Thromboprophylaxis Guidelines for Patients Undergoing Urological Surgery

• 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 urology 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

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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 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 on ppm+)
• Bleeding Risks / contraindications (see VTE assessment form on ppm+)
• Procedure Risk Factors (see below)

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

Treatment Pathway: Thromboprophylaxis in the Urological Surgical Patient

Patients should be reassessed for bleeding risk and VTE risk 24 - 48 hours post admission, at Consultant review and whenever their clinical condition changes, as per NICE guidance. Reassessment of risk should also be carried out every 5 - 7 days during the patients stay in hospital.

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 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
• Pregnant or up to 6 weeks post-partum, termination or miscarriage within last 6 weeks

Surgical risk factors

• 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)

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.

1.6 Extended Prophylaxis

The following procedures should receive extended thromboprophylaxis:

Lap Deroofing Cyst; Lap Nephrectomy - Benign; Lap Radical < T1b;; Lap Partial Nephrectomy - 7 days
Malignant - Lap Radical Nephrectomy > T2; Major open nephrectomy, Cystectomy, Open radical prostatectomy, Robotic Prostatectomy, Retroperitoneal Lymph Node Dissection, Ureterolysis - 28days

Patients undergoing procedures which do not fall into the above categories should be reviewed by the operating surgeon individually and a plan for VTE prophylaxis post op documented in the operation note. Where there is no such documentation and it is unclear whether the patient needs extended post-operative prophylaxis, the consultant must be contacted. 

1.7 Patients on Oral Anticoagulants

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

Warfarin in patients undergoing elective procedures

Direct Oral Anticoagulants for Patients Undergoing Elective Procedures

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 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

1.11 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

1.12 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.

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