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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

dvt_proph_surg.txt · Last modified: 2011/01/28 03:45 by

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