Venous Thromboembolism Prophylaxis Policy - Royal United ...

Venous Thromboembolism 

Prophylaxis 

Reference Number: 795 

Author & Title: 

Josephine Crowe 

Consultant Haematologist 

Responsible Director: 

Medical Director 

Review Date: 23 January 2016 

Ratified by: 

Tim Craft 


Date Ratified: 24 July 2014 

Version: 1.3 

Related Policies and 

Guidelines: 

• Oral Anticoagulation Guideline 

• Venous Thromboembolism in Pregnancy, 

Labour and the Puerperium 

Document name: Venous Thromboembolism Prophylaxis Ref.: 795 

Issue date: 30 July 2014 

Status: Final 

Author: Josephine Crowe – Consultant Haematologist Page 1 of 57

Index: 

1 Policy Summary _______________________________________________ 4 

2 Policy Statements _____________________________________________ 4 

3 Definition of Terms Used _______________________________________ 5 

4 Duties and Responsibilities _____________________________________ 5 

4.1 Hospital Thrombosis Committee ____________________________________ 5 

4.2 Admitting doctor _________________________________________________ 5 

4.3 Medical, nursing or pharmacy staff on wards __________________________ 5 

4.4 Medical, nursing or pharmacy staff on ICU ____________________________ 5 

5 Risk Assessment on Admission and During Stay ___________________ 6 

5.1 Surgical patients and patients with trauma ____________________________ 6 

5.2 Regional anaesthesia ______________________________________________ 7 

5.3 Medical patients __________________________________________________ 7 

5.4 Risk factors for medical and surgical patients _________________________ 7 

6 Information for Patients ________________________________________ 8 

6.1 All patients on admission __________________________________________ 8 

6.2 All patients on discharge ___________________________________________ 8 

7 Reducing the Risk of VTE Prophylaxis ____________________________ 8 

7.1 General Measures ________________________________________________ 8 

7.2 Pharmacological prophylaxis and methods ___________________________ 9 

7.3 Patients already on antiplatelet agents or anticoagulation on admission or 

needing them for treatment ___________________________________________ 10 

7.4 Cautions and contraindications to pharmacological thromboprophylaxis 

using LMWH (Dalteparin) and Rivaroxaban ______________________________ 10 

7.5 Mechanical thromboprophylaxis ___________________________________ 11 

7.6 Vena Caval Filters _______________________________________________ 13 

8 Procedure if Venous Thromboembolism is Suspected ______________ 13 

9 Hospital Acquired Thrombosis (HAT) ____________________________ 14 

10 Monitoring Compliance ________________________________________ 14 

11 Review _____________________________________________________ 14 

12 Training _____________________________________________________ 14 

References ______________________________________________________ 15 

Appendix 1: Guideline for the Prevention of Venous Thromboembolism in 

Adults ___________________________________________________ 17 



Status: Final 


Appendix 2: General Medicine Thromboprophylaxis Guideline __________ 19 

Appendix 2a: Stroke Thromboprophylaxis Guideline _________________ 20 

Appendix 2b: Palliative Care Thromboprophylaxis Guideline _____________ 22 

Appendix 2c: 

Cancer and Central Catheters Thromboprophylaxis Guideline 

__________________________________________________ 24 

Appendix 3: Pregnancy and up to 6 weeks Postpartum Thromboprophylaxis 

Guideline ___________________________________________________ 26 

Appendix 4: General Surgical Thromboprophylaxis Guideline __________ 30 

Appendix 4a: Vascular, Gastrointestinal, Gynaecological and Urological 

Surgery Thromboprophylaxis Guideline ______________________________ 33 

Appendix 4b: Day Surgery Thromboprophylaxis Guideline ____________ 36 

Appendix 5: Trauma and Orthopaedic Thromboprophylaxis Guideline _____ 38 

Appendix 5a: Trauma and Orthopaedic Procedure Specific 

Thromboprophylaxis Guideline _____________________________________ 44 

Appendix 5b: Trauma and Orthopaedic Major Trauma and Spinal Injury 


Appendix 5c: Trauma and Orthopaedic Lower Limb Plaster Casts 


Appendix 6: Critical Care Thromboprophylaxis Guideline ________________ 53 

Document Control Information ______________________________________ 55 

Ratification Assurance Statement _____________________________________ 55 

Consultation Schedule _______________________________________________ 56 

Equality Impact: (A) Assessment Screening ____________________________ 57 

Amendment History 

Issue Status Date Reason for Change Authorised 

1.2 Approved 17/01/2013 Recording of VTE 

Dr Tim Craft 

assessment; update 

reference to trust drug chart 

and Millennium update format 

1.3 Approved 24/07/2014 Align with the NICE 

recommendations CG92 

Dr Tim Craft 



Status: Final 


1 Policy Summary 

A significant number of people die each year as a result of hospital acquired venous 

thromboembolism (VTE). Many of these deaths are preventable through the use of 

thromboprophylaxis. The House of Commons Select Committee Report on the 

Prevention of Venous Thromboembolism in Hospitalised Patients Feb 2005 and The 

Venous Thromboembolism in Hospitalised Patients Expert Working Group have been 

tasked with addressing this issue. NICE Clinical Guideline 92 – “Reducing the risk of 

venous thromboembolism (deep vein thrombosis and pulmonary embolism) in 

patients admitted to hospital” January 2010, gives clear guidance regarding national 

standards. 

Patients with cancer have an approximate 7 fold increased risk of VTE, accounting 

for ~20% of the community presenting VTE. Cancer patients undergoing surgery 

have a two-fold or greater increased risk for fatal PE compared with those without 

cancer who are undergoing similar procedures. Patients with active cancer and 

particularly those with central venous lines and those receiving chemotherapy are at 

a significantly increased risk for VTE. In-patients with cancer must be managed 

according to the medical, surgical or critical care guidelines as appropriate. 

The appropriate use of thromboprophylaxis will: 

• Reduce morbidity due to VTE 

• Reduce mortality rates due to VTE 

• Reduce the cost of treatment of VTE 

This policy summarises best practice based on current evidence for the prevention of 

Hospital acquired VTE. 

2 Policy Statements 

• All inpatients must have their risk of developing VTE assessed on admission 

using the risk assessment tool on one of the Trust Medicines Administration 

Records. 

• All patients must have this risk assessment reviewed within 24 hours of 

admission and when clinical condition changes 

• If risk of VTE is identified and prophylaxis withheld, the reason(s) for this must 

be documented clearly 



Status: Final 


3 Definition of Terms Used 

AES 

DH 

DVT 

FID 

HAT 

ICE 

IPC 

LMWH 

NOAC 

PE 

UFH 

VTE 

Anti-Embolic Stockings 

Department of Health 

Deep Vein Thrombosis 

Foot Impulse Devices 

Hospital Acquired Thrombosis 

Integrated Clinical Environment 

Intermittent Pneumatic Compression 

Low Molecular Weight Heparin 

Novel oral anticoagulant 

Pulmonary Embolism 

Unfractionated heparin 

Venous Thromboembolism 

4 Duties and Responsibilities 

4.1 Hospital Thrombosis Committee 

This comprises representatives from Medicine, Surgery, Obstetrics & Maternity, 

Orthopaedics, Pharmacy, Haematology and Oncology. The Committee will: 

• Promote best practice through local policies based on National 

Guidelines 

• Lead multi professional audit of the use of thromboprophylaxis 

• Promote education and training 

• Report quarterly to the Operational Governance Committee. 

4.2 Admitting doctor 

Responsible for completing and documenting the risk assessment and prescribing 

prophylaxis if indicated. Decision not to prescribe pharmaceutical prophylaxis must 

be documented and alternative mechanical prophylaxis recommended. 

4.3 Medical, nursing or pharmacy staff on wards 

Responsible for prescribing, checking and administering thromboprophylaxis and 

ensuring risk assessments are repeated by the medical staff at 24 hours and 

reviewed whenever the clinical situation changes. 

4.4 Medical, nursing or pharmacy staff on ICU 

Responsible for ensuring risk assessments are repeated every 24 hours and 

documented on medication chart. 



Status: Final 


5 Risk Assessment on Admission and During Stay 

• All patients must have their risk of developing VTE assessed on admission 

and have this assessment reviewed within 24 hours of admission and if their 

clinical condition changes, using the risk assessment tool which is on the 

Trust Medicines Administration chart. 

