Upload
others
View
34
Download
0
Embed Size (px)
Citation preview
Anticoagulation Related Bleeding - Guideline Summary
Page 1 of 23
VTE PROPHYLAXIS PRESCRIBING - GUIDELINE SUMMARY Click here for the full RCHT Thrombosis Prevention and Anticoagulation Policy
Click on the appropriate link below:
o RISK ASSESSMENT FOR ALL PATIENTS ADMITTED TO HOSPITAL
o GIVING INFORMATION AND PLANNING FOR DISCHARGE
o GUIDANCE FOR MECHANICAL PROPHYLAXIS (STOCKINGS)
Prophylaxis Recommendations by specialty (select option)
o ACUTE CORONARY SYNDROME
o ACUTE STROKE
o CANCER AND PALLIATIVE CARE
o CRITICAL CARE PATIENTS o ORTHOPAEDIC SURGICAL PATIENTS
o NON-BARIATRIC ABDOMINAL SURGERY
o BARIATRIC ABDOMINAL SURGERY
o ORAL / MAXILLO-FACIAL AND ENT SURGERY
o VASCULAR SURGERY PATIENTS
o PREGNANT WOMEN INCLUDING BIRTH, MISCARRIAGE OR TERMINATION OF PREGNANCY IN THE PAST 6 WEEKS
o FURTHER SUPPORTING INFORMATION FOR PROPHYLAXIS MANAGEMENT
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 2 of 23
RISK ASSESSING PATIENTS >16 YEARS ADMITTED TO HOSPITAL
CLICK HERE TO RETURN TO OPTIONS FOR SPECIFIC PROPHYLAXIS ACTIONS FOR INDIVIDUAL PATIENT GROUPS
Review and re-assess patient whenever their clinical condition changes
If using pharmacological prophylaxis start it as soon as possible and within 14 hours
of admission
Balance the risk of VTE against the risk of bleeding when deciding whether to offer pharmacological prophylaxis to patients
Use VTE risk assessment tool within EPMA
Assessment should be completed as soon as possible after admission or by time of
initial consultant review
Assess all patients to identify the risk of Venous Thrombo-Embolism and bleeding
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 3 of 23
GIVING INFORMATION AND PLANNING FOR DISCHARGE
At discharge provide patients at risk (or their carers) appropriate verbal and written information on re:
- Signs and symptoms of VTE and how to seek help if VTE is suspected
- Reducing risk of VTE by keeping mobile and hydrated
Be aware Heparins are of animal origin - advise patients and if necessary discuss alternatives
Before prescribing prophylaxis provide patients at risk (or their carers) appropriate verbal and written
information before providing prophylaxis on:
- risks and consequences of VTE
- importance of prophylaxis and side effects
- Correct use of prophylaxis (ie AE stockings)
- how patients can reduce their risk of VTE
On admission ensure people understand the reason for having a risk assessment for VTE and
bleeding
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 4 of 23
GUIDANCE FOR MECHANICAL PROPHYLAXIS (STOCKINGS)
DO NOT offer Anti-embolism stockings to patients with known contra-indications (ie peripheral vascular disease / neuropathy / stroke / severe leg oedema / major limb deformity / allergy to stocking material)
Patients who require Anti-Embolism stockings should have their legs measured and be provided with the correct size
Stockings should be fitted and patients shown how to use then by staff trained in their use
Post-operative patients and patients with oedema should have their legs regularly re-measured and stockings re-fitted as required
If arterial disease is suspected seek expert opinion before fitting stockings
Patients should be encouraged to wear stockings day and night until they no longer have reduced mobility
Stockings should be removed at least daily for skin inspection and hygiene reasons or more frequently where there is recorded sensory loss or poor skin integrity
STOP using the stockings if patients experience marking, blistering or discolouration of the skin – if needed offer intermittent pneumatic compression as an alternative
In cases where patients are declining stockings they should be counselled as to their risks of developing VTE. If patients continue to decline then the prescription for stockings should be discontinued and the patients choice recorded in the notes and/or on EPMA
Prescriptions for stockings should be discontinued once the patient has regained their normal level of mobility. Continuing the use of stocking post-discharge is generally not recommended and should only occur at request of consultant in charge of the patient’s care
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 5 of 23
ACUTE CORONARY SYNDOMES
ACUTE STROKE PATIENTS
People receiving anticoagulant drugs as part of their treatment for an acute coronary syndrome do not usually need additional VTE prophylaxis -
Review current ACS treatment first
When using intermittent pneumatic compression for people who are admitted with acute stroke,
provide it for 30 days or until the person is mobile or discharged, whichever is sooner
Explain to the person with acute stroke that IPC:
- reduces risk of DVT & may increase chances of survival
- will not help them recover from stroke, & there may be an increased risk of surviving with severe disability.
