neurological (cranial or spinal) surgery and reduction in risk of venous thromboembolism (VTE)

Last edited 08/2018

• Cranial surgery

  • consider mechanical VTE prophylaxis for people undergoing cranial surgery
  • if using mechanical VTE prophylaxis for people undergoing cranial surgery, start it on admission. Choose either:
    • anti-embolism stockings or
    • intermittent pneumatic compression
    • continue for 30 days or until the person is mobile or discharged, whichever is sooner
  • consider adding pre-operative pharmacological VTE prophylaxis with LMWH. Give the last dose no less than 24 hours before surgery for people undergoing cranial surgery whose risk of VTE outweighs their risk of bleeding
  • consider adding pharmacological VTE prophylaxis with LMWH, starting 24-48 hours after surgery for people undergoing cranial surgery whose risk of VTE outweighs their risk of bleeding. Continue for a minimum of 7 days
  • if needed, start LMWH earlier than 24 hours after the operation for people undergoing cranial surgery. Base the decision on multidisciplinary or senior opinion, or a locally agreed protocol
  • do not offer pharmacological VTE prophylaxis to people with ruptured cranial vascular malformations (for example, brain aneurysms) or people with intracranial haemorrhage (spontaneous or traumatic) until the lesion has been secured or the condition has stabilised
    
    
• Spinal injury
  • consider mechanical VTE prophylaxis on admission for people with spinal injury. Choose either:
    • anti-embolism stockings or
    • intermittent pneumatic compression
  • reassess risk of bleeding 24 hours after initial admission in people with spinal injury
  • consider adding pharmacological VTE prophylaxis with LMWH 24 hours after initial admission for people with spinal injury who are not having surgery in the next 24-48 hours, if the benefit of reducing the risk of VTE outweighs the risk of bleeding
  • continue VTE prophylaxis in people with spinal injury for 30 days or until the person is mobile or discharged, whichever is sooner

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