Download Thromboprophylaxis and Risk Assessment Guideline for Adults

Thromboprophylaxis and
Risk Assessment Guideline for Adults
Care pathway
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Assess level of mobility, VTE and bleeding risk for every adult patient admitted to SUHT, including ambulatory patients: (1) Complete national risk assessment tool, and (2) document assessment in the relevant section on the patient’s drug chart
(Significantly reduced mobility is defined as: bed bound, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair)
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Medical patients who are NOT expected to have significantly reduced mobility relative to normal state are not regarded at increased VTE risk and do not need to be risk assessed further
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All other patients should be fully risk assessed.
Balance risks of VTE and bleeding
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If any VTE risk factors identified, offer VTE prophylaxis as appropriate according to the speciality specific flow charts, ensuring that there are no contraindications.
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Do not offer pharmacological prophylaxis if bleeding risk outweighs risk of VTE. Refer to the most recent edition of the BNF or the Summary of Product Characteristics for contra-indications and cautions before prescribing.
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Prescribe mechanical and pharmacological prophylaxis in separate boxes on the drug chart if indicated.
Reassess VTE and bleeding risk within 24 hours of admission and whenever the clinical situation changes. Document re-assessment in the relevant section on the patient’s drug chart and any subsequent re-assessments in the medical notes.
If the VTE or bleeding risk changes during the admission the VTE prophylaxis must be reviewed and adjusted as appropriate.
Risk assessment
VTE prophylaxis
VTE risk factors
Patient related
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Active cancer or cancer treatment
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Age > 60
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Dehydration
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Known thrombophilias
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Obesity (BMI >30 kg/m2)
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One or more significant medical comorbidities (e.g. heart disease; metabolic,endocrine or respiratory
pathologies; acute infectious diseases; inflammatory conditions)
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Personal history or first-degree relative with a history of VTE
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Use of hormone replacement therapy (HRT)
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Use of oestrogen-containing contraceptive therapy
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Varicose veins with phlebitis
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Pregnancy or < 6 weeks post partum (see obstetric section for specific risk factors)
Admission related
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Significantly reduced mobility relative to normal state for ≥ 3 days
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Total anaesthetic + surgical time > 90 minutes
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Surgery involving pelvis or lower limb and total anaesthetic + surgical time > 60 minutes
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Acute surgical admission with inflammatory or intra-abdominal condition
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Surgery with significant reduction in mobility
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Hip or knee replacement
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Hip fracture
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Bariatric Surgery
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Critical care admission
Bleeding risk factors
Patient related
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Active bleeding
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Acquired bleeding disorders (such as acute liver failure)
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Concurrent use of anticoagulants known to increase the risk of bleeding
(such as warfarin with INR > 2)
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Acute stroke
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Thrombocytopaenia (platelets < 75 x 109/l)
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Uncontrolled systolic hypertension (≥ 230/120 mmHg)
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Untreated inherited bleeding disorders (such as haemophilia or von Willebrand’s disease)
Admission related
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Neurosurgery, spinal surgery or eye surgery
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Other procedure with high bleeding risk
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Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours or expected within the next
12 hours
Patients already having antiplatelet or anticoagulant therapy
to treat other conditions
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Do not regard aspirin or other antiplatelet agents as adequate prophylaxis for DVT
Consider offering additional mechanical or pharmacological VTE prophylaxis if patient is at risk of VTE.
Take into account risk of bleeding and of comorbidities such as arterial thrombosis.
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If the risk of VTE outweighs the risk of bleeding, consider offering pharmacological VTE
prophylaxis according to the reason for admission.
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If the risk of bleeding outweighs the risk of VTE, offer mechanical VTE prophylaxis.
Do not offer additional pharmacological or mechanical VTE prophylaxis to patients who are taking
vitamin K antagonists and who are within their therapeutic range, providing anticoagulant therapy is
continued.
Do not offer additional pharmacological or mechanical VTE prophylaxis to patients who are having
therapeutic anticoagulant therapy (e.g. treatment dose Enoxaparin or Heparin Infusions)
Medical patients
Pharmacological VTE prophylaxis
For all patients
Enoxaparin and unfractionated Heparin dosing in renal impairment
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Offer verbal and written information on VTE on admission (SUHT patient information leaflet available)
Do not allow patients to become dehydrated unless clinically indicated
Encourage patients to mobilise as soon as possible
Consider offering temporary inferior vena cava filters to patients who are at very high risk of VTE (such
as patients with a previous VTE event or active malignancy) if mechanical and pharmacological VTE
prophylaxis contraindicated.
