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NICE Clinical Guideline 46

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To develop safety guidance for the NHS in England and Wales on prophylaxis against venous thromboembolism (VTE) for patients undergoing orthopaedic surgery and other surgical procedures for which there is a high risk of VTE. The guidance should set out the principles of clinical and cost effective practice and in particular should address:

NICE Clinical Guideline 46 – remit

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(i) the assessment of risk for particular procedures and for individual patients

(ii) the circumstances in which prophylaxis can be recommended as clinically and cost effective

(iii) the appropriate selection of interventions including both pharmaceutical and mechanical methods of prophylaxis

NICE Clinical Guideline 46 – remit

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Adults (age 18 and older) undergoing inpatient surgery that carries a high risk of VTE, including:

• orthopaedic surgery (for example, total hip/knee replacement/hip fracture)

• major general surgery• major gynaecological surgery (not including elective/emergency caesarean)

• urological surgery (including major or open urological procedures)

• neurosurgery• cardiothoracic surgery• major peripheral vascular surgery

There may be other surgical procedures requiring an inpatient stay andhealthcare professionals should exercise their clinical judgement when

making decisions on the appropriateness of VTE prophylaxis.

What NICE Clinical Guideline 46 covers

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• Patients should be assessed to identify their risk factors for developing VTE

• Healthcare professionals should give patients verbal and written information, before surgery, about the risks of VTE and the effectiveness of prophylaxis

• Healthcare professionals should inform patients that the immobility associated with continuous travel of more than 3 hours in the 4 weeks before or after surgery may increase the risk of VTE

• Healthcare professionals should advise patients to consider stopping combined oral contraceptive use 4 weeks before elective surgery

Assessment of risk and patient advice

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• Healthcare professionals should give patients verbal and written information on the following, as part of their discharge plan:

• The signs and symptoms of DVT and PE• The correct use of prophylaxis at home• The implications of not using the prophylaxis correctly

Assessment of risk and patient advice

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Risk factors for VTE

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DVT 11,893

No VTE 45,793

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• Patients having elective orthopaedic surgery should be offered mechanical prophylaxis and either LMWH or fondaparinux

• Patients having hip replacement surgery with one or more risk factors for VTE (see box 1) should have their LMWH or fondaparinux therapy continued for 4 weeks after surgery

Elective orthopaedic surgery

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• Patients having surgery for hip fracture should be offered mechanical prophylaxis and either LMWH or fondaparinux

• LMWH or fondaparinux therapy should be continued for 4 weeks after hip fracture surgery

Hip fracture surgery

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• Patients having general surgery should be offered mechanical prophylaxis

• Patients having general surgery with one or more risk factors for VTE (see box 1) should be offered mechanical prophylaxis and either LMWH or fondaparinux

General surgery

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• Patients having gynaecological surgery should be offered mechanical prophylaxis

• Patients having gynaecological surgery with one or more risk factors for VTE (see box 1) should be offered mechanical prophylaxis and LMWH

Gynaecological surgery

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• Patients having cardiac surgery should be offered mechanical prophylaxis

• Patients having cardiac surgery with one or more risk factors for VTE (see box 1) should be offered mechanical prophylaxis and LMWH

Cardiac surgery

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• Patients having thoracic surgery should be offered mechanical prophylaxis

• Patients having thoracic surgery with one or more risk factors for VTE (see box 1) should be offered mechanical prophylaxis and LMWH

Thoracic surgery

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• Patients having urological surgery should be offered mechanical prophylaxis

• Patients having urological surgery with one or more risk factors for VTE (see box 1) should be offered mechanical prophylaxis and LMWH

Urological surgery

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• Patients having neurosurgery should be offered mechanical prophylaxis

• Patients having neurosurgery with one or more risk factors for VTE (see box 1) should be offered mechanical prophylaxis and LMWH

• Patients with ruptured cranial or spinal vascular malformations should not be offered pharmacological prophylaxis until the lesion has been secured

Neurosurgery

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"In many surgical patients the appropriate form of protection against blood clots is both compression stockings and heparin, but very often they are offered just one of these treatments.

This guideline should ensure that both are considered routinely and thereby help avoid much unnecessary suffering caused by blood clots in the legs and pulmonary embolism.”

Professor Colin BaigentEpidemiologist and member of panel