DVT prophylaxis for the surgical patient
As at 2010 for Western Health:
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
|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:
• 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