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Clinical Practice Guidelines

Deep vein thrombosis prophylaxis in surgical patients

ABH/SUR/CLN/001/V01
Clinical Practice Guideline Title: Deep vein thrombosis prophylaxis in surgical patients Ownership: General surgery Department Al Baraha hospital Code: ABH/SUR/CLN/001/V01 Effective Date: August 2014 Revision Due Date: August 2015 Applies to: Albaraha Hospital
Introduction:
 DVT presents an important morbidity and mortality in surgical patients.
 Decision regarding method of VTE prophylaxis (pharmacological and mechanical needs to weigh bleeding risk versus risk of VTE.
 Bleeding risk is very low for general surgery patients receiving most forms of pharmacologic thromboprophylaxis (<5%)
 Prophylaxis is ideally started during hospitalization, either before or shortly after surgery, and continued at least until the patient is fully ambulatory.
 This policy is set for prevention of VTE and sequel( PTS and PE) in surgical patients undergoing bariatric surgery and abdominal wall repair.
 To categorize patients according to risk factors for developing VTE and start the appropriate VTE prophylaxis.
1) Clinical Criteria 1.1 All patients admitted to the surgical wards for abdominal wall repair and bariatric surgery will be categorized according to risk factors for developing VTE and started on the appropriate VTE prophylaxis. 1.2 Exclusion criteria:
 Recent hemorrhagic stroke
 Bleeding peptic ulcer
 Known allergy to anticoagulation
 Patients already on anti-coagulation
 INR>2.5
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2) Protocol 2.1Caprini scoring system will be used to help predict and estimate VTE (venous thrombo embolism) risk. 2.2 Prophylaxis will be started during hospitalization, within 24 hrs prior/post surgery. 3) Algorithm Procedure sequence Responsibilities of
3.1
Thrombosis Risk Factor Assessment form should be attached to patients files undergoing bariatric and abdominal wall surgery
Physician, Nurse in charge
3.2
Form should be filled and proper VTE prophylaxis started during patient’s hospital admission course with 24 hrs prior/post surgery
Physician
3.3
Re assessment will be done if any change in patient’s clinical condition occurs
Physician
4) Other Healthcare Provider Role Ward nurse:
 Confirm presence of form in each patient file.
 Encourage patient mobilization.
 Report patient’s complain
 Patient education
Physiotherapist:
 Aid in early patient mobilization as appropriate.
Pharmacist:
 Confirm dose and route of medication.
 Report if any expected medication interaction may exist.
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5) Participant (Patient) Role Report to physician/nurse in case of :
 Newly developed body rash
 Pain and swelling in lower limbs
 Bleeding ( nose ,mouth, Per rectum, hematuria, canulation site)
 Difficulty breathing
 Chest pain
 Neurological symptoms ( head ache, blurring of vision, limb weakness, slurred speech)
 Sudden joint swelling
 Vaginal bleeding
6) Patient Reassessment Criteria Any change in patient’s clinical condition after admission will need revision of the scoring system and change of management accordingly.
 Immobilization/mobilization,
 Bleeding
 Surgery
 Malignancy
 Anticoagulation allergy
 Diagnosed DVT /PE/ stroke ( hemorrhagic/ischemic)
7) Definitions:
 Venous thromboembolism (VTE)
 Post-thrombotic syndrome (PTS)
 Pulmonary embolism (PE)
 Deep vein thrombosis (DVT)
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8) Tools/Attachments Forms: Deep Vein Thrombosis (DVT) Prophylaxis Orders Thrombosis Risk Factor Assessment
Each Risk Factor Represents 1 Point
 Age 41-60 years
 Acute myocardial infarction
 Swollen legs (current)
 Congestive heart failure (<1 month)
 Varicose veins
 Medical patient currently at bed rest
 Obesity (BMI >25)
 History of inflammatory bowel disease
 Minor surgery planned
 History of prior major surgery (<1 month)
 Sepsis (<1 month)
 Abnormal pulmonary function (COPD)
 Serious Lung disease including pneumonia (<1 month)
 Oral contraceptives or hormone replacement therapy
 Pregnancy or postpartum (<1 month)
 History of unexplained stillborn infant, recurrent spontaneous
abortion (> 3), premature birth with toxemia or growth-restricted infant
 Other risk factors___________________
Each Risk Factor Represents 3 Points
 Age 75 years or older
 Family History of thrombosis*
 History of DVT/PE
 Positive Prothrombin 20210A
 Positive Factor V Leiden
 Positive Lupus anticoagulant
 Elevated serum homocysteine
 Heparin-induced thrombocytopenia (HIT)
(Do not use heparin or any low molecular weight heparin)
 Elevated anticardiolipin antibodies
 Other congenital or acquired thrombophilia
 If yes: Type_____________________________
* most frequently missed risk factor
TOTAL RISK FACTOR SCORE:
Each Risk Factor Represents 2 Points
 Age 61-74 years
 Central venous access
 Arthroscopic surgery
 Major surgery (>45 minutes)
 Malignancy (present or previous)
 Laparoscopic surgery (>45 minutes)
 Patient confined to bed (>72 hours)
 Immobilizing plaster cast (<1 month)
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Total risk factor score
Risk level
Incidence of DVT
Prophylaxis regimen
0-1
Very low
0.5%
Early ambulation
2
Low
1.5%
 Sequential compression device
OR
 LMWH
3-4
Moderate risk
3%
Choose ONE of the following medications +/- compression devices:
 Sequential Compression Device (SCD) – Optional
 Heparin 5000 units SQ TID
 Enoxaparin/Lovenox:
 40mg SQ daily (WT < 150kg, CrCl > 30mL/min)
 30mg SQ daily (WT < 150kg, CrCl = 10-29mL/min)
 30mg SQ BID (WT > 150kg, CrCl > 30mL/min)

>5
High risk
6%
Choose ONE of the following medications PLUS compression devices:
 Sequential Compression Device (SCD)
 Heparin 5000 units SQ TID (Preferred with Epidurals)
 Enoxaparin/Lovenox (Preferred):
 40mg SQ daily (WT < 150kg, CrCl > 30mL/min)
 30mg SQ daily (WT < 150kg, CrCl = 10-29mL/min)
 30mg SQ BID (WT > 150kg, CrCl > 30mL/min)
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 Early and frequent ambulation is preferred in surgical patients at very low risk of VTE (eg, patients undergoing general and abdominal-pelvic surgery with a Caprini score of zero OR plastic/reconstructive surgery with a Caprini score of zero to two).
 Mechanical methods are preferred in patients with a contraindication to pharmacologic prophylaxis and in low-risk surgical patients (eg, patients undergoing general and abdominal-pelvic surgery with a Caprini score of 1 to 2 OR plastic/reconstructive surgery with a Caprini score of 3 to 4
 Pharmacologic prophylaxis is preferred in surgical patients at moderate and high risk of VTE (eg, patients undergoing general and abdominal-pelvic surgery with a Caprini score of ≥3 OR plastic/reconstructive surgery with a Caprini score of ≥5).
 Combined pharmacologic and mechanical methods (usually intermittent pneumatic compression) rather than either method alone can be considered in surgical patients assessed to be at very high risk of VTE (eg, high risk cancer surgery and multiple additional risk factors).
 Extended VTE prophylaxis is offered to patients at high risk for VTE to accommodate earlier discharge and in recognition that VTE can occur days to weeks post discharge .Evidence is strongest for patients who have undergone major orthopedic surgery (total hip replacement [THR], total knee replacement [TKR], hip fracture surgery [HFS]), and cancer and major abdominal surgery. Low-molecular-weight (LMW) heparin is the preferred agent. The optimal duration of extended prophylaxis is unknown but is usually given beyond 10 days and up to 35 days following major orthopedic surgery and for a period of three to four weeks for selected high-risk patients who undergo major abdominal and/or pelvic surgery for cancer.
9) Audit :
 Caprini score on admission( manual)
 Patient’s Body Mass Index on admission (BMI). (wareed)
 Duration of surgery(manual)
10) Performance Indicator: Number of indicated patients who received anticoagulation with 24hrs prior to surgery /total number of patients included in the criteria with caprini score 3 and above 11) Search words: DVT, VTE, Prophylaxis
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12) References:
 Chest 2012;141(2)(suppl):e227S-e277S
 Uptodate : Prevention of venous thromboembolic disease in surgical patients March 19/2014
 25. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:381S.
 Hull RD, Brant RF, Pineo GF, et al. Preoperative vs postoperative initiation of low-molecular-weight heparin prophylaxis against venous thromboembolism in patients undergoing elective hip replacement. Arch Intern Med 1999; 159:137.
 .Jørgensen CC, Jacobsen MK, Soeballe K, et al. Thromboprophylaxis only during hospitalisation in fast-track hip and knee arthroplasty, a prospective cohort study. BMJ Open 2013; 3:e003965.
 Hull RD, Pineo GF, Francis C, et al. Low-molecular-weight heparin prophylaxis using dalteparin in close proximity to surgery vs warfarin in hip arthroplasty patients: a double-blind, randomized comparison. The North American Fragmin Trial Investigators. Arch Intern Med 2000; 160:2199.
 Planes A, Vochelle N, Darmon JY, et al. Risk of deep-venous thrombosis after hospital discharge in patients having undergone total hip replacement: double-blind randomised comparison of enoxaparin versus placebo. Lancet 1996; 348:224.
 White RH, Romano PS, Zhou H, et al. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med 1998; 158:1525.
Prepared by: Dr . Arwa Shabbir Al Harazi Designation: General Practitioner Signature: Date: 1/8/2014
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Dr . Haitham Fuad Designation: Specialist surgeon Signature: Date: 1/8/2014 Approved by: Dr. Shuaib Kazim Designation: Head of Surgical Department Signature: Date: 1/8/2014 Reviewed by: Al Anoud salman Designation: Head of Quality & Excellance department Signature: Date: 1/8/2014 Approved by: Dr .Ahmed Al Ammadi Designation: Medical Director Signature: Date: 1/8/2014 Authorized by: Mr. Ahmed Khadiem Designation:Hospital Director Signature: Date: 1/8/2014
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AlgorithmPatients admitted to the surgical wards for abdominal wall repair and bariatric surgery yesContraindication to pharmacological prophlaxis:•Recent hemorrhagic stroke ?•Bleeding peptic ulcer ?•Known allergy to anticoagulation ?•Patients already on anti-coagulation ?•INR>2.5 ?yesMechanical prophylaxis +/-Refer to medical team as necessaryThrombosis Risk Factor Assessment should be done as per capriniscore and appropriate VTE prophylaxis started 24 hrs prior/post surgeryNoChange in patient clinical conditionNoContinue same managementyesRe assessment will be done and revision of capriniscore
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