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Thrombosis Prevention Investigation and Management of Anticoagulation Clinical Guideline

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Thrombosis Prevention Investigation and Management of Anticoagulation Clinical Guideline Thrombosis Prevention Investigation and Management of Anticoagulation Clinical Guideline V12.2 May 2020 Summary This guidance provides information on the risks and prevention of VTE in the setting of hospital in-patients and the management of venous thrombosis, together with reference to other areas of clinical practice and Trust guidance, such as ischaemic heart and cerebral disease and also special circumstances such as pregnancy. Thrombosis Prevention Investigation and Management of Anticoagulation Clinical Guideline V12.2 Page 2 of 100 Summary of contents / links to guidance Summary ............................................................................................................................. 2 1. Aim/Purpose of this Guideline ................................................................................... 6 2. The Guidance ............................................................................................................ 6 2.1. Definitions / Glossary ................................................................................................ 6 2.2. Reducing the risk of venous thrombo-embolism in patients in hospital ........... 7 2.3. Venous thrombo-embolism disease. ..................................................................... 8 2.4. Anticoagulants ........................................................................................................... 8 2.5. Drug interactions, cautions and contra-indications for Non-Vitamin K Oral Anticoagulants (NOAC’s) ................................................................................................... 14 2.6. Anti-platelet agents: aspirin, clopidogrel, prasugrel, ticagrelor in cardiac and peripheral vascular prophylaxis. Abciximab in coronary artery disease ............................. 15 2.7. Graduated Elastic Compression Stockings for the prevention of VTE..................... 16 2.8. Venous Thrombo-embolism Assessment and Prophylaxis ..................................... 17 2.9. General risk factors for venous thrombo-embolism: ................................................ 17 2.10. Acknowledged factors for risk of bleeding for consideration as possible preclusions to pharmacological intervention: ........................................................................................ 18 2.11. Procedure for Risk Assessment, Appropriate Prophylaxis, and Documentation on Admission to Hospital: ....................................................................................................... 18 2.12. Recommendations for prophylaxis in medical and non-interventional surgical in- patients, usually to be given until discharge ....................................................................... 20 2.13. Prophylaxis recommendations for surgery by specialty and identifiable risk factors usually given until discharge .............................................................................................. 21 2.14. Doses of thrombo-prophylaxis for adult patients at extremes of body weight: Obesity and low weight (less than 50kg) ......................................................................................... 22 2.15. Lower limb plaster casts .......................................................................................... 23 2.16. Day case procedures, which may be exempted from further formal assessment ... 23 2.17. Monitoring for heparin induced thromobcytopaenia (HIT). ...................................... 24 2.18. Thrombotic Risk of Hormonal Therapy .................................................................... 25 2.19. Analgesia and Thrombo-embolism Prophylaxis ...................................................... 26 2.20. Therapeutic Anticoagulation .................................................................................... 26 2.21. Venous Thrombo-embolic Disease ......................................................................... 27 2.22. Dalteparin schedule for DVT and PE treatment: ..................................................... 31 2.23. Massive pulmonary embolus (with haemodynamic instability) ................................ 31 2.24. Venous thrombolytic therapy: .................................................................................. 32 2.25. Alteplase for PE:...................................................................................................... 32 2.26. Graduated Elastic Compression Stockings (Post deep venous thrombosis compression support hosiery >23 mm Hg at the ankle) ..................................................... 34 2.27. Inferior vena caval (IVC) filters ................................................................................ 35 Thrombosis Prevention Investigation and Management of Anticoagulation Clinical Guideline V12.2 Page 3 of 100 2.28. Complications of IVC filters: .................................................................................... 35 2.29. Cancer and VTE disease, complications and choice of anti-coagulant ................... 35 2.30. Recurrent thrombosis despite anticoagulation ........................................................ 36 2.31. Anti-platelet therapy for acute coronary syndrome (cf RCHT chest pain and Acute coronary syndrome pathway): ............................................................................................ 37 2.32. Anti-thrombotic schedule for acute coronary syndrome (cf RCHT chest pain and Acute coronary syndrome pathway) .................................................................................. 37 2.33. Cardiac thrombolysis and the use of tenecteplase and enoxaparin LMWH for the clinical diagnosis of myocardial infarction .......................................................................... 37 2.34. Ischaemic Stroke Thrombolysis............................................................................... 38 2.35. Unfractionated heparin (Pump-Hep) indications and schedule: ........................... 38 2.36. Warfarin, loading schedule, target INR and duration of therapy .............................. 39 2.37. Therapeutic loading schedule for acute thrombosis: ............................................... 40 2.38. Prophylactic warfarin initiation schedule (e.g. as with AF): ...................................... 40 2.39. Warfarin target INR and duration of therapy (cf BNF 2.8.2): ................................... 41 2.40. Management of sub-therapeutic anticoagulation in the first month after acute VTE 41 2.41. Cardiologist’s or Cardiothoracic surgeon’s decision*: .............................................. 42 2.42. Warfarin anticoagulation continued: ........................................................................ 42 2.43. Complications of therapeutic anticoagulation including bleeding ............................ 44 2.44. Management of bleeding with warfarin or other vitamin K antagonist oral anticoagulants: ................................................................................................................... 49 2.45. The use and dosage of **Beriplex® P/N prothrombin complex concentrate (factors II, VII, IX and X) in major bleeding in coumarin anticoagulated patients ............................ 50 2.46. Management of Variable INRs ................................................................................ 52 2.48. Bleeding with thrombolytic therapy: ......................................................................... 53 2.49. Bleeding with Anti Xa inhibitors (Rivaroxaban, Apixaban, Edoxaban): .................... 53 2.50. Bleeding with Dabigatran Exetilate (Pradaxa®): ..................................................... 53 2.51. Non-steroidal analgesics or anti-platelet therapy (aspirin and the P2Y12 inhibitors [clopidogrel and prasugrel] and GPIIa/IIIb inhibitors (eg abciximab): ................................. 56 2.52. Heparin induced thrombocytopaenia (HIT) .............................................................. 56 2.53. Discharge of patients on anticoagulants, education, the DOH Anticoagulant Therapy Record and liaison with primary care ................................................................................. 59 2.54. Special Circumstances: Thrombophilia and Pregnancy Related Thrombosis ......... 60 2.55. Surgery/invasive procedures in anticoagulated patients: ........................................ 64 2.56. Non Vitamin K oral anticoagulants (Apixaban, Edoxaban, Dabigatran elixate and Rivaroxaban) and surgery/ invasive procedures ................................................................ 69 2.57. Urgent surgery......................................................................................................... 71 2.58. Recommencing apixaban, dabigatran elixate, rivaroxaban and Edoxaban post procedure ........................................................................................................................... 71 2.59. Fondaparinux and Surgery ...................................................................................... 72 Thrombosis Prevention Investigation and Management of Anticoagulation Clinical Guideline V12.2 Page 4 of 100 2.60. Investigation and management of venous thrombosis at unusual sites ................... 72 2.61. Guidance on travel and venous thrombosis ............................................................ 74 2.62. Clinical governance. ................................................................................................ 74 3. Monitoring compliance and effectiveness ...............................................................
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