Venous thromboembolism (VTE) still accounts for a significant proportion of avoidable hospital deaths. In an effort to tackle this problem NICE produced guidelines in 2010.
- advise women to consider stopping oestrogen-containing oral contraception or HRT 4 weeks before surgery.
- assess the risks and benefits of stopping antiplatelet therapy 1 week before surgery.
The following patients are deemed at risk of VTE
- if mobility significantly reduced for >= 3 days or
- if expected to have ongoing reduced mobility relative to normal state plus any VTE risk factor (see below)
Surgical patients and patients with trauma
- if total anaesthetic + surgical time > 90 minutes or
- if surgery involves pelvis or lower limb and total anaesthetic + surgical time > 60 minutes or
- if acute surgical admission with inflammatory or intra-abdominal condition or
- if expected to have significant reduction in mobility or
- if any VTE risk factor present (see below)
VTE risk factors
- active cancer or cancer treatment
- age > 60 years
- critical care admission
- known thrombophilias
- obesity (BMI > 30 kg/m2)
- one or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions)
- personal history or first-degree relative with a history of VTE
- use of HRT
- use of oestrogen-containing contraceptive therapy
- varicose veins with phlebitis
In-patient VTE prophylaxis
As a general rule pharmacological VTE prophylaxis is used for medical patients unless there is a contraindication.
For surgical patients mechanical VTE prophylaxis is offered for patients at risk. Pharmacological VTE prophylaxis is also given for if the risk of major bleeding is low.
Pharmacological VTE prophylaxis options:
- fondaparinux sodium
- low molecular weight heparin (LMWH)
- unfractionated heparin (UFH) (for patients with renal failure)
Mechanical VTE prophylaxis options:
- anti-embolism stockings (thigh or knee length)
- foot impulse devices
- intermittent pneumatic compression devices (thigh or knee length)
Post-procedure VTE prophylaxis
For certain procedures pharmacological VTE prophylaxis is recommended for all patients, using one of the following:
- dabigatran, started 14 hours after surgery
- fondaparinux, started 6 hours after surgery
- LMWH, started 6-12 hours after surgery
- rivaroxaban, started 6-10 hours after surgery.