Provide Intermittent pneumatic compression as VTE prophylaxis. Start within 3 days of stroke
DO NOT offer Anti-embolism stockings to patients with acute stroke
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 6 of 23
CANCER AND PALLIATIVE CARE
VTE prophylaxis should be reviewed regularly particularly for palliative care patients
VTE Prophylaxis should be with either:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxparin 20mg once daily (eGFR <30)
DO NOT offer cancer patients prophylaxis in the last days of life
Cancer patients receiving palliative care as an inpatient should be offered prophylaxis taking
into account temporary increased risks, life expectancy and views of the patient and their
family or carers
ALL Cancer patients receiving inpatient care should be offered prophylaxis.
Cancer patients receiving cancer-modifying treatments as outpatients should not be offered
routine prophylaxis if they are mobile
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 7 of 23
PATIENTS ADMITTED TO CRITICAL CARE
If using mechanical prophylaxis start on admission to critical care and continue until the patient no longer
has reduced mobility
Consider mechanical prophylaxis for all patients who are contra-indicated to pharmacological prophylaxis
Pharmacological Prophylaxis should be provded to all patients if not contra-indicated using either:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxparin 20mg once daily (eGFR <30)
ALL patients admitted to critical care should be assessed daily for their risks of VTE and bleeding or
more frequently if patients condition changes rapidly
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 8 of 23
ORTHOPAEDIC SURGERY PATIENTS
Click on the appropriate link below:
o LOWER LIMB IMMOBILISATION
o FRAGILITY FRACTURES OF THE PELVIS, HIP AND PROXIMAL FEMUR
o ELECTIVE HIP REPLACEMENT o ELECTIVE KNEE REPLACEMENT o NON-ARTHROPLASTY ORTHOPAEDIC SURGERY o FOOT AND ANKLE ORTHOPAEDIC SURGERY o UPPER LIMB ORTHOPAEDIC SURGERY
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 9 of 23
LOWER LIMB IMMOBILISATION
FRAGILITY FRACTURES OF THE PELVIS, HIP AND FEMUR
Offer pharmacological VTE prophylaxis to all patients assessed as high risk (score ≥3) using either:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxaparin 20mg once daily (eGFR <30)
Consider stopping prophylaxis if lower limb immobilisation continues beyond 42 days
Assess all patients using RCHT approved VTE risk assessment tool for patients with lower leg
immobilisation (CHA3592)
Consider intermittent pneumatic compression if pharmacological prophylaxis is contraindicated. Continue
until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility
Consider pre-operative prophylaxis if surgery is delayed beyond the day of admission
Offer VTE prophylaxis for one month to all patients with fragility fractures if risk of VTE is greater than risk
of bleeding using either:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxaparin 20mg once daily (eGFR <30)
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 10 of 23
ELECTIVE HIP REPLACEMENT
Consider Anti-embolism stockings until discharge for patients who are contra-indicated to
pharmacological prophylaxis
If using LMWH this should either be:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxaparin 20mg once daily (eGFR <30)
Offer VTE prophylaxis to all patients undergoing elective hip replacement if risk of VTE is greater than risk of bleeding. Choose any one of either:
- LMWH for 10 days followed by aspirin 75mg for 28 days
- LMWH for 28 days combined with Anti-Embolism stockings until discharge
- Rivaroxaban 10mg once daily for 35 days
Prophylaxis should start 6-12hrs post surgery
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 11 of 23
ELECTIVE KNEE REPLACEMENT
Consider Anti-embolism stockings until discharge for patients who are contra-indicated to
pharmacological prophylaxis
If using LMWH this should either be:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxaparin 20mg once daily (eGFR <30)
Offer VTE prophylaxis to all patients undergoing elective Knee replacement if risk of VTE is
greater than risk of bleeding. Choose any one of
