Surgical Patients

The NICE guideline makes a series of recommendations for clinical practice to reduce the risk of VTE, firstly for all surgical patients, and subsequently for specific types of surgery [27].

For all surgical patients:

  • Advise patients to consider stopping oestrogen-containing oral contraceptives or hormone replacement therapy 4 weeks before elective surgery. If stopped, provide advice on alternative contraceptive methods.
  • Assess the risks and benefits of stopping pre-existing established antiplatelet therapy 1 week before surgery. Consider involving the multidisciplinary team in the assessment. Consider regional anaesthesia for individual patients, in addition to other methods of VTE prophylaxis, as it carries a lower risk of VTE than general anaesthesia. Take into account patients’ preferences, their suitability for regional anaesthesia, and any other planned method of VTE prophylaxis.
  • If regional anaesthesia is used, plan the timing of pharmacological VTE prophylaxis to minimise the risk of epidural haematoma. If antiplatelet or anticoagulant agents are being used, or their use is planned, refer to the summary of product characteristics for guidance about the safety and timing of these agents in relation to the use of regional anaesthesia.
  • Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients undergoing a surgical procedure with local anaesthesia by local infiltration with no limitation of mobility.

The NICE guidelines then makes recommendations for these specific groups of surgical patients: cardiac; vascular; gastrointestinal, gynaecological, thoracic and urological; neurological (cranial or spinal); orthopaedic (elective hip replacement, elective knee replacement, hip fracture, or other orthopaedic surgery) and day surgery and other surgery.

When should prophylaxis be started?

NICE guidelines recommend that pharmacological thromboprophylaxis is initiated as soon as possible after the onset of the risk-causing situation [27]. The reader is referred to the NICE guidelines for the exact recommendations on anticoagulant dosing and timing.

Initiation of VTE prophylaxis in trauma patients must be carefully considered in view of the potential bleeding complications.

  • Reassess patients’ risks of bleeding and VTE within 24 hours of admission and whenever the clinical situation changes to ensure that the methods of VTE prophylaxis being used are suitable
  • Ensure that VTE prophylaxis is being used correctly
  • Identify adverse events resulting from VTE prophylaxis

How long should pharmacological prophylaxis be continued?

The duration of pharmacological VTE prophylaxis should be determined on a case-by-case basis, while taking into account the existing relevant risk factors of VTE. The recommendations of the current NICE guideline [27] for the duration of VTE prophylaxis following surgery are shown in the table below.

Surgery type Duration of pharmacological prophylaxis
Gynaecological, thoracic, or urological surgical patients who are deemed to be at increased risk of VTE Generally 5–7 days*
Major cancer surgery in the abdomen or pelvis 28 days
Bariatric surgery Generally 5–7 days*
Gastrointestinal surgery Generally 5–7 days*
Cranial or spinal surgery Generally 5–7 days*
Vascular surgery Generally 5–7 days*
Day surgery If mobility is reduced after discharge, continue generally for 5–7 days
Hip fracture surgery 28–35 days
Elective hip replacement surgery 28–35 days
Elective knee replacement surgery 10–14 days

*Continue pharmacological VTE prophylaxis until the patient no longer has significantly reduced mobility (generally 5–7 days).