Thromboprophylaxis Guidelines for Liver Transpant Surgical Patients (all recipients and living-donors)

• 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 initial liver transplant surgery.

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.

Back to top

Treatment / Management

Transplant Recipients
All new liver transplant recipients will qualify for VTE risk assessment. This assessment is undertaken by the clerking doctor on admission to ward 83 ahead of surgery. The VTE risk assessment tool is available in electronic format which is accessible through PPM+.

This guideline only applies to the transplant surgical admission for the patient.

Pre-operative anticoagulation with oral anticoagulants is reversed, either by omission of anticoagulant in planned live donation or pharmacologically when a patient is called for a deceased-donor organ.

Patients will be prescribed prophylactic enoxaparin see doing chart 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 first dose of enoxaparin will be administered on day 0 and should only be withheld if the patient returns from theatre within 4 hours of the scheduled dose or contraindicated as per platelets or INR as per below. Subsequent doses will be given at 6pm each day. Patients with a GFR<30mL/min should receive enoxaparin 20mg sc once daily at 6pm.

Patients will not receive either enoxaparin or aspirin if they have an INR > 2 or a platelet count of <50 x 10⁹/L. Prescribers should identify this on the inpatient chart and suspend the medicine on the Emeds system so that it not accidentally administered.

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 LMWH within 12 hours of starting an epidural / spinal anaesthesia
·  Do not restart LMWH until 4 hours after epidural / spinal anaesthesia removed

Liver transplant biopsy is a procedure-related high bleeding risk which warrants omission of enoxaparin in the previous 24 hours if possible. Where not possible to omit in advance this requires discussion with the consultant surgeon or hepatologist ‘on’ for the week.

Mechanical Prophylaxis
All patients will be prescribed below-knee, graduated compression stockings on admission to be worn until discharge or review unless any of the following apply:

Do not offer anti-embolism stockings to people who have:

• suspected or proven peripheral arterial disease
• peripheral arterial bypass grafting
• peripheral neuropathy or other causes of sensory impairment
• any local conditions in which anti-embolism stockings may cause damage – for example, fragile 'tissue paper' skin, dermatitis, gangrene or recent skin graft
• known allergy to material of manufacture
• severe leg oedema
• major limb deformity or unusual leg size or shape preventing correct fit.
  
  

Use caution and clinical judgement when applying anti-embolism stockings over venous ulcers or wounds

Guideline for the care of patients wearing anti-embolic stockings.

If the surgical team feels that the patient requires intermittent pneumatic compression (flowtrons) then these can be prescribed instead of anti-embolism stockings. These should then however be carried on post-surgery and not be switched to anti-embolism stockings on step down to the ward.

Patients will be reassessed for bleeding risk and VTE risk on the daily, consultant-led ward rounds commencing within 24 hours of admission, as per NICE guidance. The re-assessment 24 hours after admission should be documented on the e-whiteboard

Living-donor transplant hepatectomy patients
All donors require VTE prophylaxis. Each will be prescribed enoxaparin 40mg sub-cutaneous injection once daily at 6pm (or lower/higher based on weight as above). This should continue until the patient no longer has significantly reduced mobility, which is considered to be until 6 weeks post-op.
On discharge the patient will be prescribed the remainder of the 6 week course on his or her discharge advice note to be administered at home.

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

Back to top