1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the 2010 recommendations. The guideline addendum gives details of the methods and the evidence used to develop the 2015 recommendations.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See about this guideline for details.

Throughout this guidance 'significantly reduced mobility' is used to denote patients who are bedbound, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair.

'Major bleeding' refers to a bleeding event that results in one or more of the following:

  • death

  • a decrease in haemoglobin concentration of 2 g/dl or more

  • transfusion of 2 or more units of blood

  • bleeding into a retroperitoneal, intracranial or intraocular site

  • a serious or life‑threatening clinical event

  • a surgical or medical intervention.

'Severe renal impairment or established renal failure' refers to an estimated glomerular filtration rate (eGFR) of less than 30 ml/min/1.73m2.

1.1 Assessing the risks of VTE and bleeding

1.1.1 Assess all patients on admission to identify those who are at increased risk of VTE. [2010]

1.1.2 Regard medical patients as being at increased risk of VTE if they:

  • have had or are expected to have significantly reduced mobility for 3 days or more or

  • are expected to have ongoing reduced mobility relative to their normal state and have one or more of the risk factors shown in box 1. [2010]

1.1.3 Regard surgical patients and patients with trauma as being at increased risk of VTE if they meet one of the following criteria:

  • surgical procedure with a total anaesthetic and surgical time of more than 90 minutes, or 60 minutes if the surgery involves the pelvis or lower limb

  • acute surgical admission with inflammatory or intra‑abdominal condition

  • expected significant reduction in mobility

  • one or more of the risk factors shown in box 1. [2010]

Box 1 Risk factors for VTE

  • Active cancer or cancer treatment

  • Age over 60 years

  • Critical care admission

  • Dehydration

  • Known thrombophilias

  • Obesity (body mass index [BMI] over 30 kg/m2)

  • One or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions)

  • Personal history or first‑degree relative with a history of VTE

  • Use of hormone replacement therapy

  • Use of oestrogen‑containing contraceptive therapy

  • Varicose veins with phlebitis

For women who are pregnant or have given birth within the previous 6 weeks see recommendations 1.6.4–1.6.6.

1.1.4 Assess all patients for risk of bleeding before offering pharmacological VTE prophylaxis[5]. Do not offer pharmacological VTE prophylaxis to patients with any of the risk factors for bleeding shown in box 2, unless the risk of VTE outweighs the risk of bleeding. [2010]

1.1.5 Reassess patients' risks of bleeding and VTE within 24 hours of admission and whenever the clinical situation changes, to:

  • ensure that the methods of VTE prophylaxis being used are suitable

  • ensure that VTE prophylaxis is being used correctly

  • identify adverse events resulting from VTE prophylaxis. [2010]

Box 2 Risk factors for bleeding

  • Active bleeding

  • Acquired bleeding disorders (such as acute liver failure)

  • Concurrent use of anticoagulants known to increase the risk of bleeding (such as warfarin with international normalised ratio [INR] higher than 2)

  • Lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hours

  • Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours

  • Acute stroke

  • Thrombocytopenia (platelets less than 75 × 109/l)

  • Uncontrolled systolic hypertension (230/120 mmHg or higher)

  • Untreated inherited bleeding disorders (such as haemophilia and von Willebrand's disease)

1.2 Reducing the risk of VTE

1.2.1 Do not allow patients to become dehydrated unless clinically indicated. [2010]

1.2.2 Encourage patients to mobilise as soon as possible. [2010]

1.2.3 Do not regard aspirin or other antiplatelet agents as adequate prophylaxis for VTE. [2010]

1.2.4 Consider offering temporary inferior vena caval filters to patients who are at very high risk of VTE (such as patients with a previous VTE event or an active malignancy) and for whom mechanical and pharmacological VTE prophylaxis are contraindicated. [2010]

1.3 Using VTE prophylaxis

Mechanical VTE prophylaxis

1.3.1 Base the choice of mechanical VTE prophylaxis on individual patient factors including clinical condition, surgical procedure and patient preference. Choose any one of:

  • anti‑embolism stockings (thigh or knee length)

  • foot impulse devices

  • intermittent pneumatic compression devices (thigh or knee length).

