Thromboprophylaxis Guidelines for Thoracic Surgical Patients

• Background
• Risk Assessment
• Treatment

Aims

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

Background

NICE clinical guideline 92; Venous thromboembolism: reducing the risk was issued in January 2010. 
NICE NG 89 Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism issued March 2018.

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Risk Assessment

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

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Treatment / Management

1.1 General Information
All patients are risk assessed on admission and identified for risk of VTE and risk of bleeding. This should comprise of: -

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

The most appropriate thromboprophylaxis is then prescribed within 14 hours of admission.

Treatment Pathway: Thromboprophylaxis in the Surgical Patient

• Start mechanical VTE prophylaxis on admission for people undergoing thoracic surgery. Choose either: anti-embolism stockings or intermittent pneumatic compression.
• Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility.
• Consider adding pharmacological VTE prophylaxis for people undergoing thoracic surgery whose risk of VTE outweighs their risk of bleeding:
• Use LMWH [4] as first-line treatment. If LMWH [4] is contraindicated due to heparin allergy, use fondaparinux sodium. If contraindicated due to HIT or other reasons discuss with haematology.

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

Patients should be reassessed for bleeding risk and VTE risk at consultant review and when clinical condition changes.

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

1.2 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.

1.3 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 prior to starting an epidural / spinal anaesthesia
• Do not restart LMWH till 4 hours after epidural / spinal anaesthesia removed

1.4 Risk Factors for Bleeding

• 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 >2 or  apixaban, dabigatran, edoxaban, rivaroxaban or INR greater than 2
• Acute stroke
• Thrombocytopenia (platelets less than 75x10⁹/l).
• Uncontrolled systolic hypertension (230/120 mmHg)

1.5 Extended Prophylaxis

1. Extend VTE prophylaxis to 28 days postoperatively for patients who have had *major thoracic cancer operations.
2. Extended VTE prophylaxis to 7 days postoperatively for patients who have undergone major thoracic surgery without a cancer diagnosis who also meet one or more of the following criteria:
   1. The patient has undergone a surgical procedure with a total anaesthetic/surgical time of more than 90 minutes
   2. An open surgical procedure was used
   3. The patient is expected to have a significant reduction in mobility
   4. The patient has undergone a procedure which caused compression of the femoral arteries due to positioning

*major thoracic surgery includes the following:
Pneumonectomy, lobectomy, wedge resection, segmentectomy.

For all OTHER thoracic surgical procedures, the duration of VTE prophylaxis should be clearly stated on the patient’s post-op notes.

Continue extended thromboprophylaxis at a weight-adjusted dose where patients are <50 or >100kg

1.6 VTE Risk Factors -
Patient risk factors see Risk assessment form

• Active Cancer treatment
• Age over 60 years
• Critical Care admission
• 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)
• History of VTE
• Use of hormone replacement therapy
• Use of oestrogen containing contraceptive therapy
• Varicose veins with phlebitis

Surgical risk factors see surgical procedure table

• Surgical procedure longer than 90 minutes, or 60 minutes for pelvis/lower limb surgery
• Acute surgical admission with inflammatory or intra-abdominal condition
• Expected significant reduction in mobility (see section 1.3 of guideline)

Consideration should be given to cease hormone replacement therapy or oestrogen containing contraceptives for 4 weeks prior to surgery, where possible, to reduce VTE risk.

1.7 Patients on Oral Anticoagulants
The guidance regarding bridging therapy for patients taking oral anticoagulants undergoing elective surgical procedures should be followed. (http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=3084)

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

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

1.10 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

1.11 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 transferred to medically optimised wards should have their VTE prophylaxis reviewed prior to discharge and the decision documented