VTE
Venous ThromboEmbolism
Version 2.0 April 2014
VTE – aims of this module


To define the terms associated with
VTE and offer evidence-based
guidance to care for patients.
To enable healthcare professionals to
give patients advice so that patients
understand their risks, and know what
they can do to help reduce their risk of
a VTE event.
VTE – What does this include?

Deep venous thrombosis (DVT)



Below knee (distal)
Above knee (proximal)
Atypical (e.g. arm)

Pulmonary embolism (PE)

Cerebral venous thrombosis
VTE - deep vein thrombosis (DVT)
& pulmonary embolism (PE)
Migration
PE
Embolus
Thrombus
DVT
VTE – Why does it happen?
(Virchow’s Triad)



Circulatory stasis (sluggish flow in the
veins)
Endothelial injury to veins (due to
trauma or inflammatory processes)
Hypercoagulable state (inherited or
acquired pro-coagulant factors in the
circulation)
VTE – national context



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VTE is a major cause of morbidity and
mortality in the UK
VTE deaths are 5 times more than total deaths
from hospital acquired infection, breast
cancer, road traffic accidents and AIDS.
Cost to NHS is £640 million (2005)
Cost of treating venous leg ulcers around
£400 million a year. 25% of DVT patients
develop Post Thrombotic Syndrome
VTE – acute consequences

Acute VTE symptoms in the patient



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Painful, swollen leg
Acute breathlessness
Incapacity or sudden death
Time & money spent on investigation
& treatment of a potentially avoidable
condition
VTE – chronic consequences

Chronic VTE symptoms in the patient (25%)

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Chronically painful, swollen leg
Leg ulcers & skin changes
Chronic breathlessness
Pulmonary hypertension
High risk of recurrence & therefore lifelong
treatment with warfarin
VTE - Who is at risk?
Most patients admitted to hospital are at risk.
Particularly where there is:

immobility

dehydration

obesity

advanced age

acute & chronic illness

surgical intervention
VTE – Why risk assess?
Documented Risk Assessment is vital as …
 it alerts both the patient & healthcare team
to VTE risk & triggers practical VTE
prevention measures (e.g. hydration,
mobilisation)
 chemical +/- mechanical prophylaxis is very
effective at preventing VTE in high risk
patients
 it is a mandatory national CQUIN: 95%
patients admitted to hospital to be risk
assessed for VTE
VTE – What is the risk?

Without thromboprophylaxis VTE may
develop in:



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Up to 50% medical patients
Up to 40% orthopaedic patients
Up to 20% surgical patients
VTE affects about 1 in 100,000 women of
childbearing age. It is up to 10 times more
common in pregnant than in non-pregnant
women of a similar age
VTE – we forget because although
the risk is high it is not immediate

Mean time to develop a VTE after
elective hip surgery?

22 days.
Mean time to develop a VTE after
elective knee surgery?
10 days
VTE – how to scale risk


Low risk (e.g. young, mobile patient, no
risk factors)
High risk (e.g. reduced mobility with any
risk factor)
What to do about VTE risk?
yes
Is the patient immobile
with at least 1 risk
factor for VTE?
no
High risk
Low risk
Are there
contraindications to
chemical prophylaxis?
Give patient advice re
early mobilisation and
hydration
no
yes
Prescribe antiembolic
stockings
Prescribe LMWH
Previous history of
VTE?
= very high
risk ∴
prescribe
both
VTE – practical prevention




Adequate hydration
Mobilisation as soon as possible
Regular leg exercises
Good positioning / posture / avoid
hypothermia
VTE – chemical prevention in
patients at high risk

Low Molecular Weight Heparin (LMWH)
Dalteparin 5000iu od @ 18:00
VTE – LMWH contraindications

Dalteparin is absolutely contraindicated in:

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Patients at high risk of a serious or life
threatening bleed
Major inherited bleeding disorders
Previous Heparin-induced thrombocytopenia
Other contraindications are relative
(ie. balance of risk / benefit)
VTE – mechanical prevention


Mechanical compression devices (e.g. sequential
compression devices - SCDs) must be used in
theatre & can be continued on the ward provided
they are not off for >3hrs
Antiembolic stockings should be used in high risk
patients who cannot have chemical prevention or
as an additional measure for patients who have
previously damaged leg veins (e.g. DVT)
VTE – contraindications to
antiembolic stockings


Leg ulcers, peripheral vascular disease,
peripheral neuropathy, lymphoedema
*** Badly fitted / applied stockings
in patients with poor peripheral
circulation can result in leg
amputation
VTE - the (haemo)dynamic balance
risk must be regularly re-assessed
– a bleed will physiologically trigger
clot formation
Clot
Bleed
Document VTE
risk assessment
here
Contraindications
to chemical
prophylaxis here
Prescribe VTE prophylaxis on
the drug chart
DALTEPARIN
5000
UNITS
OD
SC

Dr Doctor 1234
1/1/1
3
Weight adjusted dalteparin VTE
thromboprophylaxis
Weight adjusted dosing of dalteparin is not included in the product licence
for dalteparin but the following dosing schedule is supported by the
Thrombosis Committee:
For Bariatric patients only

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
(BMI>40kg/M2 or are 40kg above ideal body weight).
Weight
(kg)
50 - 99
100 - 150
> 150
Dose of
dalteparin
5000 units
once daily
5000 units
twice daily
7500 units
twice daily
Always consider relative risk of bleeding/thrombus formation before using
weight adjusted dosing
Patients <50kg may be considered for a reduced dose of 2500 units once
daily if they also have other bleeding risk factors
Please refer to separate guidance on ICID for obstetric patients
VTE - tell your patient about
their risk



verbally
offer an information leaflet
DVD / video available on
request
VTE – more information?

ICID – “VTE”

DOH electronic learning tool
www.e-lfh.org.uk/projects/vte/

VTE prevention England
www.vteprevention-nhsengland.org.uk/

SFT VTE website
www.vte.salisbury.nhs.uk

Email:
tamara.everington@salisbury.nhs.uk
Anticoagulation.service@salisbury.nhs.uk
VTE - Help prevent clots!
By kind permission of Richard Curtis and Tony Robinson