Contents:
Guideline statements
All patients being admitted to a hospital or hospice, regardless of diagnosis, should have their risk of VTE assessed to decide whether they may benefit from anticoagulation to reduce the risk of symptomatic and life limiting VTE.
The patient:
- Has contraindications for receiving LMWH (see below).
- Is actively dying.
- Actively bleeding.
- Is receiving anticoagulation with another agent.
- Has encountered previous problems with heparin, e.g., heparin-induced thrombocytopenia.
- Has a platelet count less than 50.
- Has an Australia-modified Karnofsky Performance scale (AkPs) <50 and deteriorating over the past 12 weeks.
If YES: Patient not suitable for thromboprophylaxis
If NO: Continue to Step two: Assessment of benefit of prophylaxis
Are they in a patient group who have an evidence based potential benefit from treatment i.e. recent major surgery, acute medical illness?
Other patients who may benefit, but no clear evidence base:
- Recently bed bound due to acute medical illness.
- New diagnosis of spinal cord compression, expected to recover mobility.
- Pathological fracture, expected to recover mobility.
If NO: Does not meet criteria for routine thrombo- prophylaxis
If YES: Continue to Step three: Palliative team decision
- Consider appropriateness of treatment weighing up risks and benefits and burden of monitoring with appropriate consultation with patient
- Make plan regarding duration of treatment and monitoring required (See below)
- Commence thromboprophylaxis
- Assess patient every 48hrs to review appropriateness of treatment
Consideration of primary prophylaxis in palliative care patients for VTE should keep at its centre the focus of high quality symptom control, weighed consideration of benefits and burdens, and shared decision-making.
There is insufficient evidence to treat all palliative care inpatients with advanced cancer with primary prophylaxis for VTE. Decisions should be made on an individual basis with consideration of relative risk and burden of treatment.
Consider whether patients may benefit from primary pharmacological prophylaxis, either due to evidence-based potential benefit and/or the presence of factors contributing to VTE risk (see below).
Patient groups who have an evidence based potential benefit from treatment are those who have either had recent major surgery or an acute medical illness from which they are expected to recover.
Other patients who may benefit, but for which there is no clear evidence base:
- Recently bed bound due to acute medical illness.
- New diagnosis of spinal cord compression, expected to recover mobility.
- Pathological fracture, expected to recover mobility.
- Age >60 years
- Obesity
- Malignancy
- Recent immobility (bed rest over 4 days)
- Recent major surgery
- Previous venous thrombosis
- Medical illness (eg. COPD, MI, CCF or previous stroke)
- Coexisting sepsis
- Inflammatory bowel disease
- Nephrotic syndrome
- Extensive varicose veins
- Family history of VTE including 1st degree relative
- Pregnancy or Post-partum
- Spinal injury
- Recent long distance travel
- Previous stroke
- Thrombophilia
- Lymphoedema
- Hickman line in-situ
There is evidence for stratification of risk of VTE in acutely ill medical inpatients without cancer diagnosis. However, there is no evidence to determine the impact of malignancy on this stratification.
- Acute illness + previous VTE
- Acute illness + hypercoagulable state
- Stroke
- Acute MI
- Acute respiratory failure
- Acute cardiac failure
- Lower limb paralysis
- Major medical illness
- Heart/lung disease
- Inflammatory Bowel Disease
- Sepsis
- Malignancy/myeloproliferative disorder
- Inflammatory disease
- Nephrotic syndrome
- Hormonal treatment (e.g. oestrogen therapy, high dose progestogen, tamoxifen, raloxifene)
- Major trauma or burns
- Fracture or major orthopaedic surgery of pelvis, hip or lower limb
Minor trauma or medical illness
Consider the potential risks of primary pharmacological prophylaxis, which include haemorrhage, subcutaneous bruising, heparin-induced thrombocytopenia and burden of monitoring:
The potential risks of low molecular weight heparin are as follows:
- Risk of bleeding – Incidence of haemorrhage.
- Major bleeds: 4% reported.
- Minor bleeds: 28% reported.
- Risk of subcutaneous bruising.
- Risk of thrombosis despite anticoagulation e.g. heparin induced thrombocytopenia.
- Burden of monitoring when considered necessary.
The treatment of choice is low molecular weight heparin (LMWH) in a once daily subcutaneous dose. Dose reductions may be indicated according to renal function and body weight. Novel agents such as oral or subcutaneous agents (fondaparinux/ dagabatrin etc) may be considered if indicated by the clinical context, with further specialist advice if necessary.
Review decisions about VTE prophylaxis every 48 hours*, taking into account potential risks and benefits, and views of the patient, family and multidisciplinary team (13).
The duration of primary pharmacological prophylaxis, and agents licensed, varies according to indication:
The duration of thromboprophylaxis with LMWH for patients with cancer is as follows: (13&15)
- Immobile patients with acute medical condition: Treatment until the patient achieves full ambulation or for a maximum of 14 days.
- Hip replacement or hip fracture surgery: Treat with LMWH for 28 days post surgery. Fondaparinux and other novel oral anticoagulants, within their licensed indications, may be used as an alternative to LMWH.
- Laparotomy, laparoscopy and thoracotomy lasting more than 30 minutes; treat for 14 days or until mobile.
- Major abdominal or pelvic surgery with residual disease, obesity or a history of previous VTE. This group should have treatment continued for up to 28 days.
* although NICE CG9212 suggests decisions about VTE primary prophylaxis in the palliative care setting should be reviewed every 24 hours, for pragmatic purposes e.g. over weekends, it is suggested that review take place at least once every 48 hours.
Consider incorporating the clinical consideration and decision of primary VTE prophylaxis into the documentation process of admission clerking into the inpatient hospice setting.
- Hypersensitivity to active substance or to any of excipients.
- Current or history of immune-mediated heparin-induced thrombocytopenia (type II).
- Active major haemorrhage or conditions predisposing to major haemorrhage.
- Septic endocarditis.
- In patients receiving heparin for treatment rather than prophylaxis, loco-regional anaesthesia in elective surgical procedures is contraindicated because the use of heparin may be very rarely associated with epidural or spinal hematoma resulting in prolonged or permanent paralysis.
- Renal impairment with creatinine clearance level <30ml/minute.
- Elderly – more likely to have poor renal function.
- Caution when performing neuraxial anaesthesia or lumbar puncture – risk of spinal hematoma.
- Patients at increased risk of haemorrhage.
- Concomitant intramuscular injections should be avoided.
- Discontinue use in patients who develop immune-mediated heparin-induced thrombocytopenia.
- Avoid in patients at risk of hyperkalaemia – can suppress adrenal secretion of aldosterone leading to hyperkalaemia.
- Not for use in patients with prosthetic heart valves for anticoagulation as treatment failures have been reported.
Patient information and counselling
Patients should be counselled about the primary prophylaxis for VTE as appropriate. Further information is not covered within this guideline.
Disclaimer
These Guidelines are intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
Whilst SPAGG takes every care to compile accurate information , we cannot guarantee its correctness and completeness, and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.