Thromboprophylaxis in General Medical Patients All Ages

• Aims
• Background
• Risk Assessment
• Treatment/Management

Aims

Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital to a medical admissions ward (including elderly admissions).

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Background

NICE clinical guideline 92; Venous thromboembolism: reducing the risk was issued in January 2010. NICE clinical guideline NG89 Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism was issued in March 2018

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Risk Assessment

Leeds Teaching Hospitals risk assessment tool on PPM+ used …Yes

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Treatment/Management

All patients should be risk assessed for VTE and bleeding risk on admission or by the time of first consultant review. This should be repeated at consultant review and whenever the clinical situation changes.

If a patient requires thromboprophylaxis enoxaparin is the low molecular weight heparin (LMWH) of choice and should be started within 14 hours of admission.

Usual dose 40mg s/c once a day.

Patients who weigh < 50kg or > 100kg and those with creatinine clearance < 30ml/min see dosing charts below. Ensure weight is recorded on the patient’s electronic record.

Enoxaparin Dosing for patients with creatinine clearance (CrCl) over 30mL/min

Enoxaparin Dosing for patients with creatinine clearance (CrCl) less than 30mL/min

NICE states “to offer pharmacological VTE prophylaxis for a minimum of 7 days to acutely ill medical patients whose risk of VTE outweighs their risk of bleeding.” Patients should be assessed at discharge and those with a high risk of VTE and on-going risk factors can be considered for extended prophylaxis as per NICE but it was not felt by the CSU or TSG to be required for all patients.

Patients with symptomatic Covid 19 pneumonia
For patients with symptomatic Covid 19 pneumonia please refer to the Diagnosis and Management of COVID-19 Coagulopathy, Prevention and Management of Venous Thromboembolism in COVID-19 Pneumonia guideline which can be found on Leeds Health Pathways

All heparins are porcine based. If patients do not want a porcine based product consider fondaparinux 2.5mg s/c once a day reduced to 1.5mg s/c once a day if CrCl 20-50ml/min) Contra-indicated if CrCl < 20ml/min

Falls risk: If the patient is at risk of falls consider their risk and VTE risk and document decision regarding prophylaxis. Ensure this is regularly reviewed at consultant review and documented.

Intermittent Pneumatic Compression Devices
The patient groups detailed below should be prescribed and fitted with intermittent pneumatic compression devices (IPCs) if they are unable to walk independently. IPCs should be taken off when the patient becomes independently mobile (able to walk to the toilet without the help of another person).

• Acute stroke patients
• Patients with ICH

Intermittent pneumatic compression devices (IPCs) should be considered for the patient groups detailed below if they are unable to walk independently. IPCs should be taken off when the patient becomes independently mobile (able to walk to the toilet without the help of another person).

• Patients that are on anticoagulation for previous DVT/PE but anticoagulation is contraindicated during the admission
• Patients that are high risk for VTE with a sudden/significant reduction in mobility (eg bedbound) and in whom pharmacological prophylaxis is contraindicated

Patients on anti-platelets: Review bleeding risk and VTE risk. Patients with an increased VTE risk but low bleeding risk should be offered thromboprophylaxis. Patients with an increased VTE risk but high bleeding risk should be reviewed by a senior doctor and should have regular review. They could be considered for mechanical prophylaxis as per NICE 2018

Patients on warfarin with subtherapeutic INR, consider prophylactic or treatment dose LMWH depending on reason for anticoagulation. Recent DVT/PE/stroke or known metal valve use treatment dose LMWH. Ensure the INR is monitored regularly and stop LMWH once INR in range.

Patients on DOACs (direct oral antcioagulants), apixaban, dabigatran, edoxaban, rivaroxaban, should not receive pharmacological prophylaxis unless they are not able to take their oral anticoagulant.

Patient Information
All patients should be given verbal and written information on admission of their risk of VTE, what will happen, side effects and how they can reduce the risk. On discharge they should be given verbal and written information on signs and symptoms of VTE and what to do should they occur and how to use their thromboprophylaxis if required on discharge. Leaflet LN004075 contains this information and is available to order from the print unit

Information for Discharge
Notify the patient's GP if they have been discharged with pharmacological and/or mechanical VTE prophylaxis to be used at home.

Patients who are being discharged to medically optimised wards should have their VTE prophylaxis reviewed prior to discharge and the decision documented

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