    For patients who are admitted for stroke see recommendations 1.4.2, 1.4.4 and 1.4.5. [2010]

Anti‑embolism stockings

1.3.2 Do not offer anti‑embolism stockings to patients who have:

  • suspected or proven peripheral arterial disease

  • peripheral arterial bypass grafting

  • peripheral neuropathy or other causes of sensory impairment

  • any local conditions in which stockings may cause damage, for example fragile 'tissue paper' skin, dermatitis, gangrene or recent skin graft

  • known allergy to material of manufacture

  • cardiac failure

  • severe leg oedema or pulmonary oedema from congestive heart failure

  • unusual leg size or shape

  • major limb deformity preventing correct fit.

    Use caution and clinical judgement when applying anti‑embolism stockings over venous ulcers or wounds. [2010]

1.3.3 Ensure that patients who need anti‑embolism stockings have their legs measured and that the correct size of stocking is provided. Anti‑embolism stockings should be fitted and patients shown how to use them by staff trained in their use. [2010]

1.3.4 Ensure that patients who develop oedema or postoperative swelling have their legs re‑measured and anti‑embolism stockings refitted. [2010]

1.3.5 If arterial disease is suspected, seek expert opinion before fitting anti‑embolism stockings. [2010]

1.3.6 Use anti‑embolism stockings that provide graduated compression and produce a calf pressure of 14–15 mmHg. (This relates to a pressure of 14–18 mmHg at the ankle and is in line with British Standards 6612:1985 Specification for graduated compression hosiery and 7672:1993 Specification for compression, stiffness and labelling of anti-embolism hosiery.) [2010]

1.3.7 Encourage patients to wear their anti‑embolism stockings day and night until they no longer have significantly reduced mobility. [2010]

1.3.8 Remove anti‑embolism stockings daily for hygiene purposes and to inspect skin condition. In patients with a significant reduction in mobility, poor skin integrity or any sensory loss, inspect the skin two or three times per day, particularly over the heels and bony prominences. [2010]

1.3.9 Discontinue the use of anti‑embolism stockings if there is marking, blistering or discolouration of the skin, particularly over the heels and bony prominences, or if the patient experiences pain or discomfort. If suitable, offer a foot impulse or intermittent pneumatic compression device as an alternative. [2010]

1.3.10 Show patients how to use anti‑embolism stockings correctly and ensure they understand that this will reduce their risk of developing VTE. [2010]

1.3.11 Monitor the use of anti‑embolism stockings and offer assistance if they are not being worn correctly. [2010]

Foot impulse devices and intermittent pneumatic compression devices

1.3.12 Do not offer foot impulse or intermittent pneumatic compression devices to patients with a known allergy to the material of manufacture. [2010]

1.3.13 Encourage patients on the ward who have foot impulse or intermittent pneumatic compression devices to use them for as much of the time as is possible and practical, both when in bed and when sitting in a chair. [2010]

Pharmacological VTE prophylaxis

1.3.14 Base the choice of pharmacological VTE agents on local policies and individual patient factors, including clinical condition (such as severe renal impairment or established renal failure) and patient preferences. [2010]

1.4 Medical patients

General medical patients

1.4.1 Offer pharmacological VTE prophylaxis to general medical patients assessed to be at increased risk of VTE (see section 1.1). Choose any one of:

  • fondaparinux sodium

  • low molecular weight heparin (LMWH)[6]

  • unfractionated heparin (UFH) (for patients with severe renal impairment or established renal failure).

    Start pharmacological VTE prophylaxis as soon as possible after risk assessment has been completed. Continue until the patient is no longer at increased risk of VTE. [2010]

Patients with stroke

1.4.2 Do not offer anti‑embolism stockings for VTE prophylaxis to patients who are admitted for stroke. [2010]

1.4.3 Consider offering prophylactic‑dose LMWH[6] (or UFH for patients with severe renal impairment or established renal failure) if:

  • a diagnosis of haemorrhagic stroke has been excluded, and

  • the risk of bleeding (haemorrhagic transformation of stroke or bleeding into another site) is assessed to be low, and

  • the patient has one or more of:

    • major restriction of mobility

    • previous history of VTE

    • dehydration

    • comorbidities (such as malignant disease).