• Inpatients must be re-assessed for risk factors at 24 hours post 

admission and then when clinically indicated (every 24 hours for 

ICU patients). 

• If VTE prophylaxis is withheld for any reason (e.g. bleeding risk) this 

must be documented clearly and alternative methods of prophylaxis 

prescribed. 

• The admitting doctor is responsible for completing the risk assessment and 

prescribing thromboprophylaxis. For elective patients, the risk assessment 

must be completed on admission, and the post-operative plan for VTE 

prophylaxis must be recorded in the operation note either within the health 

record, or on Millennium. 

• Extended thromboprophylaxis with low molecular weight heparin or 

rivaroxaban is recommended in patients with: 

• Elective total hip arthroplasty 

• Elective knee arthroplasty 

• Fractured neck of femur 

• Major cancer surgery in the abdomen or pelvis 

NB: It may be necessary to consider this treatment for other high risk patient 

groups. 

5.1 Surgical patients and patients with trauma 

Surgical patients and patients with trauma are regarded as being at increased risk of 

VTE if they meet one of the following criteria: 

• Surgical procedure with a total anaesthetic and surgical time of more than 

90 minutes, or 60 minutes if the surgery involves the pelvis or lower limb 

• Acute surgical admission with inflammatory or intra-abdominal condition 

• Expected significant reduction in mobility 

• One or more of the risk factors shown below (5.4) 

Surgical patients must be informed that immobility associated with continuous travel 

of more than 3 hours in the 4 weeks before or after surgery may increase the risk of 

VTE. 



Status: Final 


Surgical patients on the combined oral contraceptive pill should be advised to 

consider stopping 4 weeks before elective surgery. Alternative contraceptive 

measures should be advised. 

Inpatients must be re-assessed for risk factors at 24 hours post admission and then 

when clinically indicated (every 24 hours for ICU patients). 

5.2 Regional anaesthesia 

Regional anaesthesia reduces the risk of VTE compared to general anaesthesia. 

The suitability of regional anaesthesia for an individual patient should be considered, 

in addition to any other planned method of thromboprophylaxis. If regional 

anaesthesia is used, the timing of the thromboprophylaxis must be planned to 

minimise the risk of epidural haematoma. If antiplatelet or anticoagulant agents are 

being used or planned, refer to the Trust guideline for guidance about safety and 

timing of these agents in relation to regional anaesthesia. Pharmacological or 

mechanical VTE prophylaxis must not be routinely offered to patients having surgery 

with local anaesthesia by local infiltration with no limitation of mobility. 

5.3 Medical patients 

Medical patients are regarded as being at increased risk of VTE if they 

• (a) Have had or are expected to have significantly reduced mobility for 3 days or 

more 

OR 

• (b) Are expected to have on-going reduced mobility relative to their normal state 

AND 

• Have one or more of the risk factors below 

5.4 Risk factors for medical and surgical patients 

• Active cancer or cancer treatment 

• Age over 60 years 

• Critical care admission 

• Dehydration 

• Known thrombophilia 

• BMI > 30 kg/m 2 

• Personal or first-degree relative history of VTE 

• One or more significant medical comorbidities (heart disease; metabolic, 

endocrine or respiratory pathologies; acute infectious diseases; inflammatory 

conditions) 

• HRT or oestrogen-containing contraceptive 

• Varicose veins with phlebitis 

• Pregnant or given birth within last 6 weeks 



Status: Final 


6 Information for Patients 

6.1 All patients on admission 

All patients must be given verbal and written information on admission about the 

risks and possible consequences of VTE, the effectiveness and possible side effects 

of prophylaxis and how they can reduce the risk of VTE. 

Since heparin is derived from animal products, consider offering synthetic 

alternatives to patients who have concerns about its use. 

6.2 All patients on discharge 

All patients, and their families and carers if appropriate, must be given verbal 

and written information on the following, as part of their discharge plan: 

• The signs and symptoms of DVT / PE 

• The correct use of extended prophylaxis (if appropriate). 

• The implications of not using prophylaxis (if appropriate). 

• The importance of seeking medical help and who to contact if deep 

vein thrombosis or pulmonary embolism is suspected. 

If discharged with prophylaxis: 

• The signs and symptoms of adverse events related to VTE prophylaxis 

• The importance of seeking help and who to contact if they have any 

problems using the prophylaxis 

7 Reducing the Risk of VTE Prophylaxis 

7.1 General Measures 

Early mobilisation and leg exercises 

• Patients will be encouraged to mobilise as soon as possible. 

• Patients who are unable to mobilise will be encouraged to do regular leg 

exercises. 

Hydration 

• Ensure patients are adequately hydrated. 



Status: Final 


7.2 Pharmacological prophylaxis and methods 

The choice of pharmacological thromboprophylaxis is based on local polices, clinical 

condition (for example) and patient preference 

I: Dalteparin - Low Molecular Weight Heparin (LMWH) 

Weight (kg) 

150 kg 

Dose 

2500 units SC once daily 

5000 units SC once daily 

5000 units SC twice daily 

7500 units SC twice daily 

Renal Impairment: eGFR50%. Always 

discuss management of these patients with a Consultant Haematologist 

• Osteoporosis – Heparins are associated with an increased risk of osteoporosis 

and bone fracture with prolonged use (>12 weeks at prophylactic doses). This 

risk is greater in pregnancy and older women. 

II: Rivaroxaban 

Licensed in elective hip or knee replacement. See Orthopaedic Appendices 

III: Anti-platelet agents 

Aspirin is NOT recommended as prophylaxis against VTE in any patient group. 



Status: Final 


7.3 Patients already on antiplatelet agents or 

anticoagulation on admission or needing them for 

treatment 

• Consider offering additional mechanical or pharmacological VTE prophylaxis 

to patients who are having antiplatelet agents to treat other conditions and 

who are assessed to be at increased risk of VTE. Take into account the risk of 

bleeding and of comorbidities such as arterial thrombosis 

o If the risk of VTE outweighs the risk of bleeding, consider offering 

pharmacological VTE prophylaxis according to the reason for 

admission 

o If the risk of bleeding outweighs the risk of VTE, offer mechanical VTE 

prophylaxis 

• Do not offer additional pharmacological or mechanical VTE prophylaxis to 

patients who are taking novel oral anticoagulants (dabigatran, rivaroxaban, 

apixaban), or vitamin K antagonists (warfarin, phenindione) and who are 

within their therapeutic range, providing anticoagulant therapy is continued 

• Do not offer additional pharmacological or mechanical VTE prophylaxis to 

patients who are having treatment dose parenteral anticoagulant therapy (for 

example, fondaparinux, LMWH or UFH) 

7.4 Cautions and contraindications to pharmacological 

thromboprophylaxis using LMWH (Dalteparin) and 

Rivaroxaban 

This list is not exhaustive. Consider other factors in an individual patient. 

• Active bleeding 

• Acquired bleeding disorders (e.g. acute liver failure) 

• Concurrent use of anticoagulants known to increase bleeding risk (e.g. warfarin 

with INR >2) 

• Lumbar puncture / epidural / spinal anaesthesia within the previous 4 hours or 

expected within the next 12 hours 

• Acute stroke 

• Thrombocytopenia (platelets < 75 x 10 9 /L) 

• Uncontrolled systolic hypertension (BP ≥ 230/120 mmHg) 



Status: Final 


• Untreated inherited bleeding disorders (e.g. haemophilia or von Willebrand’s 

disease) 

• Surgery expected within the next 12-24 hours 

• Surgery in the past 48 hours +/- risk of clinically important bleeding 

• Hypersensitivity to heparin or low molecular weight heparins 

• History of heparin induced thrombocytopenia 

• Neurosurgery, spinal, eye surgery or other procedure with high bleeding risk 

• Renal failure 

o rivaroxaban: contraindicated if eGFR < 15mls/min (use 

unfractionated heparin 5,000 units sc twice daily) 

o dalteparin: contraindicated if eGFR

• Remove anti-embolism stockings daily for hygiene purposes and to inspect skin 

condition. In patients with a significant reduction in mobility, poor skin integrity or 

any sensory loss, inspect the skin two or three times per day, particularly over 

the heels and bony prominences 

Discontinue the use of anti-embolism stockings if there is marking, blistering or 

discolouration of the skin, particularly over the heels and bony prominences, or if 

the patient experiences pain or discomfort. If suitable, offer a foot impulse or 

intermittent pneumatic compression device as an alternative. 

Intermittent pneumatic compression devices (IPC), foot impulse devices (FID) 

or venous foot pumps 

• May be used as alternatives or in addition to anti-embolism stockings where 

appropriate in surgical inpatients 

• Do not offer foot impulse or intermittent pneumatic compression devices to 

patients with a known allergy to the material of manufacture 

• Encourage patients on the ward who have foot impulse or intermittent pneumatic 

compression devices to use them for as much of the time as is possible and 

practical, both when in bed and when sitting in a chair. 

Contraindications to mechanical prophylaxis 

• Suspected or proven peripheral arterial disease 

• Peripheral arterial bypass grafting 

• Peripheral neuropathy or other causes of sensory impairment 

• Local condition in which stockings may cause damage e.g. fragile tissue paper 

skin, leg ulcers, dermatitis, gangrene or recent skin graft 

• Known allergy to material of manufacture 

• Cardiac failure 

• Massive leg oedema 

• Pulmonary oedema from congestive cardiac failure 

• Unusual leg shape or size 

• Major limb deformity preventing correct fit 

Leg or foot ulcers or wounds; use caution or clinical judgement 



Status: Final 


Intermittent pneumatic compression devices and foot impulse devices 

contraindications 

• Known allergy to material of manufacture 

• Known or suspected acute DVT or PE 

• Peripheral arterial disease 

• Local skin condition precluding application 

• Severe congestive cardiac failure 

• Do not apply if the legs are elevated during surgery 

• Pre-existing thrombophlebitis, DVT or PE 

• Use cautiously on an infected or insensate extremity 

7.6 Vena Caval Filters 

These must be considered for surgical patients with recent (within 1 month) or 

existing VTE, or who have an active malignancy and in whom mechanical 

prophylaxis and anticoagulation is contraindicated. 

8 Procedure if Venous Thromboembolism is Suspected 

If an inpatient already receiving thromboprophylaxis is suspected to have a DVT or 

PE they must be treated with a therapeutic dose of LMWH and have the 

appropriate radiological investigations. 

Refer to Acute Medicine Guidelines: 

Pulmonary Embolism (ACUTE 034/2014), 

Deep venous thrombosis (DVT) (ACUTE 027/2014) 



Status: Final 


9 Hospital Acquired Thrombosis (HAT) 

A hospital acquired thrombosis (DVT or PE) is defined as being a DVT or PE which 

has occurred within 3 months of a hospital admission. 

The data on these patients is collected by BIU from the diagnostic scans reported on 

the ICE system and the community DVT Doppler service commissioned by BANES. 

This information is reviewed and those incidents that are identified as possible HATs 

are reported on the Trust incident reporting system, Datix. 

A Root Cause Analysis (RCA) investigation must be completed by the patient’s 

initial Consultant on all patients who are suspected of having a HAT. HATs and 

the RCA findings must be reported to the Hospital Thrombosis Committee for 

review, assessment of trends across the Trust and the identification of learning 

and actions required to reduce identified risks. 

10 Monitoring Compliance 

The Trust-wide audit of VTE prophylaxis is mandatory. 

Audit data on completion of risk assessment on patients admitted to hospital 

is collected and reported to Trust Board every month. 

A review of risk assessment compliance and findings is also monitored as part of 

the Trust Patient Safety Improvement Programme and is reported within the Trust. 

11 Review 

This policy will be subject to a planned review every three years as part of the Trust’s 

Policy Review Process. It is recognised however that there may be updates required 

in the interim arising from amendments or release of new regulations, Codes of 

Practice or statutory provisions or guidance from the Department of Health or 

professional bodies. These updates will be made as soon as practicable to reflect 

and inform the Trust’s revised policy and practise. 

12 Training 

Managers are responsible for ensuring all their staff receive the type of initial and 

refresher training that is commensurate with their role(s). 

Staff must refer to the Mandatory Training Profiles available on the intranet, to 

identify what training in relation to venous thromboembolism prophylaxis is relevant 

for their role and the required frequency of update. Further information is available 

on the statutory and mandatory training web pages about each subject and the 

available training opportunities. 



Status: Final 


References 

1. Scottish Intercollegiate Guidelines Network (SIGN), Prevention and 

Management of Venous Thromboembolism. 122. Dec 2010 

2. Report of the independent expert working group on the prevention of 

venous thromboembolism in hospitalised patients. Department of Health, A 

report to Sir Liam Donaldson, Chief Medical Officer. 2007 

3. Government Response to the House of Commons Health Committee 

report on the prevention of venous thromboembolism in Hospitalised 

Patients – second report of session 2004-5. July 2005. 

4. Collins R, Baigent C, Sandercock P, Peto RO. Antiplatelet therapy for 

thromboprophylaxis: the need for careful consideration of the evidence 

from randomised trials. Antiplatelet trialists collaboration. BMJ 1994; 

309; 1215-7 

5. NICE Clinical Guideline 92 Venous thromboembolism: reducing the risk. 

Reducing the risk of venous thromboembolism (deep vein thrombosis and 

pulmonary embolism) in patients admitted to hospital. January 2010 

6. All-party parliamentary thrombosis group Thrombosis: Awareness, 

Management and Prevention November 2007 

7. Kakkar AK, Coleman R et al. Prevention and Treatment of Cancer-Associated 

Thrombosis: A Report on a Roundtable Meeting. British Journal of Cancer vol 

102, supplement 1, 13 April 2010 

8. Haemostasis, Anticoagulation & Thrombosis (HAT) Committee, UK 

Clinical Pharmacy Association. UKMi Medicines Q&A 326.1: What 

doses of thromboprophylaxis are appropriate for adult patients at 

extremes of body weight? April 2010. Available from www.nelm.nhs.uk, 

date accessed: 21 st February, 2011. 

9. Templeman, E. UKMi Medicines Q&A 257.2: Should prophylactic doses of 

low molecular weight heparins be used in patients with renal impairment? 

July 2010. Available from www.nelm.nhs.uk, date accessed: 21 st February, 

2011. 

10. Ashley, C and Currie, A. Renal Drug Handbook 3 rd Edition. Dalteparin. 

11. Gould MK et al. Prevention of VTE in nonorthopedic surgical patients: 

Antithrombotic therapy and prevention of thrombosis. 9th edition: American 

College of Chest Physicians evidence based Clinical Practice Guidelines. 

Chest 2012; 141(2_suppl): e227S-e277S 



Status: Final 


12. Falck-Ytter Y et al. Prevention of VTE in orthopaedic surgical patients: 

Antithrombotic therapy and prevention of thrombosis. 9th edition: American 

College of Chest Physicians evidence based Clinical Practice Guidelines. 

Chest 2012; 141(2_suppl):e278S-e325S 

13. Kahn SR et al. Prevention of VTE in nonsurgical patients: Antithrombotic 

therapy and prevention of thrombosis. 9th edition: American College of Chest 

Physicians evidence based Clinical Practice Guidelines. Chest 2012; 

141(2_suppl):3195S- e226S 



Status: Final 


Appendix 1: Guideline for the Prevention of Venous 

Thromboembolism in Adults 

1. All in-patients and day case surgery patients must have a documented risk 

assessment performed on admission leading to a clinical decision regarding 

appropriate measures to prevent venous thromboembolism (VTE) 

2. The Trust risk assessment tool on the drug chart must be used to record the risk 

assessment. A decision on the use or otherwise of pharmacological or 

mechanical prophylaxis must be clearly documented 

3. General preventative measures (early mobilisation, leg exercises and ensuring 

adequate hydration) are appropriate for all patients and are communicated on 

admission 

4. The decision on how to manage the risk of VTE will be based on an assessment 

of the risks of VTE against the bleeding risk of preventative treatment for each 

individual patient 

5. The risk assessment must be reviewed within 24 hours of admission. 

Subsequently the risk assessment must be reviewed whenever the clinical 

situation changes (every 24 hours for ICU patients) 

6. Before starting VTE prophylaxis patients and/or their families or carers must be 

given verbal +/- written information on their risk of VTE, the importance of VTE 

prophylaxis and possible side effects, the correct use of VTE prophylaxis and 

how they can reduce their risk of VTE (i.e. keep well hydrated, do leg exercises 

and mobilise if possible) 

7. On discharge patients and/or their families or carers must be given verbal +/- 

written information on: 

• The signs and symptoms of deep vein thrombosis and pulmonary 

embolism 

• The importance of seeking medical help and who to contact if deep vein 

thrombosis or pulmonary embolism is suspected 

• If discharged with prophylaxis: 

o the correct and recommended duration of use of VTE prophylaxis 

o how to use VTE prophylaxis correctly 

o the signs and symptoms of adverse events related to VTE 

prophylaxis 

o the importance of seeking help and who to contact if they have any 

problems using the prophylaxis 



Status: Final 


8. Ensure that patients who are discharged with anti-embolism stockings: 

• Understand the benefits of wearing them 

• Understand the need for daily removal and hygiene 

• Are able to remove and replace them, or have someone available who will 

be able to do this for them 

• Know what problems to look for, such as skin marking, blistering or 

discolouration, particularly over the heels and bony prominences 

• Know who to contact if there is a problem 

9. Ensure that patients who are discharged with pharmacological and/or 

mechanical VTE prophylaxis are able to use it correctly, or have arrangements 

made for someone to be available who will be able to help them 

10. Notify the patient’s GP if the patient has been discharged with pharmacological 

and/or mechanical VTE prophylaxis to be used at home 



Status: Final 


Appendix 2: 

Guideline 

General Medicine Thromboprophylaxis 

First assessment carried out 

by admitting doctor 

Patient has had or is expected to have 

significantly reduced mobility for 3 or more 

days (i.e. bedbound, unable to walk unaided, 

or likely to spend a substantial proportion of 

the day in bed or in a chair 

Yes 

No 

Patient is expected to have ongoing 

reduced mobility relative 

to normal and has one or more 

risk factors (box 1) 

No 

Box 1. VTE risk factors: 


• Aged over 60 years 




• BMI >30 kg/m 2 

• Personal or first degree relative history of VTE 

• One or more significant medical comorbidities 

(heart disease; metabolic, endocrine or 

respiratory pathologies; acute infectious 

diseases; inflammatory conditions) 



• Pregnant or given birth within 6 weeks 

No VTE prophylaxis needed 

Yes 

Risk of bleeding from 

pharmacological prophylaxis (box 2) 

Use LMWH. Check 

renal function 

No 

Prescribe dalteparin (see full guideline). 

If renal impairment (eGFR2) 

• Concurrent anticoagulant use (e.g. warfarin 

with INR>2) 

• Lumbar puncture/epidural/spinal anaesthesia 

within next 12 hours or previous 4 hours 

• Acute stroke 

• Platelets 230/120 mmHg 

• Untreated inherited bleeding disorders (e.g. 

haemophilia, von Willebrand’s) 

• Anticipated or recent procedure 

All VTE prophylaxis contraindicated 

Consider the use of anti-embolism 

stockings. 

Need to be measured and correctly fitted 

Wear day and night 

Document assessment and management 

Avoid dehydration 

Encourage mobility 

Give patient information leaflet 

Re-assess VTE and bleeding risks within 24 hours. 

Ensure prophylaxis is being given correctly 

Box 3. Contraindications to anti-embolism stockings 

• Suspected or proven peripheral arterial disease 

• Peripheral arterial bypass graft 

• Peripheral neuropathy or other sensory impairment 

• Fragile skin, dermatitis, gangrene, recent skin graft 

• Allergy to material 

• Heart failure 

• Severe leg oedema 

• Unusual leg size or shape 

• Major deformity preventing correct fit 

• Caution with venous ulcers or wounds 



Status: Final 


Appendix 2a: Stroke Thromboprophylaxis Guideline 

• Do NOT offer anti-embolism stockings. Use IPC graded compression system 

(foot pumps) until it is deemed safe for the patient to have pharmacological 

VTE prophylaxis 

• Consider LMWH if: non-haemorrhagic stroke, and risk of haemorrhagic 

transformation is low, and one or more of: 

o Major restricted mobility 

o Previous VTE 

o Dehydration 

o Other comorbidities (e.g. cancer) 



Status: Final 


Sequential Compression Devices 

for the prevention of 

Venous thrombo-embolism in stroke patients 

A Quick Reference Guide for Prescribers 

• Indications: 

• Stroke (ischaemic or haemorrhagic) 

• Less than 30 days from stroke onset (start use ASAP after stroke) 

• Immobile or requires supervision or assistance to mobilise along the 

ward (e.g. to the bathroom) 

• No contra-indication to SCD use (see below) 

• Contra-indications: 

• Dermatitis 

• Leg ulcers 

• Severe oedema 

• Congestive cardiac failure (causing any visible pitting oedema) 

• Severe peripheral vascular disease 

• Existing DVT 

• The prescription: 

• Prescribe “Thigh-length SCD” or “Thigh-length Flowtrons” 

• Mark drug chart with a continuous 24 hour loop 

• Also tick chart 3 times a day for skin checks 

• Problems to look out for: 

• Any skin redness / breaks 

• Patient discomfort from sleeves 

• Tubing kinked, squashed or trapped e.g. between patients’ legs 

• Report any of these immediately to SCD trained nursing staff and 

consider discontinuing SCD use (seek senior advice) 



Status: Final 


Appendix 2b: Palliative Care Thromboprophylaxis 

Guideline 

• For patients undergoing terminal care or on an end-of-life pathway do not use 

pharmacological or mechanical thromboprophylaxis 

• For patients undergoing palliative care with potentially reversible acute 

pathology and is at increased risk of VTE, consider using dalteparin if no 

contraindications 

• Review decisions about VTE prophylaxis for patients in palliative care daily, 

taking into account the views of patients, their families and/or carers and the 

multidisciplinary team 



Status: Final 


PATIENTS IN PALLIATIVE 

CARE 

If patient has potentially 

reversible acute pathology 

If patient in terminal care 

or end-of-life care pathway 

Consider LMWH 1 (dalteparin) if no 

contraindications, or UFH 2 

Do not routinely offer 

pharmacological or mechanical 


Review decisions about VTE prophylaxis daily, taking into account potential risks and benefits and 

views of the patient, family and/or carers and multidisciplinary team 

1 

See Methods of Prophylaxis 

2 

For patients with renal failure (EGFR

Appendix 2c: Cancer and Central Catheters 

Thromboprophylaxis Guideline 

Cancer patients 

• If the patient is having oncological treatment and is ambulant – mechanical 

and pharmacological thromboprophylaxis are not routinely indicated 

• If the patient is assessed as having additional risks for VTE use dalteparin if 

no contraindications 

Patients with central venous catheters 

• Do not routinely offer pharmacological or mechanical VTE prophylaxis to 

patients with central venous catheters who are ambulant 

• If the patient is high risk for VTE consider dalteparin if no contraindications 



Status: Final 


Patients with cancer 

Patients with central 

catheters 

Is patient having 

oncological treatment 

and ambulant? 

Is patient ambulant? 

Yes 

No 

Yes 

No 




VTE risk 

increased? 




VTE risk 

increased? 

Yes 

No 

Yes 

No 

Use 

LMWH 1 (Dalteparin) if no 


Continue until patient no longer at 

increased risk of VTE 

Use 

LMWH 1 (Dalteparin) if no 


Reasses within 24 hours of admission and whenever clinical situation changes 

1 

See Methods of Prophylaxis 

2 

For patients with renal failure (eGFR

Appendix 3: Pregnancy and up to 6 weeks Postpartum 


Consider pharmacological prophylaxis for women who are pregnant or have given 

birth within the previous 6 weeks who are admitted to hospital but are not undergoing 

surgery and who have one or more of the following risk factors: 

• Expected to have significantly reduced mobility for 3 or more days 


• Age > 35 years 



• Excess blood loss or transfusion 


• Obesity (pre-pregnancy or early pregnancy BMI > 30 kg /m2) 

• medical comorbidity (e.g. heart disease; metabolic, endocrine or respiratory 

pathologies; acute infectious diseases; inflammatory conditions) 


• Pregnancy-related risk factor (ovarian hyperstimulation, hyperemesis, multiple 

pregnancy, pre-eclampsia) 


Consider offering combined VTE prophylaxis with mechanical methods and LMWH 

(or UFH for patients with renal failure) to women who are pregnant or have given 

birth within the previous 6 weeks who are undergoing surgery, including caesarean 

section. 

Offer mechanical and/or pharmacological VTE prophylaxis to women who are 

pregnant or have given birth within the previous 6 weeks only after assessing the 

risks and benefits and discussing these with the woman and with healthcare 

professionals who have knowledge of the proposed method of VTE prophylaxis 

during pregnancy and post-partum. Plan when to start and stop pharmacological 

VTE prophylaxis to minimise the risk of bleeding. 



Status: Final 


Antenatal VTE risk assessment 

Previous VTE on warfarin 

VTE in current pregnancy 

Anti-thrombin deficiency 

Mechanical heart valves 

VERY HIGH RISK 

Therapeutic enoxaparin 1mg/kg/bd 

or equivalent other LMWH during 

pregnancy and post partum 

warfarin 

Refer to combined Haem/ANC 

Refer to Anaesthetic ANC 

Single previous VTE plus 

thrombophilia or family history 

(1 st degree relative) 

Unprovoked/oestrogen-related 

Previous recurrent VTE (>1) 

HIGH RISK 

Requires antenatal prophylaxis 

with LMWH 

Refer to combined Haem/ANC 

Refer to Anaesthetic ANC 

Single previous VTE with no 

family history or thrombophilia 

Thrombophilia + no VTE 

Medical comorbidities, e.g. heart 

or lung disease, SLE, cancer, 

inflammatory conditions, 

nephrotic syndrome, sickle cell 

disease, intravenous drug user 

Surgical procedure during 

pregnancy, e.g. appendicectomy 

MODERATE RISK 

Consider antenatal prophylaxis 

with LMWH 

Refer to any general ANC 

Age > 35years 

Obesity (BMI > 30kg/m2) 

Parity > 3 

Smoker 

Gross varicose veins 

Current systemic infection 

Immobility, e.g. paraplegia, 

SPD, long distance travel 

Pre-eclampsia 

Dehydration/hyperemesis/ 

OHSS 

Multiple pregnancy 

3 or more risk factors 

2 or more if admitted 

> 3 risk factors 

LOWER RISK 

Mobilisation and avoidance of 

dehydration 

KEY 

BMI = body mass index (based on booking weight), gross varicose veins = symptomatic, above the knee or associated with phlebitis/oedema/skin 

changes, immobility = > 3 days, LMWH = low-molecular weight heparin, OHSS = ovarian hyperstimulation syndrome, PPH = postpartum 

haemorrhage, SLE = systemic lupus erythematosus, SPD = symphysis pubis dysfunction with reduced mobility, thrombophilia = inherited or acquired, 

long distance travel - > 4 hours, VTE = venous thromboembolism 

Antenatal and postnatal prophylactic dose of LMWH 

Weight 170 kg = 0.6mg/kg/day enoxaparin; 75 units/kg/day daltaparin; 75 units/kg/day tinzaparin 



Status: Final 


Postnatal VTE risk assessment 

• Previous VTE on warfarin 

• Anti-thrombin deficiency 

• Mechanical heart valves 

VERY HIGH RISK 

• Re-warfarinize 

• Ensure haematology follow 

up is arranged 

• Anti-embolism stockings 

• Any previous VTE 

• Anyone requiring antenatal 

LMWH 

HIGH RISK 

• At least 6 weeks postnatal 

prophylactic LMWH and 

anti-embolism stockings 

• Caesarian section in labour 

• Asymptomatic 

thrombophilia (inherited or 

acquired) 

• BMI >40 KG/M2 

• Prolonged hospital 

admission 

• Medical co-morbidities e.g. 

heart or lung disease, SLE, 

cancer, inflammatory 

conditions, nephritic 

syndrome, sickle cell 

disease, intravenous drug 

user 

MODERATE RISK 

• At least 7 days postnatal 

prophylactic LMWH and 

anti-embolism stockings 

Note: if persisting or >3 risk 

factors, consider extending 

thromboprophylaxis with 

LMWH 

• Age > 35years 

• Obesity (BMI > 30kg/m2) 

• Parity > 3 

• Smoker 

• Elective caesarean section 

• Any surgical procedure in 

the puerperium 

• Gross varicose veins 

• Current systemic infection 

• Immobility, e.g. paraplegia, 

SPD, long distance travel 

• Pre-eclampsia 

• Mid-cavity rotational 

operative delivery 

• Prolonged labour 

(>24hours) 

• PPH > 1 litre or blood 

transfusion 

2 or more risk factors 

< 2 risk factors 

LOWER RISK 

• Mobilisation and avoidance of 

dehydration 

• +/- Anti-embolism stockings 

KEY 

Gross varicose veins = symptomatic, above the knee or associated with phlebitis/oedema/skin changes 

immobility = > 3 days 

Thrombophilia = inherited or acquired 

Long distance travel = > 4 hours 



Status: Final 


Ante-natal 

or postnatal 

weight 

170 kg 

LMWH Dose 

20 milligrams enoxaparin/2500 units dalteparin/3500 units tinzaparin daily 




0.6 milligrams/kilograms/day enoxaparin, 75 units/kilogram/day dalteparin, 

75 units/kilogram/day tinzaparin 

For women with an identified bleeding risk e.g. von Willebrand’s disease, 

thrombocytopenia or severe liver disease the balance of risk and benefits should be 

discussed with a senior haematologist. 

For women who have suffered a VTE event during pregnancy, refer to the 

individualised postnatal care plan. If unavailable, discuss with senior haematologist 

at an appropriate time. 

For further information, refer to Thromboprophylaxis in pregnancy, labour and the 

pueperium policy on the RUH intranet. 



Status: Final 


Appendix 4: 

Guideline 

General Surgical Thromboprophylaxis 

All surgery 

• Assess the risks and benefits of stopping pre-existing established antiplatelet 

therapy 1 week before surgery. Consider involving the multidisciplinary team 

in the assessment 

• Consider regional anaesthesia for individual patients, in addition to other 

methods of VTE prophylaxis, as it carries a lower risk of VTE than general 

anaesthesia. Take into account patients’ preferences, their suitability for 

regional anaesthesia and any other planned method of VTE prophylaxis 

• Advise patient to stop COCP or HRT 4 weeks prior to elective surgery; ensure 

using alternative contraception 

• If regional anaesthesia is used, plan the timing of pharmacological VTE 

prophylaxis to minimise the risk of epidural haematoma. If antiplatelet or 

anticoagulant agents are being used, or their use is planned, refer to the Trust 

guideline for guidance about the safety and timing of these agents in relation 

to the use of regional anaesthesia 


patients undergoing a surgical procedure with local anaesthesia by local 

infiltration with no limitation of mobility 

• Offer VTE prophylaxis to patients undergoing surgery who are assessed to be 

at increased risk of VTE: 

• Surgical procedure with a total anaesthetic and surgical time of more than 

90 minutes, or 60 minutes if the surgery involves the pelvis or lower limb 



• One or more of the risk factors shown below 






• BMI > 30 kg/m 2 


• One or more significant medical comorbidities (heart disease; 

metabolic, endocrine or respiratory pathologies; acute infectious 





Status: Final 




Start mechanical VTE prophylaxis on admission. Use one of: 

• Anti-embolism stockings (thigh or knee length) 

• Foot impulse devices 

• Intermittent pneumatic compression devices (thigh or knee 

length) 

Continue mechanical VTE prophylaxis until the patient no longer has 

significantly reduced mobility. 

Add pharmacological VTE prophylaxis for patients who have a low risk of 

major bleeding, taking into account individual patient factors and according to 

clinical judgement. Use one of: 

• LMWH 

• UFH (for patients with renal failure) 

• Rivaroxaban (for elective knee/hip replacement) 

Continue pharmacological VTE prophylaxis until the patient no longer has 

significantly reduced mobility (generally 5–7 days). 

Elective and Emergency patients 

The VTE risk assessment must be completed on admission, and the post-operative 

plan for VTE prophylaxis must be recorded in the operation note either within the 

health record or on Millennium. 