Mild or no renal impairment (eGFR > 30mL/min/1.73m2) - Enoxaparin 40mg OD
Moderate renal impairment (eGFR 15 - 30mL/min/1.73m2) - Enoxaparin 20mg OD
Severe renal impairment (eGFR < 15mL/min/1.73m2) - Heparin 5000units BD
Patients at extremes of body weight
For patients weighing < 50kg or > 100kg refer to separate Guideline
Patients with increased bleeding risk
Clinicians may consider Enoxaparin 20mg OD for patients with bleeding risk and significant VTE risk
Mechanical VTE prophylaxis
Monitoring Enoxaparin and unfractionated Heparin treatment
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All patients on wards who are risk assessed as requiring mechanical thromboprophylaxis should be
offered AES as first line unless contraindicated.
All patients should be offered intermittent pneumatic compression during the intra-operative period unless
contraindicated and continue for as long as tolerated.
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Anti-embolism Stockings (AES)
Fitting
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Staff who fit stockings should be trained in their use.
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Measure legs and use correct stocking size. Document stocking size.
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If oedema or postoperative swelling develops, ensure legs are re-measured and stockings refitted.
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If arterial disease suspected, seek expert opinion before fitting stockings.
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Encourage patients to wear the stockings day and night from admission until they no longer have
significantly reduced mobility.
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Remove stockings daily for hygiene purposes and to inspect skin condition.
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If patient has significant reduction in mobility, poor skin integrity or sensory loss, inspect skin two or
three times per day, particularly over heels and bony prominences.
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Discontinue use of stockings if there is marking, blistering or discolouration of skin, particularly over
heels and bony prominences, or if patient has pain or discomfort. If suitable, offer intermittent
pneumatic compression or foot impulse devices as alternative.
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Show patients how to use anti-embolism stockings correctly and ensure they understand that this will
reduce their risk of developing VTE.
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Monitor use of anti-embolism stockings and offer assistance if they are not being worn correctly.
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In the case of amputation consider fitting AES to unaffected limb.
Contraindications
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Known allergy to the material of manufacture
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Suspected or proven peripheral arterial disease
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Peripheral arterial bypass grafting
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Peripheral neuropathy or other causes of sensory impairment
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Local condition in which stockings may cause damage, such as fragile ‘tissue paper’ skin, dermatitis,
gangrene or recent skin graft
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Severe leg oedema or pulmonary oedema from congestive heart failure
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Unusual leg size or shape
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Major limb deformity preventing correct fit
Use caution and clinical judgement when applying AES over venous ulcers or wounds.
Foot impulse and intermittent pneumatic compression devices (IPC)
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Encourage patients on the ward who have these devices to use them for as much of the time as is
possible and practical, both when in bed and when sitting in a chair
Contraindications
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Known acute DVT or PE
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As for AES
Check baseline platelet count before the initiation of therapy, at days 5 and 10 and then once again
between days 15-21 of treatment. If platelets fall by more than 30% of baseline stop heparin treatment
and discuss with haematology.
Remember to also consider potassium monitoring especially in those susceptible or patients
predisposed to hyperkalaemia.
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Extended pharmacological VTE prophylaxis
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Patients requiring extended prophylaxis should be identified in pre-assessment or at admission.
The extended regimen should be indicated in the medical notes and on the drug chart.
Extended prophylaxis should be offered to patients after major cancer surgery in the abdomen or
pelvis, total hip or knee replacement, or hip fracture (including #NOF). Other patients at high VTE risk
can be considered on an individual basis outside this guidance.
Timings for Epidurals/Spinals and Neurological patients
Enoxaparin
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INSERTION or REMOVAL of an epidural/spinal catheter should be delayed for 12 hours after
administration of prophylactic doses of enoxaparin.
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Enoxaparin may be administered 4 hours AFTER spinal/epidural catheter REMOVAL
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Enoxaparin should not be administered for 12 hours after insertion of external ventricular drains,
spinal drains or intracranial press monitors
Rivaroxaban
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See flow-chart for elective hip or knee replacements
Rapid reversal of Enoxaparin if bleeding occurs
Administer 40mg IV Protamine Sulphate given slowly at 5mg/min.
This may need to be repeated due to the continuous absorption of Enoxaparin.
Before discharge
For all patients
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Offer information on signs and symptoms of DVT and PE, and the importance of seeking medical help
and who to contact if DVT, PE or other adverse event is suspected
Complete a formal review at discharge and document any need for extended prophylaxis on the
discharge summary and ensure that it is prescribed
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For patients discharged on VTE prophylaxis
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Offer information on the correct use and duration of VTE prophylaxis to be used at home. Also, offer
information on signs and symptoms of adverse events related to VTE prophylaxis, and who to contact
for help.
Ensure patients are able to use VTE prophylaxis at home or have someone to help them
Inform GP if patient is discharged with VTE prophylaxis and of any monitoring requirements
Patients who are discharged on Enoxaparin should be given a suitable sharps bin from the ward. These
are provided free of charge from the manufacturer and are available on wards discharging patients on
extended thromboprophylaxis. Information on the disposal of used sharps is available on the Staffnet
http://staffnet/Departments/DivisionC/SupportServices/Pharmacy/Pharmacy.aspx
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For patients having elective surgery
Including patients with stroke, cancer, or central venous catheters
Oral contraceptives and HRT: Advise women to consider stopping oestrogen-containing contraceptives or HRT 4 weeks before surgery.
Pre-existing antiplatelet therapy: Assess risks and benefits of stopping pre-existing antiplatelet therapy 1 week before surgery. Consider involving the multidisciplinary team in the assessment.
Anaesthesia
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Consider regional anaesthesia, in addition to other methods of VTE prophylaxis, as it carries a lower risk of VTE than general anaesthesia. Take into account patient preferences, suitability for regional anaesthesia and
any other planned method of VTE prophylaxis.
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If regional anaesthesia is used, plan the timing of pharmacological prophylaxis to minimise risk of epidural haematoma. If antiplatelet or anticoagulant agents are being used or their use is planned, refer to the summary of
product characteristics for guidance about safety and timing of these agents in relation to regional anaesthesia.
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Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients having surgery with local anaesthesia by local infiltration with no limitation of mobility.
Is the patient expected to have significantly
reduced mobility relative to normal state?
Yes
No
Carry out full VTE and bleeding risk
assessment
Do not routinely offer prophylaxis
Reassess within 24 hours of admission and
whenever clinical situation changes
Does risk of bleeding outweigh risk of VTE
or is pharmacological prophylaxis
contra-indicated?
Yes
No
Has patient been
admitted for stroke?
No
Surgery including cardiac, gastrointestinal, gynaecological, thoracic, vascular,
urological, neurological (cranial or spinal), and day surgery
Offer mechanical VTE prophylaxis at admission. (See mechanical VTE prophylaxis section)
Continue until mobility no longer significantly reduced.
Consider offering
mechanical VTE
prophylaxis with:
AES (thigh or knee length)
and / or IPC or Foot
impulse devices
Is patient having neurological surgery and has ruptured cranial or spinal
vascular malformations (for example, brain aneurysms), or acute traumatic
or non-traumatic haemorrhage?
Do not offer AES for VTE
prophylaxis
Does patient have major
restriction of mobility, previous
history of VTE, dehydration or
comorbidity (e.g. malignant
disease)?
Reassess VTE and
bleeding risk within 24
hours of admission and
whenever clinical situation
changes
No
No
Offer VTE prophylaxis according to reason for admission
Pregnancy and up to 6 weeks post partum - for further information refer to
“Thromboprophylaxis and Thrombophilia in Pregnancy Guideline” on SUHTranet
Yes
Add Enoxaparin or Heparin as per renal
function and body weight.
Continue until mobility no longer significantly
reduced, (generally 5-7 days)
Do not offer Enoxaparin or Heparin until
lesion is secured or condition stabilised
Woman admitted to hospital during pregnancy or up to
6 weeks post partum
Surgery (including caesarean
section) planned?
If major cancer surgery in the
abdomen or pelvis
Yes
Haemorrhagic stroke
excluded?
Consider offering foot
impulse or intermittent
pneumatic compression
device until patient can
have pharmacological
VTE prophylaxis
No
Yes
Yes
Continue Enoxaparin or Heparin as per renal
function and body weight for 28 days after
surgery
Consider offering
mechanical and
pharmacological VTE
prophylaxis as per
separate guideline.
Major trauma or spinal injury
Risk of bleeding (haemorrhagic
transformation of stroke or
bleeding into another site) low?
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If VTE risk outweighs risk of
bleeding and bleeding risk is low
Yes
When acute event over and
patient’s condition stable
Stop pharmacological
prophylaxis
Palliative care patients
If patient has potentially
reversible acute pathology
Consider offering Enoxaparin or Heparin as
per renal function and body weight.
No
If one or more risk
factors, consider offering
pharmacological VTE
prophylaxis as per
separate guideline.