      Continue until the acute event is over and the patient's condition is stable. [2010]

1.4.4 Do not offer foot impulse or neuromuscular electrical stimulation devices for VTE prophylaxis to patients who are admitted for stroke, except in the context of research. [new 2015]

1.4.5 Consider intermittent pneumatic compression (IPC) for VTE prophylaxis in immobile patients who are admitted within 3 days of acute stroke.

  • Explain to the patient or their family members or carers (as appropriate) that:

    • it reduces the risk of deep vein thrombosis and may provide an increase in survival

    • it will not help them recover from stroke, and there may be an associated increased risk of surviving with severe disability (see table 1).

  • When using intermittent pneumatic compression for patients who are admitted for stroke, provide it for 30 days or until the patient is mobile or discharged, whichever is sooner. [new 2015]

Table 1: Average comparative outcomes with and without intermittent pneumatic compression (IPC) per 1000 patients who are immobile when admitted for stroke

Standard best medical care

(cases per 1000 patients)

Standard best medical care

plus intermittent pneumatic compression (IPC) a

(cases per 1000 patients, with 95% confidence interval)

Outcomes in hospital

Skin breaksb

14

30 (between 18 and 49)

Deep vein thrombosis that will cause symptoms and need treatmentb

63

45 (between 34 and 62)

Deep vein thrombosis that may or may not cause symptomsc

149

113 (between 94 and 136)

OHS*

Outcomes at 6 months b,d

0‑4

Alive and not severely disablede

562

550 (between 517 and 590)

5

Alive but severely disabled

180

218 (between 187 and 252)

6

Deadf

258

232 (between 204 and 259)

a Absolute risk: number of cases per 1000 patients (95% confidence interval).

b Data from CLOTS3 trial (Dennis 2013, 2014).

c Data from Lacut (2005) and CLOTS3 trial (Dennis 2013, 2014).

d These are average outcomes at 6 months after stroke, assessed using the Oxford Handicap Scale*. However, death rate and functional outcomes will vary depending on the severity of the initial stroke.

e The difference between the 2 groups on this outcome is not statistically significant.

f The difference between the 2 groups on this outcome is not statistically significant. However, when 6‑month all‑cause mortality data from the CLOTS3 trial are pooled with 3‑month data from the Lacut (2005) trial, the survival effect favouring IPC is statistically significant (see outcome 8 and figure 8 in appendix I of the full guideline).

*The Oxford Handicap Scale is a categorical scale for measuring functional outcome after a stroke. Key: 0 = Healthy survival – fully independent; 1 = Minor symptoms – independent, no interference; 2 = Minor disability – independent, some restrictions but able to self‑care; 3 = Moderate disability – significant restriction, unable to lead a totally independent existence (requires some assistance); 4 = Moderate‑to‑severe disability – unable to live independently but does not require constant attention; 5 = Severe disability – totally dependent, requires constant attention day and night; 6 = Death.

You can download a printable version of this table here.

Patients with cancer

1.4.6 Offer pharmacological VTE prophylaxis to patients with cancer who are assessed to be at increased risk of VTE (see section 1.1). Choose any one of:

  • fondaparinux sodium

  • LMWH[6]

  • UFH (for patients with severe renal impairment or established renal failure).

    Start pharmacological VTE prophylaxis as soon as possible after risk assessment has been completed. Continue until the patient is no longer at increased risk of VTE. [2010]

1.4.7 Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients with cancer having oncological treatment who are ambulant. [2010]

Patients with central venous catheters

1.4.8 Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients with central venous catheters who are ambulant. [2010]

1.4.9 Consider offering pharmacological VTE prophylaxis with LMWH[6] (or UFH for patients with severe renal impairment or established renal failure) to patients with central venous catheters who are at increased risk of VTE (see section 1.1). [2010]

Patients in palliative care

1.4.10 Consider offering pharmacological VTE prophylaxis to patients in palliative care who have potentially reversible acute pathology. Take into account potential risks and benefits and the views of patients and their families and/or carers. Choose any one of:

  • fondaparinux sodium

  • LMWH[6]

  • UFH (for patients with severe renal impairment or established renal failure). [2010]

1.4.11 Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients admitted for terminal care or those commenced on an end‑of‑life care pathway. [2010]

1.4.12 Review decisions about VTE prophylaxis for patients in palliative care daily, taking into account the views of patients, their families and/or carers and the multidisciplinary team. [2010]

Medical patients in whom pharmacological VTE prophylaxis is contraindicated

1.4.13 Consider offering mechanical VTE prophylaxis to medical patients in whom pharmacological VTE prophylaxis is contraindicated. Choose any one of:

  • anti‑embolism stockings (thigh or knee length)

  • foot impulse devices

  • intermittent pneumatic compression devices (thigh or knee length).

