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Associated Data Supplementary Materials Additional file 1 Risk categories in non-orthopaedic surgical patients [ 13 ]. Abstract Venous thromboembolism VTE is an important cause of avoidable morbidity and mortality. Which patients should be considered for routine thromboprophylaxis? Table 1 Risk factors for venous thromboembolism [ 13 ]. Open in a separate window. How should VTE be prevented in at-risk patients?

Table 2 Grades of recommendation in the IUA guidelines [ 13 ]. What treatment approaches are recommended for VTE? Is there any difference between individual LMWHs? Conclusion: improving compliance with clinical guidelines Despite the existence of comprehensive consensus guidelines for the prevention and treatment of VTE [ 7 , 12 , 13 ], thromboprophylaxis remains underused [ 14 - 18 ]. Competing interests The author declares that they have no competing interests. Supplementary Material Additional file 1: Risk categories in non-orthopaedic surgical patients [ 13 ].

Click here for file 37K, doc. Fatal pulmonary emboli in hospitalized patients. An autopsy study. Arch Intern Med. Comparison of clinical and postmortem diagnosis of pulmonary embolism. J Clin Pathol. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy.

Clinical recognition of pulmonary embolism: problem of unrecognized and asymptomatic cases. Mayo Clin Proc. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? J R Soc Med. Assessment of venous thromboembolism risk and the benefits of thromboprophylaxis in medical patients. Thromb Haemost. Cost of long-term complications of deep venous thrombosis of the lower extremities: an analysis of a defined patient population in Sweden. Ann Intern Med.

Effect of postthrombotic syndrome on health-related quality of life after deep venous thrombosis.

Venous Thromboembolism Prevention

Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery.


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Br J Surg. Prevention and treatment of venous thromboembolism. International Consensus Statement guidelines according to scientific evidence. Int Angiol. New onset of venous thromboembolism among hospitalized patients at Brigham and Women's Hospital is caused more often by prophylaxis failure than by withholding treatment. Home-treatment of deep vein thrombosis in patients with cancer.

Prophylaxis for venous thromboembolism during treatment for cancer: questionnaire survey. Br Med J. Venous thromboembolism prophylaxis in acutely ill medical patients: definite need for improvement. J Intern Med. Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials.

Mortality rates and risk factors for asymptomatic deep vein thrombosis in medical patients. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Cancer and thrombosis. Deep vein thrombosis in cancer: the scale of the problem and approaches to management. Ann Oncol.

Prevention and Treatment of Venous Thromboembolism (VTE) | American Heart Association

Symptomatic venous thromboembolism in cancer patients treated with chemotherapy: an underestimated phenomenon. Cancer and thrombosis: managing the risks and approaches to thromboprophylaxis. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada.

Thromb Res. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. National Health and Medical Research Council. Clinical practice guidelines for the prevention of venous thromboembolism deep vein thrombosis and pulmonary embolism in patients admitted to Australian hospitals rescinded Access Economics Pty Ltd for the Australia and New Zealand working party on the management and prevention of venous thromboembolism.

The burden of venous thromboembolism in Australia, 1 May Access Economics Pty Ltd; Incidences and variations of hospital acquired venous thromboembolism in Australian hospitals: a population-based study. The Lancet. Therefore the investigations for cancer should be carried out within 2 weeks of being ordered. Thrombophilia testing This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. People with provoked deep vein thrombosis DVT or pulmonary embolism PE are not offered testing for thrombophilia.

Thrombophilia testing does not provide benefit and is unnecessary for people with provoked DVT or PE. Evidence of local arrangements to ensure people with provoked DVT or PE do not have testing for thrombophilia. Numerator — the number of people in the denominator who receive testing for thrombophilia. Service providers ensure systems are in place to ensure that people with provoked DVT or PE are not tested for thrombophilia.

Commissioners ensure they commission services that do not carry out testing for thrombophilia in people with provoked DVT or PE. People who have had a provoked with an obvious cause deep vein thrombosis or pulmonary embolism are not offered tests for thrombophilia a condition that makes the blood more likely to form clots. The NICE Guideline Development Group also considered VTE that occurs in association with hormonal therapy oral contraceptive or hormone replacement therapy to be provoked because it has been shown that people having these therapies have a lower risk of VTE recurrence.

Treatment of people with active cancer This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. People with active cancer and confirmed proximal deep vein thrombosis DVT or pulmonary embolism PE are offered anticoagulation therapy.

