Venous ThromboEmbolism V T E Venous ThromboEmbolism Version 2.0 April 2014

VTE – aims of this module To define the terms associated with VTE and offer evidence-based guidance to care for patients. To enable healthcare professionals to give patients advice so that patients understand their risks, and know what they can do to help reduce their risk of a VTE event.

VTE – What does this include? Deep venous thrombosis (DVT) Below knee (distal) Above knee (proximal) Atypical (e.g. arm) Pulmonary embolism (PE) Cerebral venous thrombosis

VTE - deep vein thrombosis (DVT) & pulmonary embolism (PE) Migration PE Embolus Thrombus DVT

VTE – Why does it happen? (Virchow’s Triad) Circulatory stasis (sluggish flow in the veins) Endothelial injury to veins (due to trauma or inflammatory processes) Hypercoagulable state (inherited or acquired pro-coagulant factors in the circulation)

VTE – national context VTE is a major cause of morbidity and mortality in the UK VTE deaths are 5 times more than total deaths from hospital acquired infection, breast cancer, road traffic accidents and AIDS. Cost to NHS is £640 million (2005) Cost of treating venous leg ulcers around £400 million a year. 25% of DVT patients develop Post Thrombotic Syndrome

VTE – acute consequences Acute VTE symptoms in the patient Painful, swollen leg Acute breathlessness Incapacity or sudden death Time & money spent on investigation & treatment of a potentially avoidable condition

VTE – chronic consequences Chronic VTE symptoms in the patient (25%) Chronically painful, swollen leg Leg ulcers & skin changes Chronic breathlessness Pulmonary hypertension High risk of recurrence & therefore lifelong treatment with warfarin

VTE - Who is at risk? Most patients admitted to hospital are at risk. Particularly where there is: immobility dehydration obesity advanced age acute & chronic illness surgical intervention

Documented Risk Assessment is vital as … VTE – Why risk assess? Documented Risk Assessment is vital as … it alerts both the patient & healthcare team to VTE risk & triggers practical VTE prevention measures (e.g. hydration, mobilisation) chemical +/- mechanical prophylaxis is very effective at preventing VTE in high risk patients it is a mandatory national CQUIN: 95% patients admitted to hospital to be risk assessed for VTE

VTE – What is the risk? Without thromboprophylaxis VTE may develop in: Up to 50% medical patients Up to 40% orthopaedic patients Up to 20% surgical patients VTE affects about 1 in 100,000 women of childbearing age. It is up to 10 times more common in pregnant than in non-pregnant women of a similar age

VTE – we forget because although the risk is high it is not immediate Mean time to develop a VTE after elective hip surgery? 22 days. Mean time to develop a VTE after elective knee surgery? 10 days

VTE – how to scale risk Low risk (e.g. young, mobile patient, no risk factors) High risk (e.g. reduced mobility with any risk factor)

What to do about VTE risk? Is the patient immobile with at least 1 risk factor for VTE? yes no High risk Low risk Are there contraindications to chemical prophylaxis? Give patient advice re early mobilisation and hydration yes no Prescribe antiembolic stockings Prescribe LMWH = very high risk ∴ prescribe both Previous history of VTE?

VTE – practical prevention Adequate hydration Mobilisation as soon as possible Regular leg exercises Good positioning / posture / avoid hypothermia

VTE – chemical prevention in patients at high risk Low Molecular Weight Heparin (LMWH) Dalteparin 5000iu od @ 18:00

VTE – LMWH contraindications Dalteparin is absolutely contraindicated in: Patients at high risk of a serious or life threatening bleed Major inherited bleeding disorders Previous Heparin-induced thrombocytopenia Other contraindications are relative (ie. balance of risk / benefit)

VTE – mechanical prevention Mechanical compression devices (e.g. sequential compression devices - SCDs) must be used in theatre & can be continued on the ward provided they are not off for >3hrs Antiembolic stockings should be used in high risk patients who cannot have chemical prevention or as an additional measure for patients who have previously damaged leg veins (e.g. DVT)

VTE – contraindications to antiembolic stockings Leg ulcers, peripheral vascular disease, peripheral neuropathy, lymphoedema *** Badly fitted / applied stockings in patients with poor peripheral circulation can result in leg amputation

VTE - the (haemo)dynamic balance risk must be regularly re-assessed – a bleed will physiologically trigger clot formation Clot Bleed

Document VTE risk assessment here Contraindications to chemical prophylaxis here

Prescribe VTE prophylaxis on the drug chart DALTEPARIN 5000 UNITS SC OD  Dr Doctor 1234 1/1/13

Weight adjusted dalteparin VTE thromboprophylaxis Weight adjusted dosing of dalteparin is not included in the product licence for dalteparin but the following dosing schedule is supported by the Thrombosis Committee:  For Bariatric patients only (BMI>40kg/M2 or are 40kg above ideal body weight). Weight (kg) 50 - 99 100 - 150 > 150 Dose of dalteparin 5000 units once daily 5000 units twice daily 7500 units twice daily Always consider relative risk of bleeding/thrombus formation before using weight adjusted dosing Patients <50kg may be considered for a reduced dose of 2500 units once daily if they also have other bleeding risk factors Please refer to separate guidance on ICID for obstetric patients

VTE - tell your patient about their risk verbally offer an information leaflet DVD / video available on request

VTE – more information? DOH electronic learning tool ICID – “VTE” www.e-lfh.org.uk/projects/vte/ VTE prevention England www.vteprevention-nhsengland.org.uk/ SFT VTE website www.vte.salisbury.nhs.uk Email: tamara.everington@salisbury.nhs.uk Anticoagulation.service@salisbury.nhs.uk

VTE - Help prevent clots! By kind permission of Richard Curtis and Tony Robinson