VTE Prophylaxis Guidelines for Elective General Surgery Patients Admitted on the Same Day of Surgery - Reducing the Risk of Venous Thromboembolism

Publication: 12/08/2011  --
Last review: 03/01/2019  
Next review: 03/01/2021  
Clinical Guideline
CURRENT 
ID: 2569 
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.

Reducing the risk of venous thromboembolism - VTE Prophylaxis guidelines for elective general surgery patients admitted on the same day of surgery

Monitoring for Heparin Induced Thrombocytopenia (HIT)
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.
Further monitoring is not required for patients on low molecular weight heparin (LMWH).
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.

Flowchart

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Background

NICE clinical guideline NG891; Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism was issued in March 2018. Leeds Teaching Hospitals are adding to Leeds Health Pathways local guidance for VTE risk assessment and management based on NICE guidance.

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Risk Assessment

Leeds Teaching Hospitals risk assessment tool used? Yes

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Treatment / Management

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

1.1 General Information
All patients are risk assessed and identified for risk of VTE and risk of bleeding. This should comprise assessment of: -

  • Individual patient risk factors (see VTE assessment form)
  • Bleeding risks / contraindications (see VTE assessment form)
  • Procedure risk factors (see section 1.6)

Patients should have an initial risk assessment undertaken at their surgical pre-assessment appointment, and then be reassessed on admission and after 24-48 hours of admission. Reassessment of risk should also take place frequently during the patient’s hospital admission, and as the patient’s situation changes.

Appropriate thromboprophylaxis should be prescribed in advance of surgery according to the risk assessment; however, same day of admission surgery patients must not receive pharmacologic thromboprophylactic agents prior to their surgery unless this option has been discussed with the anaesthetist.

For women who are pregnant or have given birth within the past 6 weeks see separate guidance / seek advice.

For elective orthopaedic and plastic surgery, please see separate guidelines on Leeds Health Pathways.

There is a mandatory VTE e-learning package available online plus regular face to face training, see the training interface for details, please ensure your training is up to date.

1.2 Timing of pharmacological thromboprophylaxis
There is a lack evidence to support pre-operative administration of LMWH to patients admitted for same day of admission surgery (SDOS), when compared to starting LMWH at 6pm post-operatively, and the development of post-operative DVT/PE.
Pre-operative administration of LMWH may increase the risk of post-operative surgical bleeding and epidural haematoma formation in patients who have undergone regional (spinal, caudal or epidural) anaesthesia.
The standard position is, therefore, that SDOS patients should not receive pre-operative pharmacological thromboprophylaxis.

If the patient is felt to be at particularly high risk of VTE, after a clinical discussion one of the following resolutions should be considered:

  • Clinical discussion between surgeon and anaesthetist after anaesthetic pre-operative assessment, with pre-operative administration of LMWH if the need for regional anaesthesia has been ruled out and risks of surgical bleeding are considered low. See separate guidelines for advice on LMWH bridging of anticoagulants (detail.aspx?ID=3084)
  • Admit the patient on the evening before surgery and give LMWH in accordance with non-SDOS surgery guidelines (available via Leeds Health Pathways).

1.3 Definition of Reduced Mobility
Significantly reduced mobility is defined as: bedbound, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair.

1.4 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”: -

  • Patients must not receive LMWH prior to same day of admission surgery (unless as part of a “bridging regime” - see section 1.2)
  • Patients must not receive LMWH for at least 4 hours after epidural / spinal anaesthesia has been inserted/removed 2
  • In the event of a traumatic spinal catheter insertion, timing of the first post-operative dose of LMWH should be at the discretion of the anaesthetist and re-prescribed if necessary

1.5 Non-surgical Risk Factors for Bleeding

  • Current active bleeding
  • Acquired bleeding disorders e.g. acute liver failure
  • Untreated inherited bleeding disorders e.g. haemophilia
  • Concurrent use of anticoagulants (e.g. warfarin) with INR greater than 2
  • Concurrent use of newer oral anticoagulants, such as apixaban, dabigatran, edoxaban or rivaroxaban
  • Acute stroke
  • Thrombocytopenia (platelets less than 75x109/l)
  • Uncontrolled systolic hypertension (230/120 mmHg)

1.6 VTE Risk Factors
Patient risk factors (also see Risk assessment form) 

  • Active cancer treatment
  • Age over 60 years
  • Critical care admission
  • Dehydration
  • Known thrombophilias
  • Obesity (BMI over 30kg/m2)
  • One or more significant medical comorbidities (e.g. heart disease, metabolic, endocrine or respiratory pathologies, acute infectious disease or inflammatory conditions)
  • History of VTE
  • Use of hormone replacement therapy*
  • Use of oestrogen containing contraceptive therapy*
  • Varicose veins with phlebitis

Surgical risk factors (see surgical procedure table)

  • Surgical procedure longer than 90 minutes, or 60 minutes for pelvis/lower limb surgery
  • Acute surgical admission with inflammatory or intra-abdominal condition
  • Expected significant reduction in mobility (see section 1.3 of guideline)

*It is strongly advised that hormone replacement therapy and oestrogen-containing contraceptive therapies are stopped for 28 days prior to elective surgery1.

