Guidelines

Risk Assessment

NICE recommends the Department of Health VTE risk assessment tool

Anti-Embolism Stockings

Contraindications to Anti-Embolism Stockings

Contraindications outlined by NICE:

• Peripheral arterial disease
• Peripheral arterial bypass grafting
• Peripheral neuropathy or other causes of sensory impairment
• Severe leg oedema
• Major limb deformity or unusual leg size or shape preventing correct fit
• Any local conditions in which anti-embolism stockings may cause damage – for example, fragile 'tissue paper' skin, dermatitis, gangrene or recent skin graft
• Known allergy to material of manufacture

Use of Anti-Embolism Stockings

NICE recommendations:

• Use anti-embolism stockings that provide graduated compression and produce a calf pressure of 14-15 mmHg

• Measure the person's leg size and offer the correct size of stocking
• Encourage the person to wear it day and night until they no longer have significantly reduced mobility
• Remove anti-embolism stockings daily for hygiene purposes and to inspect skin condition.
  • In people with a significant reduction in mobility, poor skin integrity or any sensory loss, inspect the skin 2 or 3 times a day, particularly over the heels and bony prominences
• Stop the use of anti-embolism stockings if there is marking, blistering or discolouration of the skin, particularly over the heels and bony prominences, or if the person experiences pain or discomfort
  • If suitable, intermittent pneumatic compression can be offered as an alternative

Thromboprophylaxis in Various Orthopaedic Surgeries

NICE outlined different recommendations depending on the type of orthopaedic surgery.
 

Any Lower Limb Immobilisation

Definition: any clinical decision taken to manage the affected limb in a way that would prevent normal weight-bearing status or use of that limb, or both.

Consider LMWH or fondaparinux sodium if VTE risk outweighs risk of bleeding.

Fragility Pelvis / Hip / Proximal Femur Fractures

Offer VTE prophylaxis to ALL patients.

1st line:

• LMWH 6-12 hours after surgery, OR
• Fondaparinux 6 hours after surgery

If the surgery is delayed beyond the day after admission → offer pre-operative thromboprophylaxis (LMWH or fondaparinux)

• LMWH last dose no less than 12 hours before surgery
• Fondaparinux last dose no less than 24 hours before surgery

If pharmacological prophylaxis is not appropriate → consider intermittent pneumatic compression.

Elective Surgeries

Hip Replacement

Offer VTE prophylaxis to ALL patients.

1st line:

• LMWH for 10 days followed by aspirin 75mg / 150mg for 28 days, OR
• LMWH for 28 days + anti-embolism stockings until discharge, OR
• Rivaroxaban 6-10 hours after surgery for 5 weeks

2nd line: apixaban or dabigatran

3rd line: anti-embolism stockings

Knee Replacement

Offer VTE prophylaxis to ALL patients.

1st line:

• Aspirin 75mg / 150mg for 14 days, OR
• LMWH for 28 days + anti-embolism stockings until discharge, OR
• Rivaroxaban 6-10 hours after surgery for 5 weeks

2nd line: apixaban or dabigatran

3rd line: intermittent pneumatic compression

Arthroscopic Knee Surgery

VTE prophylaxis is only indicated if:

• High risk of VTE, AND
• Total anaesthesia time >90 min

VTE prophylaxis of choice: LMWH 6-12 hours after surgery for 14 days

Foot and Ankle Orthopaedic Surgery

VTE prophylaxis is generally not needed.

Consider VTE prophylaxis if:

• Patient requires immobilisation, OR
• Total anaesthesia time >90 min, OR
• Patient's risk of VTE outweighs risk of bleeding

Upper Limb Orthopaedic Surgery

VTE prophylaxis is generally not needed.

Consider VTE prophylaxis if:

• Patient requires immobilisation, OR
• Total anaesthesia time >90 min

Thromboprophylaxis in Renal Impairment Patients

NICE recommends choosing either LMWH or UFH.

BNF treatment summary says that UFH is the preferred thromboprophylaxis agent in renal impairment.

References

Original Guideline