    For patients who are admitted for stroke see recommendations 1.4.2, 1.4.4 and 1.4.5 [2010]

1.5 Surgical patients

All surgery

1.5.1 Advise patients to consider stopping oestrogen‑containing oral contraceptives or hormone replacement therapy 4 weeks before elective surgery. If stopped, provide advice on alternative contraceptive methods. [2010]

1.5.2 Assess the risks and benefits of stopping pre‑existing established antiplatelet therapy 1 week before surgery. Consider involving the multidisciplinary team in the assessment. [2010]

1.5.3 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 patients' preferences, their suitability for regional anaesthesia and any other planned method of VTE prophylaxis. [2010]

1.5.4 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 agents in relation to the use of regional anaesthesia. [2010]

1.5.5 Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients undergoing a surgical procedure with local anaesthesia by local infiltration with no limitation of mobility. [2010]

Cardiac

1.5.6 Offer VTE prophylaxis to patients undergoing cardiac surgery who are not having other anticoagulation therapy and are assessed to be at increased risk of VTE (see section 1.1).

  • Start mechanical VTE prophylaxis at admission. Choose any one of:

    • anti‑embolism stockings (thigh or knee length)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • Add pharmacological VTE prophylaxis for patients who have a low risk of major bleeding, taking into account individual patient factors and according to clinical judgement. Choose one of:

    • LMWH

    • UFH (for patients with severe renal impairment or established renal failure).

      Continue pharmacological VTE prophylaxis until the patient no longer has significantly reduced mobility (generally 5–7 days). [2010]

Gastrointestinal, gynaecological, thoracic and urological

1.5.7 Offer VTE prophylaxis to patients undergoing bariatric surgery.

  • Start mechanical VTE prophylaxis at admission. Choose any one of:

    • anti‑embolism stockings (thigh or knee length)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • Add pharmacological VTE prophylaxis for patients who have a low risk of major bleeding, taking into account individual patient factors and according to clinical judgement. Choose any one of:

    • fondaparinux sodium

    • LMWH

    • UFH (for patients with severe renal impairment or established renal failure).

      Continue pharmacological VTE prophylaxis until the patient no longer has significantly reduced mobility (generally 5–7 days). [2010]

1.5.8 Offer VTE prophylaxis to patients undergoing gastrointestinal surgery who are assessed to be at increased risk of VTE (see section 1.1).

  • Start mechanical VTE prophylaxis at admission. Choose any one of:

    • anti‑embolism stockings (thigh or knee length)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility. [2010]

  • Add pharmacological VTE prophylaxis for patients who have a low risk of major bleeding, taking into account individual patient factors and according to clinical judgement. Choose any one of:

    • fondaparinux sodium

    • LMWH

    • UFH (for patients with severe renal impairment or established renal failure).

      Continue pharmacological VTE prophylaxis until the patient no longer has significantly reduced mobility (generally 5–7 days). [2010]

1.5.9 Offer VTE prophylaxis to patients undergoing gynaecological, thoracic or urological surgery who are assessed to be at increased risk of VTE (see section 1.1).

  • Start mechanical VTE prophylaxis at admission. Choose any one of:

    • anti‑embolism stockings (thigh or knee length)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • Add pharmacological VTE prophylaxis for patients who have a low risk of major bleeding, taking into account individual patient factors and according to clinical judgement. Choose one of:

    • LMWH

    • UFH (for patients with severe renal impairment or established renal failure).

      Continue pharmacological VTE prophylaxis until the patient no longer has significantly reduced mobility (generally 5–7 days). [2010]

1.5.10 Extend pharmacological VTE prophylaxis to 28 days postoperatively for patients who have had major cancer surgery in the abdomen or pelvis. [2010]

Neurological (cranial or spinal)

1.5.11 Offer VTE prophylaxis to patients undergoing cranial or spinal surgery who are assessed to be at increased risk of VTE (see section 1.1).

