gastrointestinal, gynaecological, thoracic and urological surgery and reduction of risk of venous thromboembolism (VTE)

Last edited 08/2018

NICE have issued specific guidance regarding gastrointestinal, gynaecological, thoracic and urological surgery and reduction of risk of DVT/PE

• VTE prophylaxis should be offered to patients undergoing bariatric surgery

  • start mechanical VTE prophylaxis at admission

    • choose any one of:
    • anti-embolism stockings or
    • intermittent pneumatic compression
    • continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility
    • continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility
  • add pharmacological VTE prophylaxis for people undergoing bariatric surgery for a minimum of 7 days for people whose risk of VTE outweighs their risk of bleeding. Choose either:
    • LMWH or
    • fondaparinux sodium
      
      
      
• abdominal surgery
• offer VTE prophylaxis to people undergoing abdominal (gastrointestinal, gynaecological, urological) surgery who are at increased risk of VTE.
  • start mechanical VTE prophylaxis at admission
    • Choose any one of:
      • anti-embolism stockings or
      • intermittent pneumatic compression
      • continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility
        
        
  • add pharmacological VTE prophylaxis for a minimum of 7 days for people undergoing abdominal surgery whose risk of VTE outweighs their risk of bleeding, taking into account individual patient factors and according to clinical judgement. Choose either:
    • LMWH or
    • fondaparinux sodium
    • consider extending pharmacological VTE prophylaxis to 28 days postoperatively for people who have had major cancer surgery in the abdomen.
      
      
• thoracic surgery
• consider VTE prophylaxis for people undergoing thoracic surgery who are at increased risk of VTE
• start mechanical VTE prophylaxis on admission for people undergoing thoracic surgery. Choose either:
  • anti-embolism stockings or
  • intermittent pneumatic compression
  • continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility
• consider adding pharmacological VTE prophylaxis for people undergoing thoracic surgery for a minimum of 7 days to people whose risk of VTE outweighs their risk of bleeding:
  • use LMWH as first-line treatment
  • if LMWH is contraindicated, use fondaparinux sodium

Notes:

Box 1: Risk factors for VTE

• Active cancer or cancer treatment Age over 60 years Critical care admission Dehydration Known thrombophilias Obesity (body mass index [BMI] over 30 kg/m2) One or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions) Personal history or first-degree relative with a history of VTE Use of hormone replacement therapy Use of oestrogen-containing contraceptive therapy Varicose veins with phlebitis For women who are pregnant or have given birth within the previous 6 weeks see Box 2

Box 2: Risk factors for VTE in pregnancy or in women who have given birth within the previous 6 weeks

• consider offering pharmacological VTE prophylaxis with LMWH (or UFH for patients with renal failure) to 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 active cancer or cancer treatment age over 35 years critical care admission dehydration excess blood loss or blood transfusion known thrombophilias obesity (pre-pregnancy or early pregnancy BMI over 30 kg/m2) one or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions) personal history or a first-degree relative with a history of VTE pregnancy-related risk factor (such as ovarian hyperstimulation, hyperemesis gravidarum, multiple pregnancy or pre-eclampsia) varicose veins with phlebitis. 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 mechanical and/or pharmacological VTE prophylaxis should be offered 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

Reference:

• 1) NICE (January 2010). Reducing the risk of venous thromboembolism
• 2) NICE (March 2018). Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism