Thromboprophylaxis Guidelines for Cranial or Spinal Patients Managed by Neurosurgeons

• Aims
• Background
• Risk Assessment
• Treatment/Management

Aims

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

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Background

NICE clinical guideline 92; Venous thromboembolism: reducing the risk was issued in January 2010, updated June 2015 and replaced by NICE guideline NG89 Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism in March 2018.

Leeds Teaching Hospitals are adding to Leeds Health Pathways local guidance for VTE risk assessment and management based on NICE guidance.

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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

1.1  Identification and risk assessment

All patients should be risk assessed and identified for risk of VTE and risk of bleeding using the Leeds Teaching Hospitals risk assessment tool as soon as possible after admission or by the time of first consultant review and always within 24 hours of admission.  

The risk assessment tool (available on PPM+) comprises of:

• Individual Patient risk factors (see VTE assessment form)
• Bleeding Risks / contraindications (see VTE assessment form)
• Procedure Risk Factors (see below)

The most appropriate thromboprophylaxis is then prescribed.

Also see Thromboprophylaxis pathway for neurosurgery patients (Flow chart)

1.2  Re-assessment of risk

Re-risk assessment should be done at the time of consultant review and whenever the clinical situation changes or at least every 5-7 days whilst in hospital. VTEs have occurred in neurosurgery patients when patients have not had their VTE risk regularly reviewed.

Patients who are suspected to have a deep vein thrombosis (DVT) or Pulmonary embolism (PE) will follow a standard clinical diagnostic assessment involving appropriate investigations. Details are available in the: “Guideline for Investigation and initial management of venous thromboembolism (VTE) in Leeds Teaching hospitals (LTH)”

1.3  Non-surgical VTE risk factors

• Active Cancer or 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

1.4 Surgical VTE risk factors

• Critical Care / acute surgical admission
• Total anaesthetic + surgical time > 90 minutes
• Significantly reduced mobility for 3 days or more

1.5 Non-surgical Risk Factors for Bleeding

• Current active bleeding
• Acquired bleeding disorders e.g. acute liver failure
• Untreated inherited bleeding disorders e.g. haemophilia
• Concurrent use of anticoagulants (e.g. warfarin*) with INR greater than 2
• Concurrent use of direct oral anticoagulants (DOAC’s), such as apixaban, dabigatran, edoxaban or rivaroxaban **
• Acute stroke
• Thrombocytopenia (platelets less than 75x10⁹/l)
• Uncontrolled systolic hypertension (230/120 mmHg)

1.6 Definition of reduced mobility

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.

1.7 Pregnancy and postpartum

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

1.8 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

1.9 External CSF Drains (Includes External Ventricular Drains and Lumbar Drains)

The presence of an indwelling CSF drain does not represent an absolute contraindication to LMWH prophylaxis. LMWH prophylaxis should be omitted the evening before (and morning of, if a BD dosage) planned drain removal.

1.10 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).

In elective spinal and cranial surgery NICE states to continue mechanical prophylaxis for 30 days or until the person is mobile or discharged, whichever is sooner.

1.11 LMWH prophylaxis

After completion of the Leeds Teaching Hospitals VTE risk assessment tool, if a LMWH is indicated for VTE prophylaxis then prescribe following the dosing tables detailed below.

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

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

The choice of Low Molecular Weight Heparin (LMWH) of for prophylactic use at Leeds Teaching Hospitals NHS Trust can vary and change.  LWMHs are based on weight and renal function.

1.12 All heparins are porcine based - fondaparinux use

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.

1.13 Duration / extended VTE prophylaxis

Continue the identified method of VTE prophylaxis for 30 days or until the person is mobile or discharged, whichever is sooner.

Note: NICE recommends if a LMWH is initiated in cranial surgery is should be continued for a minimum of 7 days.

Patients whose risk of VTE outweighs their risk of bleeding may require extended LMWH prophylaxis. After taking into account individual patient factors and according to clinical judgement, this decision should be made by multidisciplinary or senior opinion.

1.14 Heparin Induced Thrombocytopenia (HIT)

1.15 - Patients on Oral Anticoagulants

*Guidelines for the perioperative management of warfarin in patients undergoing elective procedures

**Guidelines for the Peri-operative Management of Direct Oral Anticoagulants (DOACs) for patients undergoing elective procedures

1.16 Patient Information

All patients should be given verbal and written information about their risk of VTE on admission this should include what will happen, side effects and how they can help to reduce the risk.

On discharge they should be given verbal and written information about the signs and symptoms of VTE and what to do should they occur, they should also be given instructions on how to use their thromboprophylaxis if required on discharge and how long it should continue for.

Leaflet LN004075 contains this information and is available to order from the print unit -

1.17 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. Ensure the patient has been educated on how to administer or an appropriate healthcare professional can inject whilst at home (such as district nurses). Further information can be found here.

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