- Aspirin 75mg for 14 days
- LMWH for 14 days combined with Anti-Embolism stockings until discharge
- Rivaroxaban 10mg once daily for 14 days
Prophylaxis should start 6-12 hrs post surgery
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 12 of 23
NON-ARTHROPLASTY ELECTIVE KNEE SURGERY
If using LMWH this should either be:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxaparin 20mg once daily (eGFR <30)
Consider VTE prophylaxis in the following cases:
- Knee arthroplasty with anaesthesia >90 mins
- Where VTE risk outweighs risk of bleeding
- Non-arthroscopic knee surgery (ie osteotomy or fracture surgery)
Start LMWH prophylaxis 6-12 hours post surgery
VTE prophylaxis is generally not needed for patients undergoing arthroscopic knee surgery if
- Total anaesthesia time is <90 mins
- the person is low risk for VTE
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 13 of 23
FOOT AND ANKLE SURGERY
Consider stopping if immobilisation continues beyond 42 days
If using LMWH this should either be:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxaparin 20mg once daily (eGFR <30)
Consider LMWH VTE prophylaxis for patients undergoing foot and ankle surgery :
- That requires immobilisation (ie arthrodesis)
- Where anaesthesia time is >90 mins
- Where VTE risk outweighs risk of bleeding
Start LMWH prophylaxis 6-12 hours post surgery
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 14 of 23
UPPER LIMB ORTHOPAEDIC SURGERY
If using LMWH this should either be:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxaparin 20mg once daily (eGFR <30)
VTE prophylaxis is generally not needed for patients undergoing elective shoulder surgery
but should be offered if:
- Total general anaesthesia time is >90 mins
- Shoulder surgery will make it difficult for patient to mobilise
- Surgery is performed following non-elective (emergency) admission
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 15 of 23
NON-BARIATRIC ABDOMINAL SURGERY
Continue LMWH prophylaxis as inpatient then, based on clinical judgement, extend course as follows:
For up to 7 days
- where risk of VTE outweighs risk of bleeding
- in all patients with inflammatory bowel disease
For up to 28 days
- for all major abdominal cancer surgery
in addition to LMWH start mechanical prophylaxis on admission with either anti-embolism stockings or
intermittent pneumatic compression and continue until discharge
LMWH Prophylaxis should be with either:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxparin 20mg once daily (eGFR <30)
ALL patients admitted for abdominal surgery (GI, gynaecological, urological) should be offered
pharmacological prophylaxis if not contra-indicated
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 16 of 23
BARIATRIC ABDOMINAL SURGERY
Continue VTE prophylaxis (both LMWH and Anti-Embolism Stockings) for a minimum of 7 days
including beyond discharge:
in addition to LMWH start mechanical prophylaxis on admission with either anti-embolism stockings or
intermittent pneumatic compression and continue until discharge
LMWH Prophylaxis should be with either:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxparin 20mg once daily (eGFR <30)
ALL patients admitted for bariatric abdominal surgery should be offered pharmacological
prophylaxis if not contra-indicated
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 17 of 23
ORAL / MAXILLOFACIAL AND ENT SURGERY
Consider Anti-embolism stockings until discharge for patients who are high risk of VTE but also have high risk of bleeding or who are contra-
indicated to pharmacological prophylaxis
If using LMWH this should either be:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxaparin 20mg once daily (eGFR <30)
Consider LMWH VTE prophylaxis for ALL inpatients undergoing oral / maxillo-facial or ENT
surgery if their VTE risk outweighs risk of bleeding
Start LMWH prophylaxis 6-12 hours post surgery
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 18 of 23
VASCULAR SURGERY PATIENTS
Click on the appropriate link below:
o OPEN VASCULAR SURGERY OR ENDOVASCULAR ANEURYSM REPAIR
o LOWER LIMB AMPUTATION
o VARICOSE VEIN SURGERY
