Thromboprophylaxis in ENT

• 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 ENT surgery including Head and Neck Surgery performed by ENT surgeons.

Back to top

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

Back to top

Risk Assessment

Leeds Teaching Hospitals risk assessment tool is used to stratify the risk of VTE for each patient.
The attached algorithm will be used to decide prophylactic treatment for ENT and Head and Neck surgery see text below.

Back to top

Treatment/Management

ENT (non head and neck patients)

Clinical algorithms see ENT pathway.

For non head and neck surgery patients.
Patients undergoing ENT non head and neck surgery will be assessed for VTE risk factors and bleeding risk using the trust risk assessment tool.  The ENT flow algorithyms will determine the treatment.  Those patients identified as having a risk factor for venous thromboemobolism will be treated with anti-embolic stockings (providing no contra-indications - see below and link.

Non head and neck patients who have a past history of deep vein thrombosis (DVT) or pulmonary embolism (PE) will be given low molecular weight heparin.  If low molecular weight heparin is required patients should be prescribed enoxaparin 40mg daily commencing 12 hours prior to surgery until the patient is fully mobile for in-patients.  In the unusual occurrence of a day patient requiring low molecular weight heparin a single dose will be given once back from surgery.  For patients with impaired renal function and extremes of weight see dosing charts below.

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

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

Head and Neck Surgery patients
These patients will be risk assessed using the trust risk assessment tool. For those with identified risk factors the below protocol should be followed.

Anti embolic stockings only for:-

• Small Head and Neck cases
• Submandibular gland surgery
• Neck nodes
• Thyroglossal cysts
• Branchial cysts
• Parotid surgery
• Thyroid surgery

Anti embolic stockings and Flotrons for:-

• Neck dissections
• Laryngectomies

Anti embolic stockings, Flotrons and LMWH for:-

• Patients with previous thromboemobolic disease
• Patients with antiphospholipid syndrome, protein C and protein S deficiency.
• Patients who will be slow to mobilize e.g. patients with flaps or have predicted longer ICU/HDU stays (e.g. respiratory problems)

For patients requiring low molecular weight heparin the policy will be to give enoxaparin 40mg daily starting 12 hours prior to surgery until the patient is fully mobile.  Patients with a creatinine clearance less than 30mls/minute will be given enoxaparin 20mg daily.

Anti Embolic Stockings. are contra indicated in patients with:-

• Suspected/proven peripheral vascular disease
• Peripheral arterial bypass graft
• Peripheral neuropathy
• Recent skin graft
• Cardiac failure / leg oedema
• Limb deformity

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

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

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. Do not use if the patient has a latex allergy.

Back to top