In people with cancer, anticoagulation can lead to improved prognosis including a reduction in the risk of recurrent DVT or PE. Evidence of local arrangements to ensure people with active cancer and confirmed proximal DVT or PE are offered anticoagulation therapy. The proportion of people with active cancer and confirmed proximal DVT or PE who receive anticoagulation therapy. Numerator — the number of people in the denominator who receive anticoagulation therapy.

Service providers ensure systems are in place for people with active cancer and confirmed proximal DVT or PE to be offered anticoagulation therapy. Healthcare professionals ensure people with active cancer and confirmed proximal DVT or PE are offered anticoagulation therapy.


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  6. Commissioners ensure they commission services that offer people with active cancer and confirmed proximal DVT or PE anticoagulation therapy. People with active cancer who have had a deep vein thrombosis or pulmonary embolism are offered treatment with an anticoagulant a drug that helps stop blood clots forming or enlarging and makes it less likely that a blood clot will come loose and travel to the lungs.

    NICE technology appraisal guidance Contained within NICE guideline CG clinical audit tool treatment of venous thromboembolism and investigations for cancer , standards 2a and 2b. Active cancer was defined by the Guideline Development Group after considering the evidence available as cancer: receiving active antimitotic treatment; or diagnosed within the past 6 months ; or recurrent or metastatic; or inoperable. This definition excludes squamous skin cancer and basal cell carcinoma. Anticoagulation therapy For active cancer anticoagulation therapy can include treatment with LMWH or rivaroxaban given in accordance with the summary of product characteristics.

    Follow-up for people without cancer This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. People without cancer who receive anticoagulation therapy have a review within 3 months of diagnosis of confirmed proximal deep vein thrombosis DVT or pulmonary embolism PE to discuss the risks and benefits of continuing anticoagulation therapy.

    As anticoagulation therapy carries potential risks such as bleeding there is a need to ensure the therapy remains beneficial. For people who have had a confirmed proximal DVT or PE and who do not have cancer, a review should take place. Evidence of local arrangements to ensure people without cancer who have had a confirmed proximal DVT or PE and receive anticoagulation therapy receive a review within 3 months of diagnosis to discuss the risks and benefits of continuing anticoagulation therapy.

    The proportion of people without cancer who have had a confirmed proximal DVT or PE and receive anticoagulation who have a review within 3 months to discuss the risks and benefits of continuing anticoagulation therapy. Numerator — the number of people in the denominator who receive a review within 3 months to discuss the risks and benefits of continuing anticoagulation therapy.

    Denominator — the number of people who have received anticoagulation therapy following a confirmed diagnosis of proximal DVT or PE at least 3 months previously and who do not have cancer. Service providers ensure systems are in place for people without cancer who have had a confirmed proximal DVT or PE and receive anticoagulation therapy to be offered a review within 3 months to discuss the risks and benefits of continuing anticoagulation therapy beyond 3 months.

    Healthcare professionals ensure people without cancer who have had a confirmed proximal DVT or PE and receive anticoagulation therapy are offered a review within 3 months of diagnosis to discuss the risks and benefits of continuing anticoagulation therapy. Commissioners ensure they commission services that offer people without cancer who have had a confirmed proximal DVT or PE and receive anticoagulation therapy a review within 3 months to discuss the risks and benefits of continuing anticoagulation therapy.

    People without cancer who have had deep vein thrombosis or pulmonary embolism and who are having treatment with an anticoagulant a drug that helps stop blood clots forming or enlarging and makes it less likely that a blood clot will come loose and travel to the lungs are offered a review within 3 months to discuss the risks and benefits of continuing treatment with an anticoagulant. Contained within NICE guideline CG clinical audit tool treatment of venous thromboembolism and investigations for cancer , standard 3d. Timing of review Healthcare professionals need to consider the summary of product characteristics to determine the timing of the review and duration of treatment required for the anticoagulant received.

    Follow-up for people with cancer This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. People with active cancer who receive anticoagulation therapy have a review within 6 months of confirmed diagnosis of proximal deep vein thrombosis DVT or pulmonary embolism PE to discuss the risks and benefits of continuing anticoagulation therapy At the time this part of the pathway was created June some types of LMWH did not have a UK marketing authorisation for 6 months of treatment of DVT or PE in patients with cancer.

