DVT prophylaxis for the surgical patient

DVT prophylaxis in the adult general surgical patient

The application of effective prophylaxis depends on knowledge of specific clinical risk factors and the proposed surgical procedure. Weigh risk of VTE versus potential complications of bleeding
VTE risk should be assigned at the Pre-Admission Clinic
Prior to commencement of prophylaxis exclude contraindications to anticoagulant therapy (page 5)
In the setting of ongoing bleeding, abnormal coagulation and intra operative blood loss ≥ 500 ml; initiation of prophylaxis may need to be delayed. In these settings Consultant approval is required prior to initiating prophylaxis.
In very high-risk surgery or where patient has been identified as being at particular high risk of VTE e.g. previous history of post-operative pulmonary embolus (PE) and/or deep vein thrombosis (DVT) with standard prophylaxis, or multiple risk factors, discuss dose and duration of VTE prophylaxis with Haematology Unit.
Patients who are to be discharged within 24 hours of surgery & deemed to be High Risk of VTE must be discussed with the Haematology Unit prior to discharge.
Patients who are to remain as inpatients please follow recommendations set out below for subsequent VTE prophylaxis.
Neuraxial anaesthesia/analgesia: consult precautions below
A minimum of 10 days prophylaxis is recommended for patients assessed as at high risk of VTE
In orthopedic surgical patients and patients having major curative surgery for cancer, where there is no contra-indication, the option of extended (to 4 weeks) post-operative VTE prophylaxis with daily subcut Enoxaparin is recommended.
For those patients (as above point) not deemed eligible for extended post op prophylaxis then prophylaxis should continue until the patient is mobile.
Assess VTE risk, consider following recommendations and discuss with Consultant
Note: Major surgery is any intraabdominal operation and all other operations lasting more than 45 minutes
# Precaution: In patients with creatinine clearance ≤30mls/min use no more than 20mg 24 hourly of enoxaparin for VTE prophylaxis.

VTE risk and management guidelines


VTE risk	Surgery	Recommendation
Low risk	• Uncomplicated minor surgery in patients <40 years without VTE risk factors. • Any age brief gynaecological surgery – benign disease • Any age TURP	• No specific measures. • Early mobilisation
Moderate risk	• Patients <40 yrs having major general or gynaecological surgery without VTE risk factors • Patients 40 -60 years having non-major general/gynaecological surgery without VTE risk factors • Non major general/gynaecological surgery with VTE risk factors • Minor surgery in patients with risk factors. • Non major lower limb, non-orthopaedic surgery in particular where a tourniquet is applied • Non major lower limb surgery e.g. arthroscopy in patients without VTE risk factors	Enoxaparin 40mg# subcut 24 hourly • The initial dose should preferably be given on the evening of the day of surgery (i.e. post procedure) or commenced the next morning after review • Multiple trauma: if bleeding has been controlled and thromboprophylaxis is considered safe
High to Very High risk	• Major surgery in patients >40 years with previous VTE, malignancy and hypercoagulable state or at least 2 VTE risk factors • Surgery in patients >60 years without VTE risk factors (excluding major lower limb orthopaedic surgery). • Hip fractures requiring surgery: If surgery is likely to be delayed, initiation of prophylaxis during the time between admission and surgery is recommended • Major lower limb orthopaedic surgery e.g. THR/TKR • Non major lower limb orthopaedic surgery with VTE risk factors Spinal cord injury - see special note in recommendations:	Enoxaparin 40mg# subcut 24 hourly • There is no definitive data for pre or perioperative use of VTE prophylaxis with Enoxaparin • The timing of the initial dose of prophylactic Enoxaparin should be based on the efficacy-to-bleeding tradeoffs • For major orthopaedic surgery there is no advantage in preop administration provided that the first postoperative dose is administered approx 6 hours after surgery • In patients who are at high risk for bleeding, the initial dose should be delayed for 12 to 24 hours after surgery and until primary haemostasis has been demonstrated & Consultant approval given. • Where neuraxial anaesthesia /analgesia is planned or insitu see precautions below • Intermittent pneumatic compression • graded compression elastic stockings Spinal cord injury: • Consider prophylaxis & must discuss with trauma &/or neurosurgery Units. • Enoxaparin 40mg#, subcut 24 hourly • Consider post acute stage warfarinisation