8 February 2010
NICE has published new guidance which aims to reduce the risk of venous thromboembolism (VTE) in patients admitted to hospital, including day case patients. VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE). This replaces its previous guidance relating to surgical patients (CG46, April 2007) and the Department of Health guidance relating to hospitalised patients (March 2007).
This guidance is essential reading for hospital doctors, nurses, pharmacists and others involved in reducing the risk of VTE either for individual patients or at policy level. The quick reference guide contains several useful flow diagrams for medical patients (including stroke, cancer and palliative care), orthopaedic and non-orthopaedic surgical patients, patients with major trauma or spinal injury, patients with lower limb plaster casts, critical care patients, and women who are pregnant or up to six weeks post partum. In addition, there is advice on planning for discharge.
What does this guidance say?
All patients should be assessed on admission to identify those who are at increased risk of VTE. Medical patients should be considered as being at increased risk of VTE if they have had or are expected to have significantly reduced mobility for three days or more or are expected to have ongoing reduced mobility relative to their normal state and have one or more of certain risk factors specified in the guidance (these include age over 60 years, co-morbidities, certain drug treatment, etc). Surgical patients and patients with trauma should also be considered as being at increased risk of VTE if they meet certain criteria with regard to their condition, the duration and type of surgery, the expected reduction in mobility, and presence of other risk factors.
The guidance provides recommendations when pharmacological and/or mechanical prophylaxis (such as compression stockings) should and should not be used. Patients should be assessed for their bleeding risk before being offered pharmacological prophylaxis, and this should be used only if the risk of VTE outweighs the risk of bleeding. Patients’ risks of bleeding and VTE should be reassessed within 24 hours of admission and whenever the clinical situation changes.
With regard to pharmacological prophylaxis, the guidance suggests choosing any one of fondaparinux sodiumq, low molecular weight heparin (LMWH) or unfractionated heparin (UFH) (for patients with renal failure) in medical patients in whom pharmacological prophylaxis is indicated. In certain orthopaedic patients there are additional options. Dabigatranqand rivaroxabanq are both listed as recommended options for total hip and total knee replacement surgery according to current NICE guidance: TA157 for dabigatran and TA170 for rivaroxaban. It is worth noting that the order in which all these drugs appear in the guidance is merely alphabetical and not an indication of preference per se. The guidance says that the choice of pharmacological VTE agents should be based on local policies and individual patient factors, including clinical condition and patient preferences.
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