Guideline: VTE Prophylaxis within Gastrointestinal Services Flashcards
Which patients admitted under the Gastrointestinal Surgical Units should be assessed for their risk of Venous Thromboembolism (VTE) on and during admission?
All patients admitted under the Gastrointestinal Surgical Units (and all patients with an IBD flare up under Gastroenterology)
What should be done once a patient admitted under the Gastrointestinal Surgical Units or admitted with an IBD flare has been assessed for their risk of VTE?
The risk should be documented and the type of prophylaxis (mechanical and/or pharmacological) should be specified.
What are 8 factors which would make a gastrointestinal patient “at-risk” for venous thromboembolism?
- Major surgery (intra-abdominal surgery over 45 minutes in duration)
- Hospital stay expected to be 36 hours or more
- Age over 60
- History of venous thromboembolism, pulmonary embolus, or thrombophilia
- BMI >30
- Malignancy
- Taking oral contraceptives/oestrogen therapy
- Severe infection
What 3 interventions are required for gastrointestinal patients assessed as being “at-risk” for venous thromboembolism?
- Enoxaparin is required until discharge and early mobilisation is to be encouraged
- Intermittent pneumatic compression (IPC) device to be used intraoperatively for major surgery
- Graduated compression stockings or intermittent compression stockings are required if enoxaparin is contraindicated
What 2 interventions are required for gastrointestinal patients assessed as being “low-risk” (i.e. not “at-risk”) for venous thromboembolism?
- Early mobilisation
2. Documentation in medical record
What are the contraindications for enoxaparin the same as?
The contraindications for heparin
What are 6 contraindications for enoxaparin?
- Allergy to enoxaparin
- Patient already anticoagulated
- Patients where the primary diagnosis is a bleeding problem or trauma
- History of heparin-induced thrombocytopaenia (within the past 100 days, or if circulating antibodies are detected).
- Bleeding disorders (including haemophilia, thrombocytopaenia, cerebral haemorrhage, severe hepatic disease, bacterial endocarditis and severe hypertension)
- Some rectal surgery (haemorrhoidectomy, TEMS)
What 2 interventions are required in gastrointestinal patients where enoxaparin is contraindicated?
- Graduated compression stockings or intermittent pneumatic compression and early mobilisation
- For patients with prior pulmonary embolism or active venous thromboembolism consider the use of a perioperative temporary inferior vena cava device.
When is the recommended time of the first post-operative enoxaparin dose in surgical patients?
Between 6-18 hours after surgery (the registrar must clearly outline the time of the dose on the chart)
When is the recommended time of enoxaparin dose in day surgery patients?
Enoxaparin 6 hours postoperatively (or just prior to discharge if less than 6 hours after surgery).
When is the recommended time of enoxaparin dose in overnight surgical patients?
Chart the daily dose to be given at 2000 (or just prior to discharge if the patient is to be discharged before 2000)
When is the recommended time of enoxaparin dose in surgical patients?
Between 6-18 hours after surgery.
*The Registrar is required to write the time of the first post-operative dose on the drug chart.
When is the recommended time of enoxaparin dose in overnight surgical patients if surgery is completed after 1400?
Hold that evening’s dose. Chart a ‘stat medication order’ dose for 0800 the next day, and start their 2000 doses from that night.
What is the standard dose of enoxaparin for VTE prophylaxis?
40 mg subcutaneous once daily at 2000.
What are 4 precautions to consider with enoxaparin?
- Renal impairment
- Hepatic impairment
- Parents undergoing spina lower epidural anaesthesia, analgesia or lumbar puncture
- Weight < 50 kg
How does renal function effect enoxaparin dosing for VTE prophylaxis?
If creatinine clearance < 30 mL per minute, the dose of enoxaparin should be halved to 20 mg subcutaneous once daily.
How does hepatic function effect enoxaparin dosing for VTE prophylaxis?
Use should be avoided in severe impairment.
What is a consideration regarding VTE prophylaxis in patients undergoing spinal or epidural anaesthesia, analgesia or lumbar puncture?
Use of enoxaparin (or standard heparin) increases the risk of intraspinal haematoma
How does weight effect enoxaparin dosing in VTE prophylaxis?
If weight less than 50 kg, enoxaparin is halved to 20 mg subcutaneous once daily.
If a patient is scheduled for surgery, ERCP or epidural insertion the next day, can the evening dose of enoxaparin still be given?
Yes, but no later than 2000.
What is does ERCP stand for?
Endoscopic retrograde cholangiopancreatography
What is endoscopic retrograde cholangiopancreatography?
A procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas
What is an implication for VTE prophylaxis if the patient has an epidural in situ?
The line should not be removed until 12 hours after the last enoxaparin injection due to the increased risk of intraspinal haematoma
What should be done if reversal of VTE prophylaxis is required (either for bleeding or to commence surgery)?
Contact the on-call haematologist for advice.
Describe the role of extended VTE prophylaxis.
Extended VTE prophylaxis should be given for 28 days if the patient has had major abdominal/pelvic surgery for cancer, especially if they are obese, slow to mobilise or have a history of venous thromboembolism.
If a patient is unwilling to self-inject for extended VTE prophylaxis on discharge, what should be done?
Make arrangements via hospital at home or the Metropolitan Referral Unit (MRU).
What are 7 contraindications to mechanical VTE prophylaxis?
- Severe arterial disease
- Recent skin graft
- Severe peripheral neuropathy
- Peripheral ulcers
- Severe leg oedema
- Severe leg deformity
- Local problems on legs (for example untreated infection)
What patients are graduated compression stockings reserved for?
Patients in whom enoxaparin is contraindicated
How should graduated compression stockings be used?
They should be worn continuously during the period of immobility to the return of full ambulation, except for when showering.
What monitoring is required for patients using graduated compression stockings?
Skin inspection should occur daily especially around the heels and any other pressure points.
What should be done to reduce the fall hazard when using graduated compression stockings?
Patients should wear non-slip socks, slippers or shoes.
In what patients are intermittent pneumatic compression devices used?
They are used in the operating theatre for patients who have major abdominal surgery or for patients in whom enoxaparin is contraindicated.
When are intermittent pneumatic compression devices usually commenced?
In the operating theatre.
For what duration should intermittent pneumatic compression devices be used for?
They should be used during the period of restricted mobility up to the commencement of enoxaparin.
What should be done if intermittent pneumatic compression devices are removed?
They should be reapplied within 30 minutes. Longer interruptions should be avoided where possible unless the patient is actively ambulating during the interruption.
