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Venous Thromboembolism: Reducing the Risk of Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to Hospital

Venous Thromboembolism: Reducing the Risk of Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to Hospital

NICE Clinical Guidelines - National Clinical Guideline Centre – Acute and Chronic Conditions (UK)

Version: 2010

Patients with central venous catheters

Central venous catheters (CVCs) are commonly used in a wide variety of patients for indications such as monitoring of haemodynamics, administration of parenteral nutrition, blood products, chemotherapy, and infusion fluids. One important complication of the use of CVCs is catheter-related thrombosis (CRT), the majority of which are asymptomatic. These are of uncertain clinical significance, but CRT has been reported in adult patients with cancer to cause morbidities including pulmonary embolism and postphlebitic syndrome,.

Patients requiring antiplatelet agents and anticoagulants for other reasons

Aspirin, clopidogrel and dipyridamole are prescribed for their anti-platelet actions. Aspirin has been shown to be beneficial to patients with arterial blood vessel disease at a dose of 75mg daily. At this dose it has minimal anti-thrombotic effect. Even at high doses (greater than 300mg daily) it is less efficient at reducing the risk of VTE formation than standard pharmacological methods. Clopidogrel although prescribed predominantly for its antiplatelet effect in the treatment of acute coronary syndromes and following stent insertion is not licensed for VTE prophylaxis as a single agent and is less cost effective than standard pharmacological methods (chapters 9-). Dipyridamole is used as an adjunct to anticoagulation for prophylaxis of thromboembolism associated with prosthetic heart valves. It is also licensed for secondary prevention of ischaemic stroke and transient ischaemic attacks. There are no trials regarding its efficacy in the prophylaxis of VTE.

Cardiac surgery

This section covers patients undergoing cardiac surgery.

Foreword

The second report of session 2004–5 of The House of Commons Health Committee ‘The Prevention of Venous Thromboembolism in Hospitalised Patients’ opens with these worrying statistics: Each year 25,000 people in the UK die from venous thromboembolism. This figure includes both patients admitted for medical care of serious illnesses, as well as, those admitted for surgery. The report goes on to state that this is a larger number of deaths than are attributable to breast cancer, AIDS and road traffic accidents combined. It is 25 times the number of people who die as a result of MRSA infection .

Vascular surgery

This section covers inpatients undergoing vascular surgery. Vascular surgery encompasses two distinct patient populations: surgery for peripheral arterial disease (PAD) including carotid, aorto-iliac and limb arterial surgery; and patients with venous disease (superficial or deep venous reflux and varicose veins). A significant proportion of surgery for uncomplicated primary varicose veins is undertaken as day-case procedures.

Spinal injury

Spinal injury and, in particular, spinal cord injury is a significant cause of morbidity and mortality with younger age groups frequently affected. Spinal injury can occur without injury to the spinal cord and when nerve injury occurs at the level below the dorsal/lumbar junction (where the injury will be to the cauda equine and not the spinal cord). Even without injury to the spinal cord or nerve injury, patients with spinal injury may be at increased risk of VTE for reasons of prolonged immobility

Acute coronary syndromes

All patients admitted with acute coronary syndrome (ACS) consisting of a history of chest pain, and raised cardiac enzymes or altered electrocardiogram should have a VTE assessment performed on admission (section 5.9). The risk of DVT in patients with ACS is estimated from the nil prophylaxis arms of trials to be 21% (95% confidence intervals 17% to 25%).

Hip fracture surgery

Fractures of the proximal femur (commonly known as neck of femur or hip fractures) are very common in the elderly population and carry significant morbidity and mortality. They occur mainly as osteoporotic or fragility fractures but a small proportion may result from major trauma in a younger age group. The latter is covered under the section on major trauma (Section 22).

Critical care

The data available to support decision making in such critically ill patients were scarce and suffers from wide variations in the nature of such units around the world, the heterogeneous population served and the very high all cause mortality seen. Each group has its own unique risk factors for VTE and risks of bleeding or other complications.

Major trauma

The majority of patients suffering significant trauma require assessment and management by the orthopaedic service. There may be associated injury to the head, chest or abdomen, in those with multiple trauma, most frequently in road traffic collisions. However, major pelvic and spinal injury and multiple long bone fractures in isolation constitute significant orthopaedic trauma. A proportion will require management in a critical care setting, in either an Intensive Care or High Dependency Unit, for which additional guidance can be found in Chapter 29.

Cancer

Active cancer is an additional risk factor for VTE and the prothrombotic tendency varies with tumour type. Furthermore, many surgical procedures are carried out as part of curative or palliative cancer treatment.

Summary of the effectiveness of mechanical and pharmacological prophylaxis

The purpose of this chapter is to provide an overview of all the evidence comparing different prophylaxis methods across all populations (medical, surgical and trauma patients). This chapter also presents some general comparisons that are relevant to many of the patient groups in the guideline.

Development of cost-effectiveness model

Our aim in constructing the model was to determine the most cost-effective thromboprophylaxis strategy for different hospital population subgroups. The efficacy of each prophylaxis strategy is based on the results of the trials in our systematic review.

Methodology

To prepare a clinical guideline on the prevention of VTE in all patients admitted to hospital.

Pregnancy and up to 6 weeks post partum

Venous thromboembolism (VTE) remains the leading direct cause of maternal death in the UK. In the latest Confidential Enquiry into Maternal and Child Health (CEMACH) report ‘Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer, 2003–5’ there were 33 deaths from pulmonary embolism (18 events occurring antenatally, 8 after vaginal delivery and 7 after caesarean section). There is an overall incidence of approximately two episodes of VTE (including non-fatal events) per 1000 deliveries.

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