Thromboprophylaxis Guidelines for Upper Gastrointestinal and Hepatobiliary Surgical Patients

• 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 Upper Gastrointestinal and Hepatobiliary 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

1.1 General Information

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

• Individual Patient risk factors (see VTE assessment form)
• Bleeding Risks / contraindications (see VTE assessment form)
• Procedure Risk Factors (see attached table for surgical specialty)

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

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

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

Patients should be reassessed for bleeding risk and VTE risk within 24 - 48 hours of admission, as per NICE guidance. Reassessment of risk should also be carried out every 5 - 7 days during the patients stay in hospital.

Mechanical VTE prophylaxis (either anti-embolism stockings or intermittent pneumatic compression) should be started on admission for patient’s undergoing abdominal surgery. This should continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility.

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

1.2 Day surgery / Same day of surgery (SDOS) admission

See separate guidance for patients being admitted for SDOS

1.3 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.

1.4 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

1.5 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)
• Lumbar puncture/ epidural/ spinal anaesthesia expected within the next 12 hours

1.6 Extended Prophylaxis

Add pharmacological VTE prophylaxis for a minimum of 7 days for people undergoing abdominal surgery whose risk of VTE outweighs their risk of bleeding, taking into account individual patient factors and according to clinical judgement. If this is indicated, it should be clearly documented on the patient’s post-op note.

Patients undergoing surgery for cancer in the abdomen or pelvis should be considered for extended pharmacological VTE prophylaxis for up to 28 days. This includes:

• Oesophagectomy - 28 days
• Gastrectomy (total or partial) - 28 days
• Whipple's procedure/pancreaticoduodenectomy/PPPD - 28 days
• Bariatric surgery (gastric band/sleeve gastrectomy/Roux-en-Y gastric bypass) - 28 days

Please note that extended thromboprophylaxis should be prescribed and at a weight-adjusted dose where patients are <50 or >100kg

1.7 VTE Risk Factors -

Patient risk factors see Risk assessment form

• Active Cancer treatment
• Age over 60 years
• Critical Care admission
• Pro-thrombotic state (e.g dehydration, acute infection)
• Known thrombophilia
• 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 or first degree relative with a history of VTE
• Use of hormone replacement therapy
• Use of oestrogen containing contraceptive therapy
• Varicose veins with phlebitis
• Pregnancy or < 6 weeks post partum or miscarriage within the last 6 weeks

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.

1.8 Patients on Oral Anticoagulants

The guidance regarding bridging therapy for patients taking oral anticoagulants undergoing elective surgical procedures should be followed.

1.9 Patients under 50kg and over 100kg

Patients weighing under 50kg should be prescribed enoxaparin 20mg s/c daily. Patients weighing over 100kg should be prescribed enoxaparin 40mg twice daily unless they have renal impairment or weigh over 150kg - see dosing charts above for those patients.

1.10 Patients with creatinine clearance < 20ml/min

Patients with creatinine clearance < 30ml/min should be prescribed enoxaparin 20mg. For patients <50kg or >100kg and renal impairment see dosing charts above.

1.11 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

1.12 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

1.13 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