On admission the medical staff: 

• decide which thromboprophylaxis should be used 

• determine if any form of thromboprophylaxis is contraindicated 

• agree the timing of starting pharmacological thromboprophylaxis 

• prescribe the agreed pharmacological prophylaxis 

STEP 1 

Identify the patient’s VTE risk factors 



Status: Final 


STEP 2 

Identify the risk of thrombosis of the procedure: 

Risk group 

Low risk 

patient and 

procedure 

High risk 

patient or 

procedure 

Recommended Thromboprophylaxis 

• Mobilisation 

• Adequate hydration 

• Dalteparin 

• Use unfractionated heparin if eGFR

Appendix 4a: Vascular, Gastrointestinal, Gynaecological 

and Urological Surgery Thromboprophylaxis Guideline 

Vascular Surgery 

• Offer VTE prophylaxis to patients undergoing vascular surgery who are not 

having other anticoagulant therapy and are assessed to be at increased risk 

of VTE. If peripheral arterial disease is present, seek expert opinion before 

fitting anti-embolism stockings 

• Start mechanical VTE prophylaxis at admission. Use one of: 

o 

o 

o 

Anti-embolism stockings (thigh or knee length) 

Foot impulse devices 

Intermittent pneumatic compression devices (thigh or knee length) 

• Continue mechanical VTE prophylaxis until the patient no longer has 

significantly reduced mobility 

• Add pharmacological VTE prophylaxis for patients who have a low risk of 


clinical judgement. Choose one of: 

o 

o 

LMWH 

UFH (for patients with eGFR < 10 ml/min) 





Status: Final 


Gastrointestinal, Gynaecological and Urological Surgery 

• Offer VTE prophylaxis to patients undergoing bariatric surgery 

• Start mechanical VTE prophylaxis at admission. Use one of: 

o Anti-embolism stockings (thigh or knee length) 

o Foot impulse devices 

o Intermittent pneumatic compression devices (thigh or knee length) 





clinical judgement. Use one of: 

o LMWH 

o UFH (for patients with eGFR < 10 ml/min). 

• Continue pharmacological VTE prophylaxis until the patient no longer has 


• Extend pharmacological VTE prophylaxis to 28 days postoperatively for 

patients who have had major cancer surgery in the abdomen or pelvis. 



Status: Final 


Patients undergoing 

general surgery 

VASCULAR 

SURGERY 1 

GASTROINTESTINAL 

SURGERY 

GYNAECOLOGY, 

AND UROLOGY 

SURGERY 

BARIATRIC 

SURGERY 

If VTE risk 

increased 

If VTE risk 

increased 

If VTE risk 

increased 

Start mechanical VTE prophylaxis 2 at 

admission. 

If peripheral arterial disease present, seek 

expert opinion before fitting anti-embolism 

stockings. 

Continue until mobility no longer significantly 

reduced 

Offer mechanical VTE 

prophylaxis 2 at admission. 

Continue until mobility no longer 

significantly reduced 

Offer mechanical VTE 

prophylaxis 2 at admission. 

Continue until mobility no 

longer significantly 

reduced 

If risk of major 

bleeding low 


bleeding low 


bleeding low 

Add: 

LMWH (dalteparin) or 

UFH 3 . Continue until 

mobility no longer 


(generally 5-7 days) 

Add: 

LMWH (dalteparin) or UFH 3 . 


significantly reduced (generally 5- 

7 days) 

Add: 

LMWH (dalteparin) or 

UFH 3 . Continue until 




1: 

Many vascular surgical patients are already having antiplatelet or 

anticoagulant therapy. For these patients, seek expert opinion. 

2: 

Choose any one of these: 

• Anti-embolitic stockings (thigh or knee length) 


• Intermittent pneumatic compresssion devices (thigh or knee length) 

3: 


Appendix 4b: Day Surgery Thromboprophylaxis Guideline 

The following procedures are low risk: 

• Ophthalmological procedures with local anaesthetic/regional 

anaesthetic/sedation and not full general anaesthetic 

• Non-cancer ENT surgery lasting less than 90 minutes with local anaesthetic 

/regional anaesthetic / sedation and not full general anaesthetic 

• Non-cancer dental and maxillo-facial surgery lasting less than 90 minutes with 

local anaesthetic / regional anaesthetic / sedation and not full general 

anaesthetic 

Risk assessment to be completed on day surgery drug chart. 

If VTE risk high: 

• Start mechanical VTE prophylaxis at admission and continue mechanical 

thromboprophylaxis until mobility no longer significantly reduced. Use one of: 

o Anti-embolism stockings (thigh or knee length) 


o Intermittent pneumatic compression devices (thigh or knee length) 

Continue mechanical VTE thromboprophylaxis until the patient no longer has 



major bleeding. Use LMWH (dalteparin). If the patient is expected to have 

significantly reduced mobility after discharge, continue pharmacological VTE 

prophylaxis for 5-7 days. Ensure full blood count and renal function checked 

prior to commencing. 



Status: Final 


Patients having day surgery 

If VTE risk 

increased 

Start mechanical VTE 

prophylaxis at admission 1 


longer significantly reduced 

If risk of 

bleeding is 

low 

Add 

LMWH (dalteparin), or UFH 2. 



including after discharge 


1: 

Choose any of the following: 

• Anti-embolitic stockings (thigh or knee length) 


• Intermittent pneumatic compression devices (thigh or knee length) 

2 

: For patients with renal failure (eGFR

Appendix 5: Trauma and Orthopaedic Thromboprophylaxis 

Guideline 

All surgery 

• Assess the risks and benefits of stopping pre-existing established antiplatelet 

therapy 1 week before surgery. Consider involving the multidisciplinary team 

in the assessment 

• Consider regional anaesthesia for individual patients, in addition to other 

methods of VTE prophylaxis, as it carries a lower risk of VTE than general 

anaesthesia. Take into account patients’ preferences, their suitability for 

regional anaesthesia and any other planned method of VTE prophylaxis 

• Advise patient to stop COCP or HRT 4 weeks prior to elective surgery; ensure 

using alternative contraception 

• If regional anaesthesia is used, plan the timing of pharmacological VTE 

prophylaxis to minimise the risk of epidural haematoma. If antiplatelet or 

anticoagulant agents are being used, or their use is planned, refer to the Trust 

guidelines for guidance about the safety and timing of these agents in relation 

to the use of regional anaesthesia 


patients undergoing a surgical procedure with local anaesthesia by local 

infiltration with no limitation of mobility 

• Offer VTE prophylaxis to patients undergoing surgery who are assessed to be 

at increased risk of VTE: 

• Surgical procedure with a total anaesthetic and surgical time of more 

than 90 minutes, or 60 minutes if the surgery involves the pelvis or lower 

limb 



• One or more of the risk factors shown below 






• BMI > 30 kg/m 2 


• One or more significant medical comorbidities (heart disease; 

metabolic, endocrine or respiratory pathologies; acute infectious 




Status: Final 





Document the patient’s VTE risk on the Trust drug chart. The procedure 

specific guidance outlines which combination of prophylaxis to use. 

1. Low risk patients 

Early mobilisation 

2. High risk patients 

• Start mechanical VTE prophylaxis at admission and continue 

mechanical thromboprophylaxis until mobility no longer significantly 

reduced. Use one of: 

o Anti-embolism stockings 


o Intermittent pneumatic compression devices (knee length) 

• Total hip and knee arthroplasty patients and fractured neck of femur 

patients require extended pharmacological thromboprophylaxis 

Pharmacological prophylaxis 

Bleeding risk assessment: review the bleeding risk below. Pharmacological 

VTE prophylaxis should not be used where the bleeding risk outweighs the VTE 

risk. Refer to the procedure specific guidance. 

Active bleeding or risk of bleeding 

Acquired bleeding disorders (e.g. acute liver 

failure) 

Concurrent use of anticoagulants known to 

increase the risk of bleeding 

Acute stroke 

Thrombocytopenia (plt < 75 x 109/L) 

Untreated inherited bleeding disorders (e.g. 

haemophilia) 

Bleeding risks 

BP ≥230/120 mmHg 

Spinal surgery 

Epidural / spinal anaesthesia expected within 

the next 12 hours 

Epidural / spinal anaesthesia within the 

previous 4 hours 

Renal impairment eGFR < 30ml/min 

Weight < 50kg 



Status: Final 


Prescribing notes for Pharmacological Thromboprophylaxis 

For patients already on therapeutic anticoagulation with warfarin see intranet 

Periprocedural Anticoagulation Guideline 

For patients on clopidogrel / aspirin see Perioperative management of antiplatelet 

agents 

Dalteparin 

Timing Elective: 6 hours post op (18.00 / 

22.00) 

Trauma: prescribe on 

admission and 18.00 

thereafter. 

Ideally allow 6 hours postsurgery 

before administering. If 

surgery finishes in the afternoon 

delay administration until 22.00. 

Rivaroxaban 10mg po OD 

Total knee and hip arthroplasty only 

Administer day 3 post op at 

18.00. 

Dose 

adjustment 

Neuraxial 

anaesthesia 

- spinal 

Neuraxial 

anaesthesia - 

epidural 

Post op 

vomiting 

Weight: 

150kg: 7500 units bd 

eGFR

Dalteparin 

Rivaroxaban 10mg po OD 

Total knee and hip arthroplasty only 

Drug 

interactions 

Nil 

Contraindications Anticoagulated (INR > 2.0 or 

NOAC), 

treatment dose LMWH, iv 

heparin or abnormal clotting 

New onset stroke 

Emergency 

surgery or 

procedure 

Discuss with haematologist on 

call. Consider delaying 

surgery or procedure for 24 

hours. Consider the use of 

protamine sulphate 

CYP3A4 inducers e.g. rifampicin, 

reduce the levels of rivaroxaban. 

CYP3A4 inhibitors e.g. 

ketaconazole, ritonavir increase the 

levels of rivaroxaban 

eGFR < 15ml/min 

hepatic disease associated 

with a coagulopathy 

clinically relevant bleeding 

risk 

There is no antidote to 

rivaroxaban. 

If possible delay surgery or 

procedure for 36 hours. If 

this is not possible then 

inform on call haematologist 

and proceed with surgery. If 

bleeding cannot be 

controlled, consider use of 

Beriplex. 

Extended (post discharge) prophylaxis 

Surgery Prophylaxis Monitoring Dose adjustment 

Total hip 

Nil 

arthroplasty 

Total knee 

arthroplasty 

Fractured neck 

of femur 

Rivaroxaban 

10mg PO OD 

for 4 weeks 

post-operatively 

Rivaroxaban 

10mg PO OD for 2 

weeks post 

operatively 

Dalteparin for 4 

weeks postoperatively 

Nil 

Nil 

Renal impairment: 

eGFR150kg: 7500 units twice 

daily 



Status: Final 


Other high risk 

patients: personal 

history of VTE, 

lower limb 

surgery requiring 

extended postoperative 

immobilisation. 

Dalteparin for 

the duration of the 

immobilisation 

Nil 

Renal impairment: 

eGFR

ELECTIVE HIP 

REPLACEMENT 

ELECTIVE KNEE 

REPLACEMENT 

At admission: 

Start mechanical VTE prophylaxis with any one of: 

• Anti-embolism stockings (knee length), used with caution 



length) 

Continue until patient’s mobility no longer significantly reduced 

At admission: 

Start mechanical VTE prophylaxis with any one of: 

• Anti-embolism stockings (knee length), used with caution 



length) 

Continue until patient’s mobility no longer significantly reduced 

Provided there are no contraindications, start 

dalteparin 6-12 hours post surgery and continue 

for 2 days 

Continue with rivaroxaban (dalteparin if 

contraindicated) on day 3 and continue for 28 

days 1 

Provided there are no contraindications, start 

dalteparin 6-12 hours post surgery and 

continue for 2 days 

Continue with rivaroxaban (dalteparin if 

contraindicated) on day 3 and continue for 14 

days 



Status: Final 


Appendix 5a: Trauma and Orthopaedic Procedure Specific 


Hip surgery prophylaxis 

Primary and revision THA 

• IPC in theatre 

• Early mobilisation 

• FID/AES (knee length)/IPC (thigh or knee length) for 48 hours postsurgery 

• LMWH (dalteparin) 6-12 hours post-surgery to continue until day 2 

• Rivaroxaban starting day 3 post op and continuing for 4 weeks. Dalteparin 

where rivaroxaban is contraindicated. 

Neck of femur fracture patients 

• Ensure adequate hydration 

• Dalteparin from day of admission continued for 4 weeks post-surgery 

• IPC in theatre 

• AES (knee length) / IPC (thigh or knee length) / FID post-surgery 

Hip surgery procedures < 60 minutes ie LOW risk: 

Hip injections 

Hip arthrograms 

All other hip surgery procedures take > 60 minutes and are high risk 

Knee surgery prophylaxis 

Arthroscopy 


• AES (knee length) for two weeks post-surgery +/- dalteparin 

perioperatively in high risk patients 

Ligament reconstruction surgery 


• Consider AES (knee length) for two weeks post-surgery 

High tibial osteotomy 


• AES (knee length) for six weeks post-surgery 



Status: Final 


UKA, TKA, revision TKA 

• IPC (knee length) in theatre 


• Dalteparin starting 6-12 hours post-surgery and continuing until day 2 post 

op. Start rivaroxaban day 3 post op and continue for 2 weeks. Use 

dalteparin throughout if rivaroxaban contraindicated 

Knee surgery procedures < 60 minutes i.e. LOW risk: 

Knee arthroscopy 

Ligament reconstruction surgery 

High tibial osteotomy 

All other knee surgery procedures take > 60 minutes and are high risk 

Foot and ankle surgery prophylaxis 


• Choose any one of AES (knee length)/FIDs/IPC (thigh or knee length): 

continue until patient fully mobile 

• If extended immobilisation required after surgery start 

thromboprophylaxis with LMWH (dalteparin) 6-12 hours post-surgery 

and continue until mobility restored. 

Foot and ankle surgery procedures

Hand surgery procedures >90 minutes i.e. HIGH risk: 

MCPJ replacement 

Total elbow replacement 

Total wrist replacement 

Complex multi finger Dupuytrens surgery 

All other hand surgery procedures take

HIP FRACTURE 

OTHER ORTHOPAEDIC 

SURGERY 

At Admission: 

• Start mechanical VTE prophylaxis with any one of: 

- anti-embolism stockings (knee length) 

- foot impulse devices 

- intermittent pneumatic compression devices (thigh or 

knee length) 

Continue until patient’s mobility no longer significantly 

reduced 

Upper Limb 

Surgery 

• Provided there are no contraindications, start 

LMWH (dalteparin), or UFH 1 

At admission: 

Assess patient’s 

risk of VTE 

At admission: 

Assess patient’s 

risk of VTE 

12 hours before surgery 

Stop LMWH (heparin), or 

UFH 1 if using. 

Do not routinely 

offer VTE 

prophylaxis 

If VTE risk 

increased 

If VTE risk 

increased 

6 – 12 hours after surgery 

Restart LMWH (dalteparin), or UFH 1 if using. 

Continue for 28 days 

After assessing the risks and discussing with patient: 

• Consider offering mechanical VTE prophylaxis with any one 

of the following 

- anti-embolism stockings (knee length) 


- intermittent pneumatic compression devices (thigh or knee 

length) 

Consider offering LMWH (dalteparin), or UFH 1 6 – 12 hours after 

surgery and continue with mechanical prophylaxis 

- anti-embolism stockings (knee length 


- intermittent pneumatic compression devices (thigh or knee 

length) until patient’s mobility no longer significantly reduced 

1: 


Patients undergoing spinal 

surgery 

If VTE risk 

increased 

Start mechanical VTE 

prophylaxis at admission 1 



If risk of 

major 

bleeding low 3 

YES 

NO 

Add LMWH (dalteparin), or 

UFH 2 and continue until 




Do not offer dalteparin or 

UFH 2, Continue mechanical 

prophylaxis and re-assess 

every 24 hours or if 

condition changes. 

Start pharmacological 

prophylaxis when safe 

1 Choose any of these: 

• 

Anti-embolic stockings 

• 

Foot impulse devices 

• 

Intermittent pneumatic compression devices 

2 For patients with renal failure (Egfr

Appendix 5b: Trauma and Orthopaedic Major Trauma and 

Spinal Injury Thromboprophylaxis Guideline 

Major trauma 

Offer combined VTE prophylaxis with mechanical and pharmacological 

methods to patients with major trauma. Regularly reassess the patient’s risks 

of VTE and bleeding. 

• Start mechanical VTE prophylaxis at admission or as early as 

clinically possible. Choose any one of: 

o Anti-embolism stockings 


o Intermittent pneumatic compression devices 

• Continue mechanical VTE prophylaxis until the patient no longer 

has significantly reduced mobility 

If the benefits of reducing the risk of VTE outweigh the risks of bleeding and 

the bleeding risk has been established as low, add pharmacological VTE 

prophylaxis. Use one of: 

• LMWH 

• UFH (for patients with eGFR < 10 ml/min). 



Spinal injury 

Offer combined VTE prophylaxis with mechanical and pharmacological methods 

to patients with spinal injury. Regularly reassess the patient’s risks of VTE and 

bleeding. 

