VTE Extended prophylaxis for surgical patients undergoing major abdominal or pelvic surgery for cancer in NHS Borders

This guidance relates solely to patients having major abdominal or colorectal surgery for cancer.

All patients having major abdominal or colorectal surgery for cancer should receive 28 days of dalteparin 5000units daily if eGFR >30ml/min.**, unless contraindicated.
Assessment is carried out in surgical pre-assessment clinic.
- Patients admitted as emergencies with diagnosis of colorectal cancer will have plan for extended VTE prophylaxis included in “step down” information from ITU.
- Patients with complex issues should be discussed - mechanical heart valves (cardiology) or heparin allergy (haematology).
If thromboprophylaxis is withheld or there is deviation from this guidance the reasons are documented in the patient’s case notes.

Concurrent oral anticoagulant (OAC) use; warfarin or DOAC (rivaroxaban, apixaban, dabigatran, edoxaban) patients should be converted to prophylactic dose of LMWH. OAC should restart after LMWH treatment completed. Patients warfarinised for prosthetic heart valves should be discussed with cardiology. Patients who have had their cancer completely excised (macroscopic RO resection) – this should be documented in theatre notes – can be changed back to their OAC at discharge if they are well.

High risk patients on Dual Anti Platelet Treatment for stents (including aspirin, clopidogrel, ticagrelor, prasugrel) should be discussed with cardiology.
Patients on single antiplatelet treatment receive prophylactic dalteparin 5000units daily if eGFR >30ml/min. **
Patients on clopidogrel 75mg daily are changed to aspirin 75mg daily 7 days before surgery and then changed back to Clopidogrel 75mg daily post-operatively after extended treatment with LMWH completed. Patients who cannot have aspirin have clopidogrel recommenced post-operatively and DO NOT receive extended VTE prophylaxis with Dalteparin.
Surgery for stroke patients should be avoided within 6 weeks of event – discuss with stroke team if delay not possible.
On discharge from BGH eDL should contain the plan for reintroduction of antiplatelet(s)/ OAC once extended post-operative treatment with prophylactic dalteparin is complete.

Patients being discharged on extended VTE prophylaxis with dalteparin should, if possible, be taught to self-administer (or carer taught to administer) dalteparin. Alternatively ward nursing staff should confirm that community nurses can administer, and the dalteparin should be prescribed on community prescription chart by ward medical staff on discharge from hospital. On discharge from BGH patients will receive supply of dalteparin to complete their treatment (The supply will normally be dispensed from BGH pharmacy; the ward will have a supply of overlabelled dalteparin for issue, when required, out of hours).

Dose of prophylactic dalteparin on BGH discharge as per eGFR.**. (Use calculated creatinineclearance at extremes of weight and age)

**Dalteparin 5000units daily if eGFR >30ml/min.
eGFR 10ml/min – 30ml/min , 2,500units dalteparin daily (CONSIDER RISKS v BENEFITS prior to prescribing pharmacological VTE prophylaxis).