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You can always ask for help, especially from your pharmacist

Haematology registrar is another useful person you might talk to for complicated decisions around anti-coagulation.

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mechanical prophylaxis used for high bleeding risk procedures or when pharm contraindicated

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Venous thromboembolism (VTE)

Remember

• withhold if planned invasive procedure or lumbar puncture (see periop)
• withhold if platelets < 50
• cross out DVT prophylaxis if already on a DOAC (APIXIBAN/RIVAROXABAN/DABIGATRAN) /warfarin/therapeutic LMWH (1mg/kg BD)/heparin infusion.
  • write “prophylaxis not required - reason” on chart

Risk assess

• Padua prediction score

Prophylaxis

• Normal patients

  • prophylactic: Enoxaparin (clexane) 40mg subcut daily
  • if CrCl<30: Enoxaparin 20mg subcut daily
    • also consider if smaller patient (weight ~ 40kg) or old and frail, use clinical judgement

• Fatties (BMI 30+)

  • increased risk of VTE + may not follow a predictable dose-response relationship

  • LMWH at standard prophylactic dose is unlikely to be sufficient in patients with BMI 40 kg/m2 or greater.

  • For obese patients with renal impairment, seek specialist advice

    

• Severe CKD or high risk of bleeding

  • Heparin 5000units subcut 8-12hrly
    • consult haematology if you need to reverse (risk of anaphylaxis with protamine).
      • reverse with protamine

• post THR or TKR surgery

  • Apixaban (CrCl 25 mL/min or more) 2.5 mg orally, twice daily
  • rivaroxaban (CrCl 15 mL/min or more) 10 mg orally, once daily.
  • Aspirin 75 mg to 150 mg orally, once daily.
    • only consider for pts without risk factors following a total hip or knee replacement
    • Must have already received 5 days of rivaroxaban therapy.
    • Do not use aspirin for VTE prophylaxis for surgeries other than total hip or knee replacement in patients at low risk—aspirin is not as effective as anticoagulants.