VTE PROPHYLAXIS

• Complete inpatient venous thromboembolism risk assessment proforma
• for pregnant and postpartum patients, use obstetric risk assessment proforma
• sign, date and time the assessment proforma

When

• Within 12 hr of admission to hospital
• reassess within 24 hr
• whenever the clinical condition changes

General measures (GM)

• Do not allow patient to become dehydrated
• Encourage patient to mobilise when possible

Graduated compression stockings (GCS)

• Unless contraindicated, offer all surgical inpatients knee-length class 2 graduated compression/anti-embolism stockings on admission
• Show patient how to wear stockings correctly and monitor their use
• Encourage patient to wear GCS from admission until returning to their usual level of mobility 

Contraindications to GCS

• Peripheral vascular disease
• Cellulitis
• Severe dermatitis
• Recent skin graft
• Leg deformity
• Peripheral neuropathy

Intermittent pneumatic compression (IPC) device

• Surgical patients: post-operatively as advised by consultant
• Stroke patients: immobile patients following acute stroke as advised by consultant

Contraindications to IPC

• Known arteriosclerosis, peripheral neuropathy or peripheral vascular disease
• Massive oedema of the legs or pulmonary oedema secondary to congestive heart failure
• Local leg infection, dermatitis, vein ligation or skin graft
• Extreme deformity of leg
• Suspected pre-existing DVT or acute DVT
• Presence of malignancy in legs

Anti-coagulation

Medical patients

• Standard thromboprophylaxis dose: Dalteparin 5000 units SC once daily
• if eGFR 10–30 mL/min or patient weight <45 kg, use dalteparin 2500 units SC once daily

Surgical patients

• Dose: Dalteparin 2500–5000 units SC once daily. Senior surgeon to decide dose and timing of first dose by case and risk
• renal impairment (reduced dose LMWH or UFH – see IV unfractionated heparin guideline)
• If due for afternoon surgery, consider IV fluids but ideally ensure they take clear fluids liberally until 1100 hr – see Pre-operative fasting guideline in the Surgical guidelines
• If appropriate, consider using regional anaesthesia (risk of VTE higher with general anaesthesia in specific patient groups)
• Encourage patient to mobilise
• if immobilised, arrange leg exercise as soon as possible after surgery
• Do not give prophylactic LMWH in the 12-hr period preceding insertion of a spinal/epidural catheter, lumbar puncture or deep peripheral nerve block
• LMWH can be administered 4 hr following insertion/withdrawal of a spinal/epidural catheter

• Check risk factors for bleeding
• Assess risks and benefits of thromboprophylaxis
• Exercise clinical judgement

RISK FACTORS FOR BLEEDING

Regimens

How

• Prescribe on prescription chart
• Give patient leaflet ‘How to avoid blood clots while in hospital and after surgery’

• Reassess risk of bleeding and thrombosis risk at 24 hr and whenever clinical situation changes
• Monitor for any bleeding
• If renal function deteriorates, reduce dose of LMWH or use UFH
• Report all bleeding events related to LMWH

Surgical patients

• For cardiac surgery patients or those who received UFH in the last 100 days
• check baseline FBC
• monitor platelet counts as per Heparin-induced thrombocytopenia guideline