Offer mechanical VTE prophylaxis at admission as soon as clinically possible.
Continue until mobility no longer significantly reduced.
No
Offer Enoxaparin or Heparin as per renal
function and body weight.
Continue until mobility no longer significantly
reduced.
Take into account
planned
interventions and
other therapies that
may increase risk of
complications.
Consider offering
Heparin 5000 Units
BD regardless of
renal function.
Reassess risks of VTE and bleeding and review decisions about
VTE prophylaxis daily - more frequently if clinical condition is
changing rapidly
Take into account known views of the patient, family and/or carers
and multidisciplinary team.
If risk of major bleeding low
Yes
Consider offering
Enoxaparin or Heparin as
per renal function and
body weight.
Assess VTE and bleeding risk on admission to critical care unit
If VTE risk increased
Offer Enoxaparin or Heparin as per renal
function and body weight.
Continue until patient no longer at increased
risk of VTE.
Critical Care
Regularly reassess VTE
and bleeding risk
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Before offering VTE prophylaxis:
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Assess the risks and benefits
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Discuss VTE prophylaxis with the woman and
with healthcare professionals who have
knowledge of the proposed method of
prophylaxis during pregnancy and post partum.
Plan timing of VTE prophylaxis to minimise risk of
bleeding.
Risk Factors
• Expected to have significantly
reduced mobility for ≥ 3 day
• Active cancer or cancer
treatment
• Age > 35 years
• Critical care admission
• Dehydration
• Excess blood loss or blood
transfusion
• Known thrombophilias
• Obesity (pre-pregnancy or early
pregnancy BMI > 30kg/m2
• Significant medical comorbidity
(such as heart disease,
metabolic,endocrine or
respiratory pathologies, acute
infectious diseases or
inflammatory conditions)
• Personal history or first-degree
relative with history
of VTE
• Pregnancy-related risk factor
including ovarian
hyperstimulation, hyperemesis
gravidarum, multiple pregnancy,
pre-eclampsia
• Varicose veins with phlebitis
Orthopaedic Surgery and Trauma
Elective hip (THR) or knee replacement (TKR)
Hip fracture (including #NOF)
Offer IPC in recovery and continue for as long as tolerated.
Continue mechanical prophylaxis until mobility no longer
significantly reduced.
Offer IPC at admission (in Emergency Department) and continue
for as long as tolerated.
Continue mechanical prophylaxis until mobility no longer
significantly reduced.
If patient in terminal care or
end-of-life care pathway
Do not routinely offer pharmacological or
mechanical VTE prophylaxis
Review decisions about VTE prophylaxis daily, taking into account potential risks and benefits and
views of the patient, family and/or carers and multidisciplinary team.
Lower limb plaster casts
If VTE risk increased, consider offering Enoxaparin or Heparin as per renal function and body
weight after evaluating risks and benefits and based on clinical discussion with the patient.
Continue until plaster cast removed.
GU-084 Thromboprophylaxis and Risk Assessment Guideline for Adults
Provided there are no contraindications, offer Rivaroxaban 10mg
OD starting at 9am on day 1 post-op.
Continue for 35 days for THR, and 14 days for TKR
Rivaroxaban not recommended if eGFR < 15 ml/min/1.73m2 Use
with caution in patients with eGFR 15-29 ml/min/1.73m2
Patients with an epidural/spinal catheter, or contra-indication
to Rivaroxaban: offer Enoxaparin or Heparin as per renal
function and body weight. Continue Enoxaparin for 28 days for
THR, and 10 days for TKR.
Consider switching to Rivaroxaban at least 1 day after removal
of the epidural/spinal catheter.
Issued: July 2010 Review date: July 2013
Provided there are no contraindications, offer Enoxaparin or
Heparin as per renal function and body weight starting at 5pm on
day 1 post-op (24 hours).
Continue for 28 days.
If the patient is unable to self-inject on discharge, consider
offering Rivaroxaban 10mg OD to complete 35 days post-op
VTE prophylaxis. This is an un-licensed indication and is only to
be used if the Consultant accepts responsibility.
Other orthopaedic surgery and trauma
Upper limb (surgery or trauma)?
Yes
Do not routinely offer VTE
prophylaxis
No
If VTE risk increased and
after assessing risks and
discussing with patient:
Consider offering mechanical VTE prophylaxis and/or
Enoxaparin or Heparin as per renal function and body weight.
Continue until mobility no longer significantly reduced.
Disclaimer: It is your responsibility to check against SUHTranet that this is the most recent issue of this document.