1.7 Patients at extremes of body weight
See separate guidance on the Leeds Medicines Formulary (http://www.leedsformulary.nhs.uk/docs/2.8.1LMWHdosingatextremesofbodyweight.pdf?UNLID=929322480201811716023)

1.8 Impaired renal function
Patients assessed to have moderate or high risk of VTE with GFR <20 ml/min (weighing less than 100kg) should be prescribed enoxaparin 20mg once daily. For patients at extremes of body weight with renal impairment, see advice on Leeds Medicines Formulary (http://www.leedsformulary.nhs.uk/docs/2.8.1LMWHdosingatextremesofbodyweight.pdf?UNLID=929322480201811716023)

1.9 Extended thromboprophylaxis
Patients undergoing major abdominal or pelvic surgery should be considered for extended thromboprophylaxis as follows (treatment length is number of post-operative days)3:

Gynae-oncology Surgery:

  1. All open abdominal operations for gynaecological cancer - 28 days
  2. All laparoscopic staging operations which include lymphadenectomy – 28 days
  3. Simple laparoscopic/staging operations (i.e. without lymphadenectomy) – 7 days
  4. Vulvar cancers are excluded from the guidelines and should be managed on a case by case basis
  5. Variations from the above should be specified in the operation sheet

Gynaecological Surgery
Benign procedures – TEDS post discharge only (unless VTE risk factors)

Urological Surgery

  1. Lap. deroofing cyst; Lap. nephrectomy - benign; Lap. radical < T1b; Lap. pyeloplasty; Lap. partial nephrectomy- 7 days
  2. Lap. radical nephrectomy > T2; Major open nephrectomy- 28 days
  3. Cystectomy- 28 days
  4. Open radical prostatectomy; Robotic prostatectomy - 28 days

Upper GI/HPB Surgery

  1. Oesophagectomy; gastrectomy (total or partial); bariatric surgery - 28 days
  2. Whipple's procedure/pancreaticoduodenectomy/PPPD - 28 days

Colorectal Surgery
Extended prophylaxis for colorectal patients undergoing cancer resections-open/laparoscopic, inflammatory bowel disease resections, emergency laparotomies with resection, recurrent colorectal cancers (consultant to advise).

2.1 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.

2.2 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 transferred to medically optimised wards should have their VTE prophylaxis reviewed prior to discharge and the decision documented.

2.3 LMWH alternative
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).

Types of Procedure / Risk Clarification

Please scroll down to access relevant specialty

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1. Breast / Endocrine Surgery

The below procedures are based on the thrombotic risk for a “standard patient” undergoing a procedure.

If a patient has any high risk criteria (defined as one or more criteria on the VTE risk assessment form) then “high risk” advice should be followed.

No prophylaxis required

Flowtron boots / TED stockings only

Standard/ high risk (tinzaparin 4500 units) + TED stockings / Flowtron boots

 

Neck surgery all types

Breast surgery all types

 

Endocrine surgery all types

 

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2. Colo-rectal Surgery

The below procedures are based on the thrombotic risk for a “standard patient” undergoing a procedure.

If a patient has any high risk criteria (defined as one or more criteria on the VTE risk assessment form) then “high risk” advice should be followed.

No prophylaxis required

Flowtron boots / TED stockings only

Standard/ high risk (tinzaparin 4500 units) + TED stockings / Flowtron boots

EUA

Groin hernia

Left pelvic colon resection for cancer

Fistula

SNS

Close ileostomy

Sphincterotomy

Haemorrhoid procedures

Left pelvic colon resection for IBD / rev. Hartmann’s

 

 

Proctocolectomy

 

 

Incisional hernia

 

 

Colon resection (right / transverse)

 

 

Emergency laparotomy for GB / PUD / trauma

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3. General Surgery & Upper GI Surgery

The below procedures are based on the thrombotic risk for a “standard patient” undergoing a procedure.

If a patient has any high risk criteria (defined as one or more criteria on the VTE risk assessment form) then “high risk” advice should be followed.

No prophylaxis required

Flowtron boots / TED stockings only

Standard/ high risk (tinzaparin 4500 units) + TED stockings / Flowtron boots

Local anaesthetic procedures

 

Laparoscopic Nissens

Groin hernia repair

 

Laparoscopic/open oesophagectomy

 

 

Laparoscopic cholecystectomy

 

 

Laparoscopic/open gastrectomy

 

 

Hernia repair

 

 

Bariatric surgery

 

 

Laparoscopic ventral/incisional

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4. Gynaecological Surgery

The below procedures are based on the thrombotic risk for a “standard patient” undergoing a procedure.

If a patient has any high risk criteria (defined as one or more criteria on the VTE risk assessment form) then “high risk” advice should be followed.