    Prescribers should consult the summary of product characteristics for the individual LMWH and make appropriate adjustments for severe renal impairment or established renal failure. Informed consent for off-label use should be obtained and documented. For people who have had a confirmed diagnosis of proximal DVT or PE and who have cancer, a review should take place. Evidence of local arrangements to ensure people with cancer who have had a confirmed proximal DVT or PE and who receive anticoagulation are reviewed within 6 months of diagnosis to discuss the risks and benefits of continuing anticoagulation therapy.

    The proportion of people with cancer who have had a confirmed proximal DVT or PE and receive anticoagulation who have a review within 6 months of diagnosis to discuss the risks and benefits of continuing anticoagulation therapy. Numerator — the number of people in the denominator who receive a review within 6 months to discuss the risks and benefits of continuing anticoagulation therapy. Denominator — the number of people who have received anticoagulation therapy following a confirmed diagnosis of proximal DVT or PE at least 6 months previously and who have a diagnosis of cancer.

    Service providers ensure systems are in place for people with cancer who have had a confirmed proximal DVT or PE to be offered a review to discuss the risks and benefits of continuing anticoagulation therapy. Healthcare professionals ensure people with cancer who have had a confirmed proximal DVT or PE are offered a review to discuss the risks and benefits of continuing anticoagulation therapy.

    Commissioners ensure they commission services that offer people with cancer who have had a confirmed proximal DVT or PE a review to discuss the risks and benefits of continuing anticoagulation therapy. People with cancer who have had deep vein thrombosis or pulmonary embolism and who are having treatment with an anticoagulant a drug that helps stop blood clots forming or enlarging and makes it less likely that a blood clot will come loose and travel to the lungs are offered a review to discuss the risks and benefits of continuing treatment with an anticoagulant.

    Prevention and Management of Venous Thromboembolism

    Contained within NICE guideline CG clinical audit tool treatment of venous thromboembolism and investigations for cancer , standard 2c. Effective interventions library. NICE has produced resources to help implement its guidance on:. Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing.

    Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism. Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults. Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults.

    Percutaneous mechanical thrombectomy for acute deep vein thrombosis of the leg. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. Ultrasound-enhanced, catheter-directed thrombolysis for pulmonary embolism. Ultrasound-enhanced, catheter-directed thrombolysis for deep vein thrombosis. The geko device for reducing the risk of venous thromboembolism.

    Venous thromboembolism in adults: diagnosis and management. Venous thromboembolism in adults: reducing the risk in hospital quality standard. NICE has written information for the public on each of the following topics. Rivaroxaban to treat pulmonary embolism and reduce the risk of further venous thromboembolism. Rivaroxaban to treat deep vein thrombosis and to prevent deep vein thrombosis and pulmonary embolism. Apixaban to reduce the risk of venous thromboembolism after hip or knee replacement surgery.

    Rivaroxaban to reduce the risk of venous thromboembolism after hip or knee replacement surgery. Dabigatran etexilate to reduce the risk of venous thromboembolism after hip or knee replacement surgery. Information for people who use NHS services for diagnosis and management of venous thromboembolic diseases. Intermittent pneumatic compression A method of prophylaxis that includes an air pump and inflatable garments in a system designed to improve venous circulation in the lower limbs of people at risk of deep vein thrombosis or pulmonary embolism.

    The inflation-deflation cycle of intermittent pneumatic compression therapy simulates the thigh, calf and foot's normal ambulatory pump action increasing both the volume and rate of blood flow, eliminating venous stasis and replicating the effects of the natural muscle pump. Intermittent pneumatic compression devices can be thigh or knee length sleeves that are wrapped around the leg, or a garment that can be wrapped around or worn on the foot that is designed to mimic the actions of walking.

    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 the person's 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 in relation to the use of regional anaesthesia. Do not routinely offer pharmacological or mechanical VTE prophylaxis to people undergoing a surgical procedure with local anaesthesia by local infiltration with no limitation of mobility.

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    For pharmacological VTE prophylaxis in people under 18, follow the recommendations on apixaban, aspirin, dabigatran etexilate, fondaparinux sodium, low-molecular-weight heparin LMWH and rivaroxaban in this flowchart. At the time of publication March , these drugs did not have a UK marketing authorisation for use in young people under 18 for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision.

    Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. If using pharmacological VTE prophylaxis for surgical and trauma patients, start it as soon as possible and within 14 hours of admission, unless otherwise stated in the population-specific recommendations.