Thromboembolism- VTE prophylaxis, Surgical patients, Medical patients

Question 1

venous thromboembolism includes DVT and PE, explain why venous thromboembolism occurs?

Answer 1

occurs as a result of thrombus formation in a vein

Question 2

All patients should be risk assessed on admission to hospital. which patients are considered at high risk of venous thromboembolism?

Answer 2

1) May have substantial reduction in mobility
2) Obese
3) Malignant disease
4) History of venous thromboembolism
5) Thrombophilic disorder
6) Over 60 years of age
7) Pregnancy and the postpartum period

Question 3

There are two methods of thromboprophylaxis: mechanical and pharmacological. Outline the mechanical options

Answer 3

1) Anti-embolism stockings that provide graduated compression and produce a calf pressure of 14–15 mmHg
2) Intermittent pneumatic compression

Question 4

When should anti-embolism stockings be worn?

Answer 4

Anti-embolism stockings should be worn day and night until the patient is sufficiently mobile

Question 5

Which patients should not be offered anti-embolism stockings?

Answer 5

1) Admitted with acute stroke
2) Peripheral arterial disease, peripheral neuropathy, severe leg oedema, or local conditions (e.g. gangrene, dermatitis)

Question 6

If using pharmacological prophylaxis, how soon after admission should this be initiated?

Answer 6

It should start as soon as possible or within 14 hours of admission

Question 7

Should pharmacological prophylaxis be initiated in individuals with risk factors for bleeding e.g. acute stroke, thrombocytopenia, acquired or untreated inherited bleeding disorders?

Answer 7

Only when their risk of venous thromboembolism outweighs their risk of bleeding

Question 8

should patients already receiving anticoagulant therapy, who are at high risk of venous thromboembolism, ever be given anticoagulant prophylaxis therapy?

Answer 8

only given anticoagulant prophylaxis if their anticoagulant therapy is interrupted, for example during the peri-operative period

Question 9

To reduce the risk of venous thromboembolism in surgical patients what type of anesthesia should be used if possible?

Answer 9

Regional anaesthesia over general anaesthesia

Question 10

How long after a surgical procedure should mechanical prophylaxis continue?

Answer 10

until the patient is sufficiently mobile or discharged from hospital (or for 30 days in spinal injury, elective spinal surgery or cranial surgery).

Question 11

Pharmacological prophylaxis should be considered in patients undergoing what type of surgery?

Answer 11

general or orthopaedic surgery when the risk of venous thromboembolism outweighs the risk of bleeding

Question 12

1) What drugs would be suitable to use for prophylaxis in general and orthopaedic surgery?
2) what if the patient has renal impairment?

Answer 12

1) low molecular weight heparin
2) Heparin (unfractionated) is preferred in patients with renal impairment.
3) Fondaparinux sodium is an option for patients undergoing abdominal, bariatric, thoracic or cardiac surgery, or for patients with lower limb immobilisation or fragility fractures of the pelvis, hip or proximal femur.

Question 13

how long should pharmacological prophylaxis in general surgery be continued for?

Answer 13

1) At least 7 days post-surgery, or until sufficient mobility has been re-established.
2) Extended to 28 days after major cancer surgery in the abdomen, and to 30 days in spinal surgery.

Question 14

when pharmacological prophylaxis is contra-indicated e.g.in lower limb amputation, or major trauma or fragility fractures of the pelvis, what options are available to patients?

Answer 14

Mechanical prophylaxis with intermittent pneumatic compression

Question 15

what are the three pharmacological thromboprophylaxis options for patients undergoing elective hip replacement surgery?

Answer 15

1) LMWH administered for 10 days followed by low-dose aspirin for a further 28 days
2) LMWH administered for 28 days in combination with anti-embolism stockings until discharge7
3) Rivaroxaban
↳ if above unsuitable apixaban or dabigatran are alternatives

Question 16

what option would be suitable if pharmacological thromboprophylaxis was contraindicated in patients undergoing elective hip replacement surgery?

Answer 16

anti-embolism stockings can be used until discharge

Question 17

For patients undergoing an elective knee replacement, what pharmacological thromboprophylaxis options are available? (3)

Answer 17

1) low-dose aspirin for 14 days
2) LMWH administered for 14 days in combination with anti-embolism stockings until discharge
3) Rivaroxaban.
↳ If these options are unsuitable, apixaban or dabigatran can be considered

Question 18

If pharmacological prophylaxis is contra-indicated in patients undergoing an elective knee replacement, what option would be suitable?

Answer 18

Intermittent pneumatic compression can be used until the patient is mobile.

Question 19

1) Acutely ill patients who are at high risk of VTE should be offered pharmacological prophylaxis. List the first-line treatment options and the duration of therapy
2) what options are suitable in renal impairment?
3) what if pharmacological prophylaxis is contraindicated?

Answer 19

1) Either a LMWH as a first-line, or fondaparinux sodium as an alternative, for a minimum of 7 days.
2) Renal impairment: LMWH or heparin (unfractionated) and the dose should be adjusted as necessary
3) Mechanical prophylaxis- continue until the patient is sufficiently mobile.

Question 20

1) what are the suitable VTE prophylaxis options for
patients admitted with acute stroke?
2) what mechanical option would be unsuitable in these patients?

Answer 20

1) mechanical prophylaxis with intermittent pneumatic compression -Started within 3 days of the acute stroke and continued for 30 days, or until the patient is sufficiently mobile or discharged from hospital.
2) Anti-embolism stockings unsuitable