Guideline: VTE Prophylaxis within Gastrointestinal Services

Question 1

Which patients admitted under the Gastrointestinal Surgical Units should be assessed for their risk of Venous Thromboembolism (VTE) on and during admission?

Answer 1

All patients admitted under the Gastrointestinal Surgical Units (and all patients with an IBD flare up under Gastroenterology)

Question 2

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?

Answer 2

The risk should be documented and the type of prophylaxis (mechanical and/or pharmacological) should be specified.

Question 3

What are 8 factors which would make a gastrointestinal patient “at-risk” for venous thromboembolism?

Answer 3

1. Major surgery (intra-abdominal surgery over 45 minutes in duration)
2. Hospital stay expected to be 36 hours or more
3. Age over 60
4. History of venous thromboembolism, pulmonary embolus, or thrombophilia
5. BMI >30
6. Malignancy
7. Taking oral contraceptives/oestrogen therapy
8. Severe infection

Question 4

What 3 interventions are required for gastrointestinal patients assessed as being “at-risk” for venous thromboembolism?

Answer 4

1. Enoxaparin is required until discharge and early mobilisation is to be encouraged
2. Intermittent pneumatic compression (IPC) device to be used intraoperatively for major surgery
3. Graduated compression stockings or intermittent compression stockings are required if enoxaparin is contraindicated

Question 5

What 2 interventions are required for gastrointestinal patients assessed as being “low-risk” (i.e. not “at-risk”) for venous thromboembolism?

Answer 5

1. Early mobilisation

2. Documentation in medical record

Question 6

What are the contraindications for enoxaparin the same as?

Answer 6

The contraindications for heparin

Question 7

What are 6 contraindications for enoxaparin?

Answer 7

1. Allergy to enoxaparin
2. Patient already anticoagulated
3. Patients where the primary diagnosis is a bleeding problem or trauma
4. History of heparin-induced thrombocytopaenia (within the past 100 days, or if circulating antibodies are detected).
5. Bleeding disorders (including haemophilia, thrombocytopaenia, cerebral haemorrhage, severe hepatic disease, bacterial endocarditis and severe hypertension)
6. Some rectal surgery (haemorrhoidectomy, TEMS)

Question 8

What 2 interventions are required in gastrointestinal patients where enoxaparin is contraindicated?

Answer 8

1. Graduated compression stockings or intermittent pneumatic compression and early mobilisation
2. For patients with prior pulmonary embolism or active venous thromboembolism consider the use of a perioperative temporary inferior vena cava device.

Question 9

When is the recommended time of the first post-operative enoxaparin dose in surgical patients?

Answer 9

Between 6-18 hours after surgery (the registrar must clearly outline the time of the dose on the chart)

Question 10

When is the recommended time of enoxaparin dose in day surgery patients?

Answer 10

Enoxaparin 6 hours postoperatively (or just prior to discharge if less than 6 hours after surgery).

Question 11

When is the recommended time of enoxaparin dose in overnight surgical patients?

Answer 11

Chart the daily dose to be given at 2000 (or just prior to discharge if the patient is to be discharged before 2000)

Question 12

When is the recommended time of enoxaparin dose in surgical patients?

Answer 12

Between 6-18 hours after surgery.

*The Registrar is required to write the time of the first post-operative dose on the drug chart.

Question 13

When is the recommended time of enoxaparin dose in overnight surgical patients if surgery is completed after 1400?

Answer 13

Hold that evening’s dose. Chart a ‘stat medication order’ dose for 0800 the next day, and start their 2000 doses from that night.

Question 14

What is the standard dose of enoxaparin for VTE prophylaxis?

Answer 14

40 mg subcutaneous once daily at 2000.

Question 15

What are 4 precautions to consider with enoxaparin?

Answer 15

1. Renal impairment
2. Hepatic impairment
3. Parents undergoing spina lower epidural anaesthesia, analgesia or lumbar puncture
4. Weight < 50 kg

Question 16

How does renal function effect enoxaparin dosing for VTE prophylaxis?

Answer 16

If creatinine clearance < 30 mL per minute, the dose of enoxaparin should be halved to 20 mg subcutaneous once daily.

Question 17

How does hepatic function effect enoxaparin dosing for VTE prophylaxis?

Answer 17

Use should be avoided in severe impairment.

Question 18

What is a consideration regarding VTE prophylaxis in patients undergoing spinal or epidural anaesthesia, analgesia or lumbar puncture?

Answer 18

Use of enoxaparin (or standard heparin) increases the risk of intraspinal haematoma

Question 19

How does weight effect enoxaparin dosing in VTE prophylaxis?

Answer 19

If weight less than 50 kg, enoxaparin is halved to 20 mg subcutaneous once daily.

Question 20

If a patient is scheduled for surgery, ERCP or epidural insertion the next day, can the evening dose of enoxaparin still be given?

Answer 20

Yes, but no later than 2000.

Question 21

What is does ERCP stand for?

Answer 21

Endoscopic retrograde cholangiopancreatography

Question 22

What is endoscopic retrograde cholangiopancreatography?

Answer 22

A procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas

Question 23

What is an implication for VTE prophylaxis if the patient has an epidural in situ?

Answer 23

The line should not be removed until 12 hours after the last enoxaparin injection due to the increased risk of intraspinal haematoma

Question 24

What should be done if reversal of VTE prophylaxis is required (either for bleeding or to commence surgery)?

Answer 24

Contact the on-call haematologist for advice.

Question 25

Describe the role of extended VTE prophylaxis.

Answer 25

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.

Question 26

If a patient is unwilling to self-inject for extended VTE prophylaxis on discharge, what should be done?

Answer 26

Make arrangements via hospital at home or the Metropolitan Referral Unit (MRU).

Question 27

What are 7 contraindications to mechanical VTE prophylaxis?

Answer 27

1. Severe arterial disease
2. Recent skin graft
3. Severe peripheral neuropathy
4. Peripheral ulcers
5. Severe leg oedema
6. Severe leg deformity
7. Local problems on legs (for example untreated infection)

Question 28

What patients are graduated compression stockings reserved for?

Answer 28

Patients in whom enoxaparin is contraindicated

Question 29

How should graduated compression stockings be used?

Answer 29

They should be worn continuously during the period of immobility to the return of full ambulation, except for when showering.

Question 30

What monitoring is required for patients using graduated compression stockings?

Answer 30

Skin inspection should occur daily especially around the heels and any other pressure points.

Question 31

What should be done to reduce the fall hazard when using graduated compression stockings?

Answer 31

Patients should wear non-slip socks, slippers or shoes.

Question 32

In what patients are intermittent pneumatic compression devices used?

Answer 32

They are used in the operating theatre for patients who have major abdominal surgery or for patients in whom enoxaparin is contraindicated.

Question 33

When are intermittent pneumatic compression devices usually commenced?

Answer 33

In the operating theatre.

Question 34

For what duration should intermittent pneumatic compression devices be used for?

Answer 34

They should be used during the period of restricted mobility up to the commencement of enoxaparin.

Question 35

What should be done if intermittent pneumatic compression devices are removed?

Answer 35

They should be reapplied within 30 minutes. Longer interruptions should be avoided where possible unless the patient is actively ambulating during the interruption.