DVT Prophylaxis

Options are pharmacological, mechanical or combination.
- hmwh (e.g 5000 heparin SC bd) and lmwh (e.g. clexane 20-40 daily) similar efficacy but probably clexane has lower bleeding and HIT risk.
Malignancy is the paramount risk factor

Consider
Personal risk factors (e.g. smoker)
Disease risk factors (e.g. malignancy)
Procedural risk factors (e.g. laparoscopy higher)
Immobility risk factors (e.g. trauma, orthopedic surgery).

Surgical Patients

Low Risk
Moderate Risk
High Risk


Medical Patients
Low Risk
Moderate Risk
High Risk

Dose adjustment in renal impairment


Anti VTE compression stockings
Average pressure 18mmHg; not graduated
No evidence that stockings and calf compressors together reduce risk, but reasonable to do both to ensure a transition to the other.



Surgical Patients

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Low Risk Patients

    <30 min operation, regardless of age
    >30 min operation and <40 years
    not laparoscopic surgery

No prophylaxis required

Moderate Risk Patients
    >30 min operation and >40 years
    Cancer
    High dose estrogen therapy
    Epidural

Graduated compression stockings
20mg sc enoxaparin nocte (commenced the night before surgery) continued until fully mobilising

High Risk Patients
    Previous DVT/PE
    Pelvic surgery
    Known thrombophilia
    >2hr operation
    Orthopaedic surgery of pelvis, hip or lower limb
    Multiple trauma

Graduated compression stockings
Intraoperative pneumatic calf compression
40mg enoxaparin nocte (commenced the night before surgery) continued until fully mobilising

Consider also extended prophylaxis as per algorithm above
- 30d required in patients with abdominal malignancy and pelvic cancer / surgery
--> evidence for reduced VTE and improved outcomes

Pre-surgical or early (<6h) post-surgical?
- either probably equally ok.
- but slightly higher bleeding risk with preoperative administration.

Epidural catheters
Esp risk with LMWH, in presence of spinal or epidural catheters
Risk is epidural haematoma and cord compromise
Increases with coagulopathy, traumatic insertion, old age, females.
E.g. allow 2h between prophylaxis administration and catheter removal.

Non-Op Patients
Low Risk
    Minor medical illness

Consider graduated compression stockings

Moderate Risk
   
Immobilised patient with active disease, <70 years old and without additional risk factors

Graduated compression stockings
40mg enoxaparin nocte for 6-14 days

High Risk
    >70 years
    Stroke
    Congestive cardiac failure
    Presence of shock
    History of DVT/PE
    Cancer
    Thrombophilia

Graduated compression stockings
40mg enoxaparin nocte for 6-14 days

Consider pneumatic stockings


Dose adjustment in renal impairment
Dose adjustment is required in patients with severe renal impairment (EGFR <30ml/min)

Patients requiring 40mg sc nocte should be given only 20mg sc
Patients requiring 20mg sc nocte do not require dose adjustment


REFERENCES
RMO Clinical Handbook 2003, Auckland District Health Board
Clexane Dosing Recommendations Handbook


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