General advice regarding reducing the risk of venous thromboembolism in surgical patients

• All surgery
  • advise patients to consider stopping oestrogen-containing oral contraceptives or hormone replacement therapy 4 weeks before elective surgery. If stopped, provide advice on alternative contraceptive methods
  • 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
  • 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 summary of product characteristics for guidance about the safety and timing of these agents in relation to the use of regional anaesthesia.
  • do not routinely offer pharmacological or mechanical VTE prophylaxis to patients undergoing a surgical procedure with local anaesthesia by local infiltration with no limitation of mobility
  • reducing the risk of VTE (1)
    • do not allow patients to become dehydrated unless clinically indicated
    • encourage patients to mobilise as soon as possible
    • consider offering temporary inferior vena caval filters to patients who are at very high risk of VTE (such as patients with a previous VTE event or an active malignancy) and for whom mechanical and pharmacological VTE prophylaxis are contraindicated
      
      
• general guidance concerning measures to reduce the risk of venous thromboembolism (VTE) in surgical patients has been issued by NICE:
  
  
  • inpatients having surgery should be offered thigh-length graduated compression/anti-embolism stockings from the time of admission to hospital unless contraindicated (for example, in patients with established peripheral arterial disease or diabetic neuropathy)
    • if thigh-length stockings are inappropriate for a particular patient for reasons of compliance or fit, knee-length stockings may be used as a suitable alternative
  • stocking compression profile should be equivalent to the Sigel profile, and approximately 18 mmHg at the ankle, 14 mmHg at the mid-calf and 8 mmHg at the upper thigh
  • in addition to mechanical prophylaxis, patients at increased risk of VTE because they have individual risk factors (see linked item)
  • healthcare professionals should encourage patients to wear their graduated compression/anti-embolism stockings until they return to their usual level of mobility. Patients should be informed that this will reduce their risk of developing VTE
  • patients using graduated compression/anti-embolism stockings should be shown how to wear them correctly by healthcare professionals trained in the use of that product. Stocking use should be monitored and assistance provided if they are not being worn correctly
  • intermittent pneumatic compression or foot impulse devices may be used as alternatives or in addition to graduated compression/anti-embolism stockings while surgical patients are in hospital
  • when used on the ward, intermittent pneumatic compression or foot impulse devices should be used for as much of the time as is possible and practical while the patient is in bed or sitting in a chair
  • vena caval filters should be considered for surgical inpatients with recent (within 1 month) or existing VTE and in whom anticoagulation is contraindicated
  • risks and benefits of stopping pre-existing established anticoagulation or antiplatelet therapy before surgery should be considered
  • regional anaesthesia reduces the risk of VTE compared with general anaesthesia. Its suitability for an individual patient and procedure should be considered, along with the patient's preferences, in addition to any other planned method of thromboprophylaxis
    • if a regional anaesthetic technique is used, the timing of pharmacological prophylaxis should be carefully planned to minimise the risk of haematoma.
  • healthcare professionals should not allow patients having surgery to become dehydrated during their stay in hospital
  • healthcare professionals should encourage patients to mobilise as soon as possible after surgery
  • healthcare professionals should arrange for immobilised patients to have leg exercises

Notes (3):

• Mechanical prophylaxis
  • do not offer anti-embolism stockings to people who have:
    • 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 - for example, fragile 'tissue paper' skin, dermatitis, gangrene or recent skin graft
    • known allergy to material of manufacture
    • severe leg oedema
    • major limb deformity or unusual leg size or shape preventing correct fit
      
      
  • use caution and clinical judgement when applying anti-embolism stockings over venous ulcers or wounds

Reference:

1. NICE (January 2010). Reducing the risk of venous thromboembolism
2. NICE (April 2007). Venous thromboembolism Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery)
3. NICE (March 2018). Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolis