Thromboprophylaxis in Stroke Patients
|Publication: 24/09/2012 --|
|Last review: 01/11/2018|
|Next review: 01/11/2021|
|Approved By: Trust Clinical Guidelines Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2018|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Thromboprophylaxis in stroke patients
Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital with a stroke.
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 92; Venous thromboembolism: reducing the risk was issued in January 2010.
NICE NG 89 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 VTE risk assessment tool on PPM+ used …Yes
All patients should be risk assessed for VTE and bleeding on admission to hospital and by the time of first consultant review
Venous thromboembolism is the term for deep vein thrombosis (DVT) and pulmonary embolism (PE).
In the recently published CLOTS trial1, Intermittent Pneumatic Compression (IPC) devices worn on both lower limbs were an effective method of reducing the risk for DVT and improving survival in patients who were immobile after a stroke. Significantly fewer IPC patients than controls had DVT (8.5% vs. 12.1%; absolute risk reduction, 3.6%). Six-month mortality was significantly lower in the IPC group (adjusted cumulative hazard ratio, 0.86).
The trial switched to the Kendall SCDTM sequential compression “Comfort” sleeves to maximise adherence and these are the IPCs that must be used in patients with acute ischaemic or haemorrhagic stroke who are:
- for active treatment (i.e. not simply for palliation)
- immobile (unable to walk independently to the toilet)
- willing to wear compression sleeves
- not suffering contraindications to IPC
- severe congestive heart failure
- severe skin problems on legs
- severe peripheral vascular disease
IPC should be applied as soon as possible after admission and definitely within the first 3 days. IPC should be taken off (whichever comes first)
- when the patient becomes independently mobile
- at discharge from hospital
- if the patient develops any adverse effects
- by 30 days
NICE CG92 has been updated in July 2015 and in March 2018 (NICE NG 89) and now states the following on IPC devices:
Consider intermittent pneumatic compression (IPC) for VTE prophylaxis in immobile patients who are admitted within 3 days of acute stroke.
- Explain to the patient or their family members or carers (as appropriate) that:
- it reduces the risk of deep vein thrombosis and may provide an increase in survival
- it will not help them recover from stroke, and there may be an associated increased risk of surviving with severe disability.
Although low molecular weight heparin (LMWH) prevents DVTs in immobile stroke patients, the risk of fatal PE is lower than the risk of intracranial haemorrhage in the first 2 weeks or so. Therefore heparin prophylaxis should not be routinely used in the first 2 weeks unless on consultant recommendation but reconsider and perform a re-risk assessment after that time using the Trust VTE risk assessment tool.
Patients who cannot tolerate IPCs should be discussed with a senior member of the clinical team and a decision made as to whether LMWH VTE prophylaxis is appropriate.
Patients with an ischaemic stroke but with previous VTEs or with a number of risk factors for VTE should be discussed with a Consultant on the post-take ward round.
Early use of heparin is associated with no overall benefit because of bleeding risk. The greatest risk of haemorrhagic transformation of infarct (HTI) is in the first two weeks. After that, it is reasonable to give enoxaparin subcutaneously once a day to patients who remain at high risk i.e. those who are immobile, CCF etc. The license states a duration of two weeks only as this was the duration of the trials.
IPCs and LMWH can be used together in the same patient
Stroke patients are at high risk of venous thromboembolism (VTE) so any leg swelling should be carefully evaluated. D-dimer may be used if there is clinical suspicion, but it is frequently elevated in acute stroke limiting its value in decision making. It has high negative predictive value (if low, VTE very unlikely) but poor positive predictive value (high value not specific, so need further investigation). This would lead on to doppler scan of popliteal fossa. Any unexplained hypotension or hypoxia (as well as pleuritic chest pain, dyspnoea or haemoptysis) should result in action to positively rule out PE.
Symptomatic venous thromboembolism should be managed with low molecular weight heparin and warfarin - must always be discussed with a Consultant. Some patients have an absolute contraindication to anticoagulation and in these cases a vena cava filter may be considered.
In the case of primary intracerebral haemorrhage (ICH), VTE prophylaxis with low molecular weight heparin (LMWH) after 2 weeks MAY be indicated after re-risk assessment. This will always be a Consultant led decision.
Anti-embolism stockings have been shown NOT to result in any reduction in proximal DVT and should not be used in stroke patients.
Ref: 1: (CLOTS (Clots in Legs Or sTockings after Stroke) trials collaboration. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet 2013; published online May 31. http://dx.doi.org/10.1016/S0140-6736(13)61050-8.
Patients should be risk assessed on admission, after 14 days, then whenever the clinical situation changes. It should be a consultant decision on when to start LMWH
Enoxaparin is the drug of choice for stroke patients.
Dose in normal renal function 40mg subcutaneously once a day,
Creatinine Clearance < 30ml/min 20mg subcutaneously once a day
*For patients at extremes of body weight see document on net formulary LMWH section
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
Check for adherence problems to the IPCs daily
Ensure baseline FBC, U/E and LFTs have been checked. Patients with concern about bleeding risk should have a coagulation screen checked. Whenever possible, the patient should be weighed.
All patients should be monitored clinically for signs of VTE, signs of bleeding, and signs of adverse effects of LMWH eg skin reactions.
When to monitor for Heparin induced thrombocytopenia (HIT):
HIT is an allergic drug reaction which paradoxically results in thrombosis. Examples are stroke, myocardial infacrction, acute leg ischaemia, DVT, PE.
The risk of HIT in patients receiving LMWH is thought to be 0.5%.
All patients should have a FBC prior to starting prophylaxis with a LMWH.
Patients who have received heparin in the last 100 days should have a FBC 24 hours after starting LMWH
A fall of >30% starting platelet count may indicate the development of HIT. Further discussion on investigation and management should be undertaken with the haematologists.
To provide evidence-based recommendations for appropriate venous thromboembolism (VTE) risk assessment and management of patients admitted to hospital
VTE thromboprophylaxis for patients admitted with acute stroke
|Target patient group:||Stroke patients|
|Target professional group(s):||Secondary Care Doctors
Secondary Care Nurses
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.
Trust Clinical Guidelines Group
LHP version 1.0
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