VTE Prophylaxis for Patients Undergoing Upper Gastrointestinal and Hepatobiliary Surgery - Reducing the risk of venous thromboembolism

Publication: 06/12/2016  --
Last review: 29/02/2020  
Next review: 28/02/2023  
Clinical Guideline
CURRENT 
ID: 4829 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

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 Upper Gastrointestinal and Hepatobiliary Surgical Patients

Aims

Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital for Upper Gastrointestinal and Hepatobiliary Surgery.

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

1.1 General Information

All patients are risk assessed and identified for risk of VTE and risk of bleeding on admission. This should comprise of: -

  • Individual Patient risk factors (see VTE assessment form)
  • Bleeding Risks / contraindications (see VTE assessment form)
  • Procedure Risk Factors (see attached table for surgical specialty)

The most appropriate thromboprophylaxis is then prescribed within 14 hours of admission.

Treatment Pathway: Thromboprophylaxis in the Surgical Patient

Patients should be reassessed for bleeding risk and VTE risk within 24 - 48 hours of admission, as per NICE guidance. Reassessment of risk should also be carried out every 5 - 7 days during the patients stay in hospital.

Mechanical VTE prophylaxis (either anti-embolism stockings or intermittent pneumatic compression) should be started on admission for patient’s undergoing abdominal surgery. This should continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility.

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

1.2 Day surgery / Same day of surgery (SDOS) admission
See separate guidance for patients being admitted for SDOS (detail.aspx?id=2569).

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

1.4 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 prior to starting an epidural / spinal anaesthesia
  • Do not restart LMWH till 4 hours after epidural / spinal anaesthesia removed

1.5 Risk Factors for Bleeding

  • 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 >2 or apixaban, dabigatran, edoxaban, rivaroxaban or INR greater than 2
  • Acute stroke
  • Thrombocytopenia (platelets less than 75x109/l
  • Uncontrolled systolic hypertension (230/120 mmHg)
  • Lumbar puncture/ epidural/ spinal anaesthesia expected within the next 12 hours

1.6 Extended Prophylaxis

Add pharmacological VTE prophylaxis for a minimum of 7 days for people undergoing abdominal surgery whose risk of VTE outweighs their risk of bleeding, taking into account individual patient factors and according to clinical judgement. If this is indicated, it should be clearly documented on the patient’s post-op note.

Patients undergoing surgery for cancer in the abdomen or pelvis should be considered for extended pharmacological VTE prophylaxis for up to 28 days. This includes:

  • Oesophagectomy - 28 days
  • Gastrectomy (total or partial) - 28 days
  • Whipple's procedure/pancreaticoduodenectomy/PPPD - 28 days
  • Bariatric surgery (gastric band/sleeve gastrectomy/Roux-en-Y gastric bypass) - 28 days

Please note that extended thromboprophylaxis should be prescribed and at a weight-adjusted dose where patients are <50 or >100kg

1.7 VTE Risk Factors -
Patient risk factors see Risk assessment form

  • Active Cancer treatment
  • Age over 60 years
  • Critical Care admission
  • Pro-thrombotic state (e.g dehydration, acute infection)
  • Known thrombophilia
  • 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)
  • 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
  • Pregnancy or < 6 weeks post partum or miscarriage within the last 6 weeks

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)

Consideration should be given to cease hormone replacement therapy or oestrogen containing contraceptives for 4 weeks prior to surgery, where possible, to reduce VTE risk.

1.8 Patients on Oral Anticoagulants
The guidance regarding bridging therapy for patients taking oral anticoagulants undergoing elective surgical procedures should be followed. (detail.aspx?ID=3084)

1.9 Patients under 50kg and over 100kg
Patients weighing under 50kg should be prescribed tinzaparin 2500 units s/c daily. Patients weighing over 100kg should be dosed with tinzaparin 50units/kg, unless they have renal impairment - see section 1.10. See also LMWH prophylactic dosing at extremes of body weight (http://www.leedsformulary.nhs.uk/docs/2.8.1LMWHdosingatextremesofbodyweight.pdf)

1.10 Patients with creatinine clearance < 20ml/min
Patients with creatinine clearance < 20ml/min should be swapped to enoxaparin 20mg. For patients <50kg or >100kg and renal aimpairment see “LMWH prophylactic dosing at extremes of body weight” (http://www.leedsformulary.nhs.uk/docs/2.8.1LMWHdosingatextremesofbodyweight.pdf)

1.11 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

1.12 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

1.13 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

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.

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Provenance

Record: 4829
Objective: To provide evidence-based recommendations for appropriate venous thromboembolism (VTE) risk assessment and management of patients admitted to hospital
Clinical condition: VTE thromboprophylaxis in surgical patients
Target patient group: Surgical patients
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Evidence Bases:

  1. Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. NICE guideline [NG89]. Accessed December 2019. https://www.nice.org.uk/guidance/ng89
  2. Clinical Practice Guidelines for the Delivery of Epidural and Paravertebral Analgesia in Adult Acute Pain Management - Leeds Teaching Hospitals NHS Trust , Last review: December 2013, accessed March 2016 detail.aspx?ID=187
  3. Guidelines For The Perioperative Management Of Oral Anticoagulation In Patients Undergoing Elective Procedures - Leeds Teaching Hospitals NHS Trust, published September2012, accessed March 2016.
  4. LMWH prescribing at extremes of body weight - Leeds Teaching Hospitals NHS Trust, published July 2015, accessed March 2016

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

Not supplied

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