Liver Surgery - Reducing the Risk of Venous Thromboembolism ( Deep Vein Thrombosis and Pulmonary Embolism ) in Patients Admitted to Hospital for Patients Undergoing

Publication: 18/04/2017  --
Last review: 10/08/2021  
Next review: 10/08/2024  
Clinical Guideline
CURRENT 
ID: 4985 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

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 Patients Undergoing Liver Surgery

Aims

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

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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

1.1 General Information
All patients are risk assessed and identified for risk of VTE and risk of bleeding as soon as possible after admission or by the time of first consultant review and always within 24 hours of 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 should be prescribed within 14 hours of admission if required.

Treatment Pathway: Thromboprophylaxis in the Surgical Patient

Enoxaparin Dosing for patients with creatinine clearance (CrCl) over 30mL/min

Weight

Dose of Enoxaparin

<50kg

20mg daily

50 - 100kg

40mg daily

101 - 150kg

40mg twice daily

>150kg

60mg twice daily

Enoxaparin Dosing for patients with creatinine clearance (CrCl) less than 30mL/min

Weight

Dose of Enoxaparin

<50kg

20mg daily with caution - consider Factor Xa levels

50 - 100kg

20mg OD daily

101 - 150kg

40mg OD daily

>150kg

60mg OD daily

1.2 Re-risk assessment
Patients should be reassessed for bleeding risk and VTE risk at the time of consultant review and whenever the clinical situation changes, as per NICE guidance. Reassessment of risk should also be carried out every 5 - 7 days during the patients stay in hospital.

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

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

1.4 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.

1.5 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

1.6 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 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)

1.7 Extended Prophylaxis
Patients who have had an abdominal sarcoma, liver resection or undergone liver surgery should receive 28 days post-operative thromboprophylaxis.
Including:

  • Open procedures
  • Laparoscopic procedures
  • Benign procedures
  • Cancer procedures

Continue extended thromboprophylaxis at a weight-adjusted dose where patients are <50 or >100kg

1.8 VTE Risk Factors -
Patient risk factors 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)

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.

1.9 Patients on Oral Anticoagulants
The guidance regarding bridging therapy for patients taking oral anticoagulants undergoing elective surgical procedures should be followed.

2.0 Patients under 50kg and over 100kg
Patients weighing under 50kg should be dosed with enoxaparin 20mg daily, Patients weighing over 100kg should be dosed with enoxaparin 40mg twice daily. For patients with renal impairment - see dosing chart detailed above.

2.1 Patients with creatinine clearance < 30ml/min
Patients with creatinine clearance < 30ml/min should be prescribed enoxaparin see dosing chart detailed above.
2.2 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

2.3 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

2.4 All heparins are porcine based
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.

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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.

Provenance

Record: 4985
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: Liver Surgery patients
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  1. “Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital” produced by the National Collaborating Centre for Acute Care.http://guidance.nice.org.uk/CG92/Guidance/pdf/English
  2. Clinical Practice Guidelines for the Delivery of Epidural and Paravertebral Analgesia in Adult Acute Pain Management - Leeds Teaching Hospitals NHS detail.aspx?ID=187
  3. Guidelines For The Perioperative Management Of Oral Anticoagulation In Patients Undergoing Elective Procedures - Leeds Teaching Hospitals NHS Trust,
  4. LMWH prescribing at extremes of body weight - Leeds Teaching Hospitals NHS Trust, published July 2015
  5. NICE NG 89  Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism issued March 2018

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

Not supplied

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