Thromboprophylaxis in Thoracic Surgery

Thromboprophylaxis in Thoracic Surgery

Many Thoracic patients have a high risk for peri-operative thrombo-embolism (TE) because of:

  1. •Age

  2. •Cancer
    Word documentThromboprophylaxis_files/DVT_prophylaxis.doc

  3. •Pre-operative chemotherapy

  4. •Position on table

  5. •Withdrawal of Aspirin/Plavix
    pdfThromboprophylaxis_files/DVT_prophylaxis.pdf

  6. •Complex major surgery


Standard thromboprophylaxis

Low/intermediate risk patients (benign, pleurectomy, mediastinoscopy, sympathectomy etc.) This includes most thoracoscopies.

  1. •TED stockings fitted properly(for large patients these must include waist band)


High risk patients (malignant, lung resection, TTO etc.)

  1. •TED stockings fitted properly(for large patients these must include waist band) – to continue at home post-operatively for 6 weeks

  2. •Enoxoparin (Clexane) 0.5mg per kg – to continue during inpatient stay and in extreme risk patients to continue at home for 6 weeks.

  3. •SCD compression system - to continue till patient fully mobile on the ward


Enoxoparin dosage

  1. •Prophylactic dose is Enoxoparin (Clexane) 0.5mg per kg (rounded up to 20, 40, 60, or 80mg)

  2. •To be given as a single dose in the evenings


Epidural

  1. •There is a risk of bleeding and paralysis if excessive doses (therapeutic as opposed to prophylactic) are administered to a patient who subsequently has an epidural inserted.

  2. •Low dose Aspirin does not need to be stopped

  3. •If Plavix or therapeutic heparin cannot be stopped this should be discussed with the anaesthetist and may be a contraindication to epidural

  4. •Prophylactic doses of Enoxoparin are safe as long as they are titrated to the patient’s weight.

  5. •Such bleeding can also occur during or after removal. Therefore Plavix is again a contraindication and therapeutic enoxoparin must be held prior to epidural removal

  6. •Avoid b.d. doses of Enoxoparin in patients with epidural as this may affect the timing of removal

  7. •If b.d. dosage has been used, the morning dose of Clexane should be omitted and the epidural should not be removed till 12 hours has passed since the last dose.


Pleurectomy

  1. •Most patients for pleurectomy are low risk, young patients

  2. •Pleurectomy has a high risk for bleeding

  3. •Clexane should NOT be used in pleurectomies

  4. •TED stockings should be routine and SCD for high risk


Mediastinoscopy

  1. •Usually this is a short procedure with reduced risk of thrombo-embolism

  2. •Clexane should be avoided if possible


Sympathectomy

  1. •Most patients for sympathectomy are low risk, but most are young women and should be asked about the contraceptive pill

  2. •TED stockings should be routine and SCD for high risk


Contraceptive pill

  1. •In general for elective benign surgery the contraceptive pill should be stopped 6 weeks prior and effective alternative contraception used.

  2. •Where this is not possible or stopping is judged unwise, the patients should be regarded as high risk and treated with Enoxoparin, TED’s and SCD.


Continuation of thromboprophylaxis post discharge

High risk patients remain at risk for approximately 6 weeks post discharge and should continue on prophylaxis.

  1. •TED stockings to continue at home post-operatively for 6 weeks

  2. •Enoxoparin (Clexane) 0.5mg per kg – to continue during inpatient stay and in extreme risk patients to continue at home for 6 weeks.


This document has been prepared with advice from colleagues in cardiology, cardiac surgery, anaesthetics and thoracic surgery. However, as at 1st July 2008 this advice has not been fully ratified as an accepted guideline and is expected to further evolve.

 

Report of the independent expert working group on prevention of venous thromboembolism in hospitalised patients

This 2005 report by Liam Donaldson and an expert committee is the basis of recommendations by the HSS in Northern Ireland.


The major recommendation is that there be  “a mandatory VTE risk assessment of every hospitalised patient on admission”.


Specific recommendations are as follows:


Surgical Patients


All high risk surgical/orthopaedic patients should be managed according to the available evidence.  The NICE clinical guideline on the prevention of venous thromboembolism in patients undergoing orthopaedic surgery and other high risk procedures is scheduled to be published in April 2007.


Intermediate risk surgical patients or those with concomitant medical conditions should, as part of a mandatory risk assessment, be considered for the following thromboprophylaxis measures:

      1. •graduated compression stockings combined with heparin (both unfractionated or low-molecular-weight forms)

      2. •aspirin is not recommended for thromboprophylaxis in intermediate risk surgical patients.


Low risk surgical patients do not require specific prophylaxis other than early mobilisation because of duration or nature of surgical procedure unless other factors are present which increase overall risk and thus place them in intermediate or high risk categories.

      1. • aspirin is not recommended for thromboprophylaxis in low risk surgical patients.


Non surgical Medical Patients


All medical patients should, as part of a mandatory risk assessment, be considered for thromboprophylaxis measures; in particular, patients likely to be in hospital for longer  than four days and with reduced mobility, with either severe heart failure, respiratory failure (due either to exacerbation of chronic lung disease or pneumonia), acute infection, inflammatory illness or cancer (with additional risk factors for VTE) should be considered for the following regime.


  1. •heparins (both unfractionated and low-molecular-weight forms) are effective preventive treatments.  Low-molecular-weight heparins are the preferred prophylactic method;

  2. •aspirin is not recommended for thromboprophylaxis in medical patients;