• Start mechanical VTE prophylaxis at admission or as early as clinically 

possible. Use one of: 

o anti-embolism stockings 

o foot impulse devices 

o intermittent pneumatic compression devices 



If the benefits of reducing the risk of VTE outweigh the risks of bleeding and the 

bleeding risk has been established as low, add pharmacological VTE prophylaxis. 

Use one of: 

o LMWH 

o UFH (for patients with eGFR < 10 ml/min). 





Status: Final 


MAJOR TRAUMA OR 

SPINAL INJURY 

Patient 

admitted with 

major trauma 

Patient 

admitted with 

spinal injury 

Start mechanical VTE prophylaxis at admission or as 

soon as clinically possible with any of the following: 

• Anti-embolic stockings (knee length) 


• Intermittent pneumatic compression devices (thigh or 

knee length) 

Continue until mobility no longer significantly reduced 

Assess patient’s risks of 

VTE and bleeding 

If risk of VTE 

outweighs risk of 

bleeding 

YES 

Continue 

mechanical 

prophylaxis 

NO 

If bleeding 

risk is low 

Start LMWH (dalteparin) or UFH 

(for patients with renal failure) 



Regularly re-assess risks of 

VTE and bleeding 



Status: Final 


Appendix 5c: Trauma and Orthopaedic Lower Limb Plaster 

Casts Thromboprophylaxis Guideline 

Lower limb plaster casts 

If high risk for VTE start pharmacological VTE prophylaxis with LMWH (or UFH for 

patients with eGFR < 10 ml/min) and continue until lower limb plaster cast removal. 



Status: Final 


Patient having lower limb plaster 

cast 

Assess risk of VTE 

If VTE risk increased 

Start LMWH (dalteparin), or UFH for patients with renal 

failure after evaluating risks and benefits and based on 

clinical discussion with patient. 

Continue until plaster cast is removed and mobility is no 




Status: Final 


Appendix 6: Critical Care Thromboprophylaxis Guideline 

Assess risks of VTE and bleeding on admission to critical care unit. Reassess risks 

of VTE and bleeding daily. 

Offer VTE prophylaxis to patients admitted to the critical care unit according to the 

reason for admission, taking into account: 

• Any planned interventions 

• The use of other therapies that may increase the risk of complications 

Pharmacological thromboprophylaxis 

LMWH – dalteparin 

Mechanical methods (check contraindications section 7.5) 

Anti-embolic stockings (AES) – thigh or knee length 

Use as an adjunct or alternative to pharmacological prophylaxis when 

there is increased risk of bleeding from heparin use due to patient or 

procedure related factors. 

Intermittent Pneumatic Compression (IPC) devices - thigh or knee 

length 

Use when pharmacological prophylaxis is contraindicated as part of 

speciality specific guidelines. 

Foot Impulse Devices 

Require correct use and should only be used as part of speciality specific 

guidelines 

ICU specific guidance 

• Prophylaxis can be introduced within 24 hours post-operatively in vascular 

surgery 

• In spinal injuries, prophylaxis can generally be commenced after 24 hours 

postoperatively or post-injury if the management is to be conservative: 

discuss with the orthopaedic team 

• In head injuries, prophylaxis can be commenced 24 hours post-injury provided 

haemostasis is achieved and surgery is not planned within the next 12 hours 

• Inferior vena cava filters are only indicated to prevent PE in patients with DVT 

who have a contraindication to anticoagulation. If possible removable filters 

should be used. 



Status: Final 


Patient admitted to critical care unit 

Assess risks of VTE and 

bleeding on admission to critical 

care unit 

Take into account planned 

interventions and other 

therapies that may increase 

risk of complications 

Offer mechanical 1 and/or 

pharmaceutical VTE 

prophylaxis according to 

reason for admission 

• Reassess risks of VTE and bleeding and 

review decisions about VTE prophylaxis 

daily – more frequently if clinical condition 

is changing rapidly 

• Take into account known views of the 

patient, family and/or carers and 

multidisciplinary team 

1. Choose any one of: 

• Anti-embolic stockings (thigh or knee length) 


• Intermittent pneumatic compression devices (thigh or knee length) 



Status: Final 


Document Control Information 

Ratification Assurance Statement 

Dear 

Tim Craft 

Please review the following information to support the ratification of the below named 

document. 

Name of document: 

Name of author: 

Venous Thromboembolism Prophylaxis 

Josephine Crowe 

Job Title: 


I, the above named author confirm that: 

• The Policy presented for ratification meets all legislative, best practice and other 

guidance issued and known to me at the time of development of the Policy; 

• I am not aware of any omissions to the Policy, and I will bring to the attention of the 

Executive Director any information which may affect the validity of the Policy 

presented as soon as this becomes known; 

• The Policy meets the requirements as outlined in the document entitled Trust-wide 

Policy for the Development and Management of Policies (v4.0); 

• The Policy meets the requirements of the NHSLA Risk Management Standards to 

achieve as a minimum level 2 compliance, where applicable; 

• I have undertaken appropriate and thorough consultation on this Policy and I have 

documented the names of those individuals who responded as part of the 

consultation within the document. I have also fed back to responders to the 

consultation on the changes made to the Policy following consultation; 

• I will send the Policy and signed ratification checklist to the Policy Coordinator for 

publication at my earliest opportunity following ratification; 

• I will keep this Policy under review and ensure that it is reviewed prior to the review 

date. 

Signature of Author: 

Name of Person 

Ratifying this policy: 

Job Title: 

Dr Tim Craft 


Date: 

Signature: Date: 24 th July 2014 



Status: Final 


To the person approving this policy: 

Please ensure this page has been completed correctly, then print, sign and 

post this page only to: The Policy Coordinator, John Apley Building. 

The whole policy must be sent electronically to: ruh-tr.policies@nhs.net 

Consultation Schedule 

Original Document: 

Name and Title of Individual 

Date Consulted 

Dr Tim Craft, Deputy Medical Director 28/10/2009 

Dr Regina Brophy, Head Pharmacist 28/10/2009 

Dr. William Hubbard, Clinical Director of Medicine 28/10/2009 

Mr. Chris Gallegos, Clinical Director for Surgery 29/10/2009 

Elizabeth Beech, prescribing adviser BANES PCT 28/10/2009 

Name of Committee/s (if applicable) 

Date of 

Committee 

Hospital Thrombosis Committee 04/11/2009 

Clinical reference group 12/01/2010 

Operational Governance Committee 14/07/2010 

Document Revised to include Dalteparin: 

Name and Title of Individual 

Date Responded 

Caroline Quinn, Surgical Pharmacist 14/03/2011 

Gayle Wynn, Admissions Pharmacist 14/03/2011 

Matthew Jones, Medicines Information Pharmacist 14/03/2011 

Dr. Mark Mallet, Consultant Physician, Acute Medicine 14/03/2011 

Document Revised to clarify recording of VTE Assessment: 


Date of 

Committee 

Dr Jo Crowe, Consultant Haematologist 17/01/2013 

Document Revised to meet NICE guidance recommendations 


Date of 

Committee 

Dr Jo Crowe, Consultant Haematologist 17/07/2014 



Status: Final 


Equality Impact: (A) Assessment Screening 

To be completed when submitted to the appropriate Executive Director for 

consideration and approval. 

Person responsible for the assessment: 

Name: 

Dr Josephine Crowe 

Job Title: 


Does the document/guidance affect one 

group less or more favourably than another 

on the basis of: 

Yes/No 

Comments 

Race Yes No 

Ethnic origins (including gypsies and travellers) Yes No 

Nationality Yes No 

Gender (including gender reassignment) Yes No 

Culture Yes No 

Religion or belief Yes No 

Sexual orientation Yes No 

Age Yes No 

Disability 

(learning disabilities, physical disability, sensory impairment and 

mental health problems) 

Yes 

No 

Is there any evidence that some groups are affected 

differently? 

Yes No 

If you have identified potential discrimination, are there 

any valid exceptions, legal and/or justifiable? 

Yes No 

Is the impact of the document/guidance likely to be 

negative? 

Yes No 

If so, can the impact be avoided? Yes No 

What alternative is there to achieving the 

document/guidance without the impact? 

Yes No 

Can we reduce the impact by taking different action? Yes No 

If you answered NO to all the above questions, the assessment is now complete, and no 

further action is required. 

If you answered YES to any of the above please complete the 

Equality Impact: (B) Full Analysis 



Status: Final

Venous Thromboembolism Prophylaxis Policy - Royal United ...

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