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 19 of 23
OPEN VASCULAR SURGERY OR ANEURYSM REPAIR
Consider Anti-embolism stockings until discharge for patients who are high risk of VTE but who
also have high risk of bleeding or who are contra-indicated to pharmacological prophylaxis
If using LMWH this should either be:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxaparin 20mg once daily (eGFR <30)
Consider LMWH VTE prophylaxis for ALL inpatients undergoing open vascular surgery or
major vascular surgery procedures
Start LMWH prophylaxis 6-12 hours post surgery
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 20 of 23
LOWER LIMB AMPUTATION
Continue mechanical VTE prophylaxis until the person no longer has significantly reduced
mobility relative to their anticipated mobility
Consider mechanical prophylaxis with intermittent pneumatic compression on the
contra-lateral leg from admission for patients who are high risk of VTE but who are contra-
indicated to pharmacological prophylaxis
If using LMWH this should either be:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxaparin 20mg once daily (eGFR <30)
Consider LMWH VTE prophylaxis for ALL inpatients undergoing lower limb amputation
whose risk of VTE outweighs the risk of bleeding
Start LMWH prophylaxis 6-12 hours post surgery
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 21 of 23
VARICOSE VEIN SURGERY
Consider mechanical prophylaxis with anti-embolism stockings from admission for patients
who are high risk of VTE but who are contra-indicated to pharmacological prophylaxis
If using LMWH this should either be:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxaparin 20mg once daily (eGFR <30)
Consider VTE prophylaxis in the following cases:
- total anaesthesia time >90 mins
- Where VTE risk outweighs risk of bleeding
Start LMWH prophylaxis 6-12 hours post surgery
VTE prophylaxis is generally not needed for patients undergoing varicose vein surgery if:
- total anaesthesia time is <90 mins
- the person is low risk for VTE
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 22 of 23
PREGNANT WOMEN, BIRTH, MISCARRIAGE OR TOP
Add mechanical prophylaxis for women who are likely to be immobilised or have significantly
reduced mobility for 3 or more days after their clinical event including caesarian section
DO NOT offer VTE prophylaxis to women in active labour and discontinue any previous prescription for LMWH when labour starts
If using LMWH this should either be:
- Dalteparin 5000units once daily (eGFR >30)
- Enoxaparin 20mg once daily (eGFR <30)
Start within 14 hours of admission in pregnancy or 4-8 hours after birth, miscarriage or TOP
Consider LMWH VTE prophylaxis for ALL women admitted to hospital who are pregnant, have
given birth or had a miscarriage or TOP in past 6 weeks whose risk of VTE outweighs bleed risk
VTE prophylaxis prescribing - Guideline Summary Nov 19
Page 23 of 23
FURTHER SUPPORTING INFORMATION:
People using Anti-platelet agents
Patients already taking oral anticoauglation
General Care: Early mobilisation and Hydration
Extended Prophylaxis
Encourage people to mobilise as soon as possible
Do not allow people to become dehydrated unless clinically indicated.
Consider VTE prophylaxis for people who are having antiplatelet agents for other conditions and whose risk of VTE outweighs their risk of bleeding. Take into account the risk of bleeding and of comorbidities such as arterial thrombosis.
If the risk of VTE outweighs the risk of bleeding, consider pharmacological VTE prophylaxis with LMWH based on their condition or procedure.
If the risk of bleeding outweighs the risk of VTE, consider mechanical VTE prophylaxis.
Consider VTE prophylaxis for people at increased risk of VTE who are interrupting their usual oral anticoagulant therapy. If patients are taking Warfarin provide LMWH prophylaxis whenever INR is below therapeutic levels (ie INR <2.0)
Be aware that in some clinical cases there is an indication to continue Prophylaxis beyond discharge. For a full list of indications please see Appendix 9 of the Trust VTE prevention policy at: RCHTThrombosisPreventionAndAnticoagulationPolicy.pdf