leedsth.nhs.uk/netformulary/docs/LMWHdosingatextremesofbodyweight.pdf

The first dose of tinzaparin will be administered on day 0 and should only be withheld if the patient returns from theatre within 4 hours of the scheduled dose or contraindicated as per platelets or INR as per below. Subsequent doses will be given at 6pm each day. Patients with a GFR<20mL/min should receive enoxaparin 20mg sc once daily at 6pm instead of tinzaparin.

Patients will not receive either tinzaparin, enoxaparin or aspirin if they have an INR > 2 or a platelet count of <50 x 109/L. Prescribers should identify this on the inpatient chart and suspend the medicine on the Emeds system so that it not accidentally administered.

Patients undergoing Spinal/regional analgesia
For patients who will be receiving a lumbar puncture/epidural/spinal anaesthesia see “Clinical Practice Guidelines for the Delivery of Epidural and Paravertebral Analgesia in Adult Acute Pain Management”.
 
·  Do not give LMWH within 12 hours of starting an epidural / spinal anaesthesia
·  Do not restart LMWH until 4 hours after epidural / spinal anaesthesia removed

Liver transplant biopsy is a procedure-related high bleeding risk which warrants omission of tinzaparin in the previous 24 hours if possible. Where not possible to omit in advance this requires discussion with the consultant surgeon or hepatologist ‘on’ for the week.

Mechanical Prophylaxis
All patients will be prescribed below-knee, graduated compression stockings on admission to be worn until discharge or review unless any of the following apply:

Do not offer anti-embolism stockings to people who have:

  • suspected or proven peripheral arterial disease
  • peripheral arterial bypass grafting
  • peripheral neuropathy or other causes of sensory impairment
  • any local conditions in which anti-embolism stockings may cause damage – for example, fragile 'tissue paper' skin, dermatitis, gangrene or recent skin graft
  • known allergy to material of manufacture
  • severe leg oedema
  • major limb deformity or unusual leg size or shape preventing correct fit.

    Use caution and clinical judgement when applying anti-embolism stockings over venous ulcers or wounds

detail.aspx?id=2435
Guideline for the care of patients wearing anti-embolic stockings.

If the surgical team feels that the patient requires intermittent pneumatic compression (flowtrons) then these can be prescribed instead of anti-embolism stockings. These should then however be carried on post-surgery and not be switched to anti-embolism stockings on step down to the ward.

Patients will be reassessed for bleeding risk and VTE risk on the daily, consultant-led ward rounds commencing within 24 hours of admission, as per NICE guidance. The re-assessment 24 hours after admission should be documented on the e-whiteboard

Living-donor transplant hepatectomy patients

All donors require VTE prophylaxis. Each will be prescribed tinzaparin 4,500 units sub-cutaneous injection once daily at 6pm (or higher based on weight as above). This should continue until the patient no longer has significantly reduced mobility, which is considered to be until 6 weeks post-op.

On discharge the patient will be prescribed the remainder of the 6 week course on his or her discharge advice note to be administered at home.

Patient Information
All patients should be given verbal and written information about their risk of VTE on admission, this should include what will happen, side effects and how they can help to reduce the risk. On discharge they should be given verbal and written information about the signs and symptoms of VTE and what to do should they occur, they should also be given instructions on how to use their thromboprophylaxis if required on discharge and how long it should continue for. 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

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

Provenance

Record: 2051
Objective: To provide evidence-based recommendations for appropriate venous thromboembolism (VTE) risk assessment and management of patients admitted to hospital.
Clinical condition: Transplant Surgery (Liver)
Target patient group: Adults
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

NICE Clinical Guideline 92

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

Not supplied

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