No prophylaxis required

Flowtron boots / TED stockings only

Standard/ high risk (tinzaparin 4500 units) + TED stockings / Flowtron boots

 

Hysteroscopy +/- minor treatment

Major oncology procedures

 

Endometrial ablation (not including TCRE)

Laparoscopic ovarian cystectomy

 

Cystoscopy

Vaginal hysterectomy

 

Cervical cautery

Salpingectomy

 

Vulval biopsies

Pelvic floor repair

 

Marsupialisation Bartholins cyst

Oophorectomy

 

Termination of pregnancy

Abdominal hysterectomy

 

Evacuation of uterus

Diagnostic laparoscopy with minor treatment

 

 

Lap. assisted vaginal hysterectomy

 

 

TVT/TVT-O

 

 

Sacrocolpopexy

 

 

Isolated anterior or Posterior repair

 

 

TVM

 

 

Myomectomy

 

 

Operative hysteroscopy > 30 minutes duration

 

 

Laparotomy

 

 

Open salpingectomy

 

 

Oophorectomy, ovarian

 

 

Cystectomy

 

 

Open sterilisation

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5. HBP Surgery

The below procedures are based on the thrombotic risk for a “standard patient” undergoing a procedure.

If a patient has any high risk criteria (defined as one or more criteria on the VTE risk assessment form) then “high risk” advice should be followed.

No prophylaxis required

Flowtron boots / TED stockings only

Standard/ high risk (tinzaparin 4500 units) + TED stockings / Flowtron boots

Lumps

 

Inpatient hernias

Day case hernias

 

Laparoscopic cholecystectomy

 

 

Liver resections with prothrombin time <24

 

 

Bile duct excision or reconstruction

 

 

Pancreatic resections

 

 

Pancreatic drainage procedures

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6. Thoracic Surgery

The below procedures are based on the thrombotic risk for a “standard patient” undergoing a procedure.

If a patient has any high risk criteria (defined as one or more criteria on the VTE risk assessment form) then “high risk” advice should be followed.

No prophylaxis required

Flowtron boots / TED stockings only

Standard/ high risk (tinzaparin 4500 units) + TED stockings / Flowtron boots

 

Mediastinal procedures

  • Resection
  • Mediastinoscopy
  • Mediastinotomy
  • Other mediastinal procedure

Chest wall / diaphragmatic procedures

 

 

VATS procedures

  • Primary malignant wedge resection
  • Primary malignant lobectomy
  • Primary malignant pneumonectomy
  • Lobectomy
  • Lung volume reduction surgery
  • Pleurectomy/decortication for mesothelioma
  • Wedge resection - therapeutic or diagnostic
  • Bullectomy
  • Pneumothorax surgery
  • Sympathectomy
  • Correction of pectus wall
  • Resection of mediastinal procedure

 

 

Pleural procedure - other

  • Thoracotomy

 

 

Mediastinal procedures

  • Thymectomy
  • Thyroidectomy

 

 

Mesothelioma surgery

 

 

Tracheal surgery

 

 

Lung resection - primary malignant / other

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7. Urology Surgery

The below procedures are based on the thrombotic risk for a “standard patient” undergoing a procedure.

If a patient has any high risk criteria (defined as one or more criteria on the VTE risk assessment form) then “high risk” advice should be followed.

No prophylaxis required

Flowtron boots / TED stockings only

Standard/ high risk (tinzaparin 4500 units) + TED stockings / Flowtron boots

Local anaesthetic procedures

Endoscopic urology for a procedure of expected duration of less than 60 minutes e.g.:

  • Ureteroscopy
  • Flexible Ureteroscopy
  • Cystoscopy
  • TURBT
  • TURP
  • Urethroscopy

Urology surgery all types

 

 

All day case urology procedures under general anaesthetic

(unless high patient risk factor)

PCNL - timing of administration as per patient undergoing spinal/epidural

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8. Vascular Surgery

The below procedures are based on the thrombotic risk for a “standard patient” undergoing a procedure.

If a patient has any high risk criteria (defined as one or more criteria on the VTE risk assessment form) then “high risk” advice should be followed.

No prophylaxis required

Flowtron boots / TED stockings only

Standard/ high risk (tinzaparin 4500 units) + TED stockings / Flowtron boots

 

 

All vascular procedures are classified as high risk

Note: - patients with renal failure (GFR <20ml/min) should receive enoxaparin

Provenance

Record: 2569
Objective:

Aims

Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital on the same day of their surgical procedure.

Objectives

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

Clinical condition:

VTE Prophylaxis in patients admitted to hospital on the same day of surgery

Target patient group: Elective surgical patients admitted on same day of surgery
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

Evidence Bases:

  1. “Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism” produced by the National Institute for Health and Care Excellence [NG89] published March 2018. Accessed via https://www.nice.org.uk/guidance/ng89/resources/venous-thromboembolism-in-over-16s-reducing-the-risk-of-hospitalacquired-deep-vein-thrombosis-or-pulmonary-embolism-pdf-1837703092165 accessed April 2018.
  2. Clinical Practice Guidelines for the Delivery of Epidural and Paravertebral Analgesia in Adult Acute Pain Management - Leeds Teaching Hospitals NHS Trust , Last review: 15/11/2016, accessed April 2018 detail.aspx?ID=187
  3. Geerts WH, Bergqvist D et al. Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest 2008;133: 381S-453S.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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