1. Hospital Acquired Venous Thromboembolism Beverley Hunt Simon Noble

2. Hospital- acquired VTE Estimates • VTE in the UK -an estimated 60,,000 deaths: at least 32,000 due to hospital admission of which 25,000 are preventable • More people die from VTE than breast cancer, HIV and road traffic accidents combined • Hospital acquired VTE causes more deaths than hospital -acquired infection (MRSA & C difficile, peaked at 10,000) Facts • Definition includes any VTE within 90 days of discharge • Hospital-acquired clots account for 2/3 of all VTE • Registered deaths due to VTE in England in 2007 -19,000- but under diagnosed…….(House of Commons Question summer 2009) • Autopsy data suggests reported incidences are markedly underestimated. Baglin et al J Clin Path 1997; 50: 609-10

3. Death due to PE in England and Walesfrom the National Statistics office

4. Postoperative risk of VTE in middle aged women: prospective cohort studySweetland et al. BMJ 2009; 339: 583 1 in 140 middle aged women (55+/-4.6) post surgery will be admitted with a VTE during 12/52 post surgery 1 in 45 after hip/knee surgery 1 in 85 after cancer surgery

5. “WE DON’T see it anymore, a disease of the past” Anon consultant BUT VTE is a “silent disease” • -80% of DVT subclinical • -<50% of PE detected prior to death • 10% of hospital deaths due to PE • Post surgery the average VTE events occur: • DVT on day 7 • PE on day 21 • Warwick D 2009

6. Thromboprophylaxis political momentum Consistent investment and a coherent strategy leads to Department of Health taking ownership for VTE prevention NHS Operating Framework inclusion 2010/11 2004 2005 2006 2007 2008 2009 2010

7. NICE guidelines published Jan 24th 2010:Venous thromboembolism: reducing the risk of VTE in patients admitted to hospital

8. General advice • Do not allow the patients to become dehydrated unless clinically indicated • Encourage patients to mobilise as soon as possible • Do not regard aspirin or other antiplatelet drugs as adequate prophylaxis for VTE

9. Risk assessment of VTE (NICE) • Reassess patient’s risk of bleeding and VTE within 24 hours of admission, and whenever the clinical situation changes, to: • Ensure that the methods are suitable • Ensure it is being used correctly • Identify adverse events

10. Mechanical VTE prophylaxis • Base the choice of mechanical VTE prophylaxis on individual patient factors including clinical conditions, surgical procedure and patient preference. Choose any one of the following: • Anti-embolism stockings (thigh or knee length) • Foot impulse devices • Intermittent pneumatic compression devices (thigh or knee length)

11. Mechanical VTE prophylaxis • Base the choice of mechanical VTE prophylaxis on individual patient factors including clinical conditions, surgical procedure and patient preference. Choose any one of the following: • Anti-embolism stockings (thigh or knee length) • Foot impulse devices • Intermittent pneumatic compression devices (thigh or knee length)

12. Anti-embolism stockings Do not offer stockings to patients who have: • Suspected peripheral arterial disease • Peripheral arterial bypass grafting • Peripheral neuropathy or other causes of sensory impairment • Any local condition in which stockings may cause damage • Known allergy to material of manufacture • Cardiac failure/severe leg oedema • Unusual leg size or shape • If arterial disease suspected seek expert opinion Encourage them to wear them day and night until they no longer have reduced mobility Remove daily for hygiene purposes and to inspect skin 2-3 times a day for integrity or sensory impairment and discontinue if problems develop. NB WE SHOULD BE USING TEDs. SARAH & QUEEN ward are trialling Saphena

13. Medical patients • “Assess all patients on admission to identify those who are at increased risk of VTE” • At increased risk if reduced mobility for 3 days or more OR • Are expected to have ongoing reduced mobility relative to their normal state and one or more risk factor shown in Box 1 • Box 1 Risk factors for VTE • Active cancer or cancer Rx • >60 years • Critical Care admission • Dehydration • Known thrombophilias • Obesity- BMI>30 • Significant medical co-morbidity • Personal history or 1st degree relative with VTE • COC or HRT • Varicose veins with phlebitis

14. Medical patients con’t • Assess all pts for risk of bleeding before offering pharmacological agents. Do not offer pharmacological prophylaxis unless the risk of VTE outweighs the risk of bleeding- risk factors in Box 2 • Box 2 risk factors for bleeding • Active bleeding • Acquired bleeding disoreders (e.g acute liver failure) • Concurrnet use of anticoagulants • LP/epidural/spinal anaesthesia expected within next 4 hours • LP/epidural/spinal anaesthesia within the previous 4 hours • Acute stroke • Thrombocytopenia <75x109/l • Uncontrolled hypertension (>230/120) • Untreated inherited bleeding disorders (e.g haemophilia)

15. Reducing the risk of VTE in medical patientsThose at risk offer: • Fondaparinux sodium • LMWH • UFH (renal failure) Start as soon as possible after risk assessment is completed and continue until the patient is no longer at increased risk of VTE

16. Stroke patients Do not offer anti-embolism stocking Consider pharmacological if • Haemorrhagic stroke excluded • The risk of bleeding (NB haemorrhagic transformation) is low AND • The patient has one of more of • Major restriction of mobility • Prev history of VTE • Dehydration • Comorbidities e.g cancer Continue until the acute event is over and the patient’s condition is stable Until the patient can have pharmacological prophylaxis consider offering a foot impulse or intermittent pneumatice compression

17. Surgical patients Offer thromboprophylaxis to those assess to be at increased risk : • Surgical procedure total anaesthetic & surgical time >90mins or 60 mins if surgery involves pelvis or lower limb • Acute surgical admission with inflammatory or intra-abdominal condition • Expected significant reduction in mobility • One of more of the risk factors in box 1 Box 1 Risk factors for VTE Active cancer or cancer Rx >60 years Critical Care admission Dehydration Known thrombophilias Obesity- BMI>30 Significant medical co-morbidity Personal history or 1st degree relative with VTE COC or HRT Varicose veins with phlebitis

18. Reducing the VTE risk after surgery • Combined mechanical and pharmacological for those at risk • Enoxaparin 40mg or UFH 5,000 TDS in renal failure • Extended thromboprophylaxis of 28-35 days after cancer and hip fracture • (NB need trials after renal tx)

19. Total hip and knee replacement • Offer combined mechanical and pharmacological • Start mechanical on admission • We are using dabigatran etexilate • Predictable anticoagulant effect • Fixed dose • No need for monitoring • Continue for 10-12 days after TKR and 28-35 days after THR

20. General recommendation in surgical patients • Stop COC or HRT 4 weeks before elective surgery and provide alternative contraceptive advice if necessary • Assess the risks and benefits of stopping pre-existing antiplatelet therapy 1 wek before surgery. Consider involving the multidisciplinary team in the assessment • Consider using regional anaesthesia as it carries a lower risk of VTE and plan the timing to minimise the risk of epidural haematoma (Dr Thomson’s bridging clinic) • Do not offer thromboprophylaxis in surgery with local anaesthesia with no limitation of mobility

21. This needed mandating! “all patients, both medical and surgical, who are admitted tohospital should undergo a risk assessment for venous thrombosis” (House of Commons Health Committee The Prevention ofVenous Thromboembolism in Hospitalised Patients Second Report of Session 2004–05)

23. Being updated! No 2 will probably disappear…

24. Lifeblood: the thrombosis charity www.thrombosis-charity.org.uk