VTE Prophlyaxis✅

🩸 Venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE prophylaxis means assessing patients for clot risk and bleeding risk, then using mobilisation, hydration, mechanical measures and/or anticoagulant medication to reduce preventable hospital-associated thrombosis.

Why VTE prophylaxis matters 🫁

Hospital admission increases VTE risk because acute illness, surgery, trauma, immobility, inflammation and dehydration promote venous stasis and a procoagulant state. A DVT may cause leg swelling, pain and post-thrombotic syndrome, while PE can cause hypoxia, right heart strain, shock or death.

Virchow’s triad 🔺

• Venous stasis: immobility, bed rest, paralysis, long operations, plaster casts.
• Endothelial injury: surgery, trauma, inflammation, central venous catheters.
• Hypercoagulability: cancer, pregnancy, oestrogen therapy, thrombophilia, infection, dehydration.

Who needs VTE assessment? ✅

All hospital patients aged 16 and over should be assessed for both VTE risk and bleeding risk. This includes medical, surgical, trauma, critical care, psychiatric and obstetric patients.

• Assess as soon as possible after admission.
• Assess in ED if not admitted within 12 hours of arrival.
• Reassess at consultant review.
• Reassess if clinical condition changes.
• Reassess around surgery, deterioration, bleeding, pregnancy/postpartum status and discharge.

Common VTE risk factors 🚨

• Reduced mobility or bedbound state.
• Recent surgery, especially orthopaedic, pelvic, abdominal, thoracic or cancer surgery.
• Trauma or lower limb immobilisation.
• Active cancer or chemotherapy.
• Previous DVT or PE.
• Pregnancy or up to 6 weeks postpartum.
• Oestrogen-containing contraception or HRT.
• Acute infection, inflammation or sepsis.
• Obesity, dehydration or known thrombophilia.

Bleeding risk factors ⚠️

• Active bleeding or acquired bleeding disorder.
• Concurrent anticoagulant therapy.
• Recent haemorrhagic stroke.
• Thrombocytopenia.
• Severe uncontrolled hypertension.
• Severe liver disease with coagulopathy.
• Renal impairment affecting anticoagulant clearance.
• Recent lumbar puncture, spinal anaesthesia or epidural catheter.

Basic approach 🧠

• Assess VTE risk and bleeding risk.
• If VTE risk outweighs bleeding risk, offer prophylaxis.
• If bleeding risk is high, consider mechanical prophylaxis if suitable.
• Encourage mobilisation and hydration.
• Review daily and whenever the patient changes clinically.
• Document indication, agent, dose, duration and review plan.

Medication options 💉

Mechanical prophylaxis 🧦

Mechanical prophylaxis reduces venous stasis and is useful when anticoagulation is contraindicated, or as an adjunct in selected high-risk patients.

• Anti-embolism stockings.
• Intermittent pneumatic compression devices.
• Foot impulse devices in some settings.

Do not use anti-embolism stockings if 🚫

• Suspected or proven peripheral arterial disease.
• Peripheral arterial bypass grafting.
• Peripheral neuropathy or significant sensory impairment.
• Severe leg oedema.
• Major limb deformity or poor fit.
• Fragile skin, dermatitis, gangrene, wounds or recent skin graft.
• Known allergy to stocking material.

Medical patients 🏥

Acutely ill medical patients should receive pharmacological prophylaxis if their VTE risk outweighs bleeding risk. LMWH is commonly first-line, usually for at least 7 days, unless a specific contraindication or local protocol applies.

Surgical patients 🔪

Surgical VTE risk depends on both the patient and the procedure. Major abdominal, pelvic, thoracic, orthopaedic and cancer surgery are particularly high-risk.

• Use mechanical prophylaxis where appropriate.
• Add pharmacological prophylaxis if VTE risk outweighs bleeding risk.
• Continue for the recommended duration after surgery.
• Consider extended prophylaxis after major cancer or orthopaedic surgery.

Renal impairment 🫘

Renal impairment increases bleeding risk because some anticoagulants accumulate. Check renal function before prescribing and follow local renal-dose guidance.

• Adjust LMWH dose if required.
• Consider unfractionated heparin in severe renal impairment if locally recommended.
• Monitor for bleeding and thrombocytopenia.

Pregnancy and postpartum 🤰

Pregnancy and the first 6 weeks postpartum are prothrombotic states. Use an obstetric VTE risk tool and follow local maternity or RCOG-based guidance.

• Consider previous VTE, thrombophilia, obesity, immobility, infection and caesarean section.
• LMWH is commonly used when pharmacological prophylaxis is indicated.
• Reassess after delivery, miscarriage or termination.

Palliative care 🌿

VTE prophylaxis should be individualised. Consider thrombotic risk, bleeding risk, prognosis, symptom burden, treatment goals and the views of the patient and family.

• Do not prescribe automatically.
• Review if acute infection or immobility develops.
• Avoid prophylaxis where treatment burden outweighs benefit.

Patient advice 🗣️

• Explain why VTE risk assessment is needed.
• Explain DVT symptoms: unilateral calf swelling, pain, warmth or redness.
• Explain PE symptoms: breathlessness, pleuritic chest pain, haemoptysis, collapse or unexplained tachycardia.
• Explain how to use stockings or injections if prescribed.
• Give discharge advice and tell the GP if prophylaxis continues at home.

Common exam pitfalls ❌

• Giving LMWH without checking bleeding risk.
• Forgetting renal dose adjustment.
• Using stockings in peripheral arterial disease.
• Not reassessing after surgery or deterioration.
• Stopping prophylaxis too early after high-risk surgery.
• Assuming aspirin is adequate for all patients.

Makindo exam summary 🎯

Think: assess everyone, balance clot risk against bleeding risk, mobilise early, hydrate, use LMWH when appropriate, consider mechanical prophylaxis if bleeding risk is high, and reassess when the patient changes. The safest answer is usually not “give everyone heparin”, but “perform VTE and bleeding risk assessment, then prescribe appropriate prophylaxis.”

Disclaimer 📚

This article is for medical education and revision only. Prescribing decisions should follow local Trust policy, NICE guidance, the BNF, renal dosing guidance and senior clinical advice where needed.