Surgery taking >90 minutes (or >60 minutes on lower limb/pelvis)
Pregnancy/<6 weeks post-partum
Inflammatory condition
Thrombophilia or PMHx / FHx of VTE
Obesity
Critical care admission
Pharmacological prophylaxis
LMWH/fondaparinux or unfractionated heparin are the most commonly used medications for pharmacological VTE prophylaxis.
Pharmacological prophylaxis is used for most patients (unless contraindicated)
Assess for contraindications/cautions:
Not required
Patient taking therapeutic anticoagulant (INR>2 if on warfarin)
Procedures
Invasive procedure scheduled within next 12 hours
Invasive procedure performed within previous 4 hours
Significant bleeding risk
Active bleeding/stroke
Thrombocytopenia (platelets <75×109/L)
Bleeding disorders
Acute stroke
SBP >230mmHg
Weigh up the risks and benefits of anticoagulation (discuss with senior if unclear)
If the benefits outweigh the risks, determine renal function and weight. Each hospital will have a recommended protocol. Example for patients 50-100kg:
Thromboembolic deterrent stockings (TEDs) or foot impulse devices/intermittent pneumatic compression devices (IPCs) may be used for mechanical VTE prophylaxis.
Mechanical prophylaxis is used for patients unable to take pharmacological prophylaxis, and in addition to pharmacological prophylaxis in surgical patients
Choice depends on individual patient factors and condition/intervention
Assess for contraindications:
Peripheral arterial disease
Fragile skin, e.g. βtissue paper skinβ, dermatitis, or recent skin graft
βI have ensured there are no contraindications, weighed up the risks and benefits, and determined renal function and weight. After obtaining patient consent, I would like to prescribe:
LMWH/fondaparinux as per hospital protocol (e.g. enoxaparin 40mg subcutaneously) once every evening