VTE Prophylaxis for Neurological Surgery patients - Reducing the risk of venous thromboembolism

Publication: 01/08/2010  --
Last review: 31/10/2017  
Next review: 31/10/2020  
Clinical Guideline
CURRENT 
ID: 2044 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Thromboprophylaxis Guidelines for Cranial or Spinal Patients Managed by Neurosurgeons

 Flowchart

Background
Risk Assessment
Treatment/Management

Background

NICE clinical guideline 92; Venous thromboembolism: reducing the risk was issued in January 2010, updated June 2015.

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Risk Assessment

Leeds Teaching Hospitals risk assessment tool is used to stratify the risk of VTE for each patient.

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Treatment / Management

Clinical algorithm

On admission to hospital all patients should be risk assessed and identified for risk of VTE and risk of bleeding using the Leeds Teaching Hospitals risk assessment tool. This should be completed electronically via PPM+ whenever possible. If electronic completion is not possible, a paper risk assessment form should be completed. If thromboprophylaxis is indicated it should then be prescribed appropriately.

VTE risk assessment should be repeated 24 - 48 hours after admission and then whenever the clinical situation changes or at least weekly. VTEs have occurred in neurosurgery patients when patients have not had their VTE risk regularly reviewed

Significantly reduced mobility is defined as patients who are bedbound, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair which is different to mobility pre-admission.

For women who are pregnant or have given birth within 6 weeks see separate guidance / seek advice.

Patients undergoing Spinal/regional analgesia
For patients who will be receiving a lumbar puncture/epidural/spinal anaesthesia see “Clinical Practice Guidelines for the Delivery of Epidural and Paravertebral Analgesia in Adult Acute Pain Management”: -

  • Do not give Low Molecular Weight Heparin (LMWH) within 12 hours of starting an epidural / spinal anaesthesia
  • Do not restart LMWH until 4 hours after epidural / spinal anaesthesia is discontinued

VTE Risk Factors

  • Active Cancer treatment
  • Age over 60 years
  • Dehydration
  • Known thrombophilias
  • Obesity (BMI over 30kg/m2)
  • One or more significant medical comorbidities e.g. heart disease, metabolic, endocrine or respiratory pathologies, acute infectious disease or inflammatory conditions)
  • Personal history of VTE or first degree relative with a history of VTE
  • Use of hormone replacement therapy
  • Use of oestrogen containing contraceptive therapy
  • Varicose veins with phlebitis
  • Critical Care admission
  • Total anaesthetic + surgical time > 90 minutes
  • Significantly reduced mobility for 3 days or more

Risk Factors for Bleeding

  • Active bleeding
  • Acquired bleeding disorders e.g. acute liver failure
  • Concurrent use of anticoagulants e.g. warfarin with therapeutic INR, apixaban, dabigatran, edoxaban, rivaroxaban
  • Acute stroke
  • Thrombocytopenia (platelets < 75 x 109 / L)
  • Uncontrolled systolic hypertension (230/120 mmHg or higher)
  • Untreated inherited bleeding disorders e.g. haemophilia

Mechanical Prophylaxis
All patients should be fitted with anti-embolism stockings (AES) on admission (unless they are contraindicated) and should continue to wear them until they no longer have significantly reduced mobility. If AES are contraindicated medical staff should prescribe intermittent pneumatic compression devices (unless contraindicated).

Low Molecular Weight Heparins (LMWH)
The LMWH of choice at Leeds Teaching Hospitals NHS Trust is tinzaparin. Patients with creatinine clearance <20mL/min should receive enoxaparin.

Prescribing guidelines
Complete the Leeds Teaching Hospitals VTE risk assessment tool for every patient admitted for neurosurgery, if LMWH is indicated then prescribe:

  • Tinzaparin 4500 units s/c daily
  • If patient’s weight is <50kg prescribe tinzaparin 2500 units s/c daily
  • If patient’s weight is >100kg prescribe tinzaparin 50units/kg s/c daily and round to the nearest measurable dose. Refer to LMWH prophylactic dosing at extremes of body weight guideline
  • If patient’s creatinine clearance is <20mL/min and weight <100kg prescribe enoxaparin 20mg s/c daily. If the patient weighs >100kg refer to LMWH prophylactic dosing at extremes of body weight guideline

Both products are of porcine origin. If patients refuse LMWH based on religious or other grounds the synthetic product fondaparinux may be used 2.5mg s/c injection once a day if creatinine clearance > 50ml/min or 1.5mg s/c injection if creatinine clearance 20-50ml/min. Do not use if the patient has a latex allergy.

Patients on Oral Anticoagulants - see peri-operative management of warfarin guideline and peri-operative management of NOAC guideline

Monitoring for Heparin Induced Thrombocytopenia (HIT)
All patients started on any type of heparin should have a baseline platelet count performed.
For patients who have received heparin of any form in the previous 100 days a platelet count at 24 hours is advised.
Further monitoring is not required for patients on low molecular weight heparin (LMWH).
If HIT is suspected please refer to the Guideline on Diagnosis and Management of HIT
This is based on national guidance from the British Committee for Standards in Haematology November 2012.

Provenance

Record: 2044
Objective:

Aims
Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital for cranial or spinal surgery

Objectives
To provide evidence-based recommendations for appropriate venous thromboembolism (VTE) risk assessment and management of patients admitted to hospital

Clinical condition:

Venous thromboembolism prophylaxis

Target patient group: Patients undergoing Spinal or cranial surgery
Target professional group(s): Secondary Care Doctors
Pharmacists
Secondary Care Nurses
Adapted from:

Evidence base

NICE Clinical Guideline 92

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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