• Complete inpatient venous thromboembolism (VTE) risk assessment for all patients aged ≥16 yr - see page 2 of adult inpatient prescription chart
  
  • single sheet VTE risk assessments are available for use in day case areas and child health 
• For pregnant and postpartum patients, use obstetric risk assessment proforma
  
  • maternity inpatients complete via K2 system or proforma can be found on intranet 
• Assess risk factors for VTE and bleeding and for contraindications to all methods of thromboprophylaxis 
• Date, time and sign assessment proforma 

When

• Within 12 hr of admission 
• Reassess at senior review (within 24 hr) 
• Pregnant or postpartum patients, reassess risk daily 
• Reassess whenever clinical condition changes and prescription chart is rewritten 

General measures (GM)

• Do not allow patient to become dehydrated
• Encourage patient to mobilise when possible

Mechanical thromboprophylaxis

Anti-embolism stockings (AES)

• Unless contraindicated, offer all surgical inpatients below knee AES on admission with exception of patients with lower limb amputation and fragility fractures (refer to specific local guidelines for further information or discuss with relevant specialty). 
  See Surgical & Specialised | University Hospitals of North Midlands NHS Trust
• If pharmacological prophylaxis contraindicated, consider use of AES for patients having an elective hip replacement 
  AES must be prescribed
• Ensure AES are measured and sized correctly
• Ensure patients are shown how to remove and reapply AES and monitor their use
• Encourage patient to wear AES from admission until returning to their usual level of mobility

Contraindications to AES

• Suspected or proven peripheral arterial disease
• Peripheral arterial bypass grafting
• Peripheral neuropathy or other causes of sensory impairment
• Any local conditions in which anti-embolism stockings may cause damage, e.g.
  
  • fragile 'tissue paper' skin
  • dermatitis
  • gangrene
  • recent skin graft
  • cellulitis 
• Known allergy to material of manufacture
• Severe leg oedema
• Major limb deformity or unusual leg size or shape preventing correct fit

Intermittent pneumatic compression (IPC) device

Stroke patients

• Immobile patients following acute stroke as advised by consultant
• Start within 3 days of acute stroke and provide for 30 days or until patient is mobile or discharged

Surgical patient

• Post-operatively as advised by consultant 

Fragility fractures of pelvis, hip and femur

• Consider if pharmacological thromboprophylaxis is contraindicated 

Elective knee replacement

• Consider if pharmacological thromboprophylaxis is contraindicated 

Major trauma

• Offer IPC on admission and continue until the patient adequately mobile

Elective spinal, spinal injuries and cranial surgery

• Offer either AEC or IPC, continue for 30 days or until patient is mobile or discharged 

Abdominal, thoracic, bariatric, cardiac surgery

• Offer either AES or IPC and continue until the patient adequately mobile

Head and neck surgery

• Consider use of AES or IPC for patients at increased risk of VTE and high risk of bleeding
  
  • continue until patient has adequate mobility approaching their normal or anticipated mobility

Pregnant or up to 6 week postpartum

• If immobilised for 3 or more days post-surgery (including caesarean section) consider IPC

Contraindications to IPC

• Known arteriosclerosis, peripheral neuropathy or peripheral vascular disease
• Massive oedema of the legs or pulmonary oedema secondary to congestive heart failure
• Local leg infection, dermatitis, vein ligation or skin graft
• Extreme deformity of leg
• Suspected pre-existing DVT or acute DVT
• Presence of malignancy in legs

GEKO device

• Used for stroke patients only where all other methods of thromboprophylaxis contraindicated 
• GEKO device must be prescribed 
• Device must be monitored and changed every 24 hr 

Medical patients

• Start as soon as possible and within 14 hr of admission 
• Adjust dose according to CrCl and body weight, see Table 1 below 

Table 1: Weight based prophylactic enoxoparin dose

Surgical patients

• Adjust dose according to CrCl and body weight, see Table 1 above
• If due for afternoon surgery, consider IV fluids, but ideally ensure they take clear fluids liberally until 1130 hr, then Sip Til Send - see Pre-operative fasting guideline in the Surgical guidelines
• If appropriate, consider using regional anaesthesia (risk of VTE higher with general anaesthesia in specific patient groups)
• Do not give prophylactic low molecular weight heparin (LMWH) in the 12 hr period preceding insertion of a spinal/epidural catheter, lumbar puncture or deep peripheral nerve block
• LMWH can be administered 4 hr following insertion/withdrawal of a spinal/epidural catheter

Orthopaedic surgery

• Appropriate thromboprophylaxis as per local guidelines available on intranet 

Table 2

Action if risk factor for bleeding present

• Discuss with senior to confirm if VTE risk outweighs risk of bleeding
• If patient normally receives anticoagulant and INR sub-therapeutic, contact anticoagulation management team
  
  • out-of-hours, contact on-call haematologist

• For each type of surgery or medical admission, follow regimen guidance - see page 3 of adult inpatient prescription chart 
• Refer to local guidelines available on intranet 

How

• Prescribe on prescription chart 
• Do not prescribe LMWH at the same time as a DOAC
• Give patient leaflet 'Preventing blood clots while in hospital'

• Reassess risk of bleeding and thrombosis risk at 24 hr and whenever clinical situation changes
• Monitor for any bleeding
• If renal function deteriorates (or have CrCl <30 mL/min), reduce dose of LMWH as per guidance 
• Report all bleeding events via Datix related to LMWH 

Surgical patients

• For cardiac surgery patients or those who received unfractionated heparin (UFH) in the last 100 days
• check baseline FBC
• monitor platelet counts as per Heparin-induced thrombocytopenia guideline