  • Start mechanical VTE prophylaxis at admission. Choose any one of:

    • anti‑embolism stockings (thigh or knee length)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • Add pharmacological VTE prophylaxis for patients who have a low risk of major bleeding, taking into account individual patient factors and according to clinical judgement. Choose one of:

    • LMWH

    • UFH (for patients with severe renal impairment or established renal failure).

      Continue pharmacological VTE prophylaxis until the patient no longer has significantly reduced mobility (generally 5–7 days). [2010]

1.5.12 Do not offer pharmacological VTE prophylaxis to patients with ruptured cranial or spinal vascular malformations (for example, brain aneurysms) or acute traumatic or non‑traumatic haemorrhage until the lesion has been secured or the condition is stable. [2010]

Orthopaedic surgery – elective hip replacement, elective knee replacement and hip fracture

The summaries of product characteristics state postoperative start times for dabigatran, rivaroxaban and fondaparinux, and preoperative start times for most LMWHs, although individual start times vary depending on the specific LMWH. In this guideline it is recommended that LMWH is started postoperatively, which is off‑label use, because of concerns about the risk of bleeding into the joint. Patients would be protected preoperatively by mechanical VTE prophylaxis. [2010]

Elective hip replacement

1.5.13 Offer combined VTE prophylaxis with mechanical and pharmacological methods to patients undergoing elective hip replacement surgery.

  • Start mechanical VTE prophylaxis at admission. Choose any one of the following, based on individual patient factors:

    • anti‑embolism stockings (thigh or knee length), used with caution (see recommendations 1.3.2–1.3.11)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • Provided there are no contraindications, start pharmacological VTE prophylaxis after surgery. Choose any one of:

    • dabigatran etexilate, starting 1–4 hours after surgery[7]

    • fondaparinux sodium, starting 6 hours after surgical closure provided haemostasis has been established

    • LMWH, starting 6–12 hours after surgery

    • rivaroxaban, starting 6–10 hours after surgery[8]

    • UFH (for patients with severe renal impairment or established renal failure), starting 6–12 hours after surgery.

      Continue pharmacological VTE prophylaxis for 28–35 days, according to the summary of product characteristics for the individual agent being used. [2010]

Elective knee replacement

1.5.14 Offer combined VTE prophylaxis with mechanical and pharmacological methods to patients undergoing elective knee replacement surgery.

  • Start mechanical VTE prophylaxis at admission. Choose any one of the following, based on individual patient factors:

    • anti‑embolism stockings (thigh or knee length), used with caution (see recommendations 1.3.2–1.3.11)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • Provided there are no contraindications, start pharmacological VTE prophylaxis after surgery. Choose any one of:

    • dabigatran etexilate, starting 1–4 hours after surgery[7]

    • fondaparinux sodium, starting 6 hours after surgical closure provided haemostasis has been established

    • LMWH, starting 6–12 hours after surgery

    • rivaroxaban, starting 6–10 hours after surgery[8]

    • UFH (for patients with severe renal impairment or established renal failure), starting 6–12 hours after surgery.

      Continue pharmacological VTE prophylaxis for 10–14 days, according to the summary of product characteristics for the individual agent being used. [2010]

Hip fracture

1.5.15 Offer combined VTE prophylaxis with mechanical and pharmacological methods to patients undergoing hip fracture surgery.

  • Start mechanical VTE prophylaxis at admission. Choose any one of the following, based on individual patient factors:

    • anti‑embolism stockings (thigh or knee length), used with caution (see recommendations 1.3.2–1.3.11)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • Provided there are no contraindications, add pharmacological VTE prophylaxis. Choose any one of:

    • fondaparinux sodium, starting 6 hours after surgical closure, provided haemostasis has been established and there is no risk of bleeding (see box 2)

    • LMWH, starting at admission, stopping 12 hours before surgery and restarting 6–12 hours after surgery

    • UFH (for patients with severe renal impairment or established renal failure), starting at admission, stopping 12 hours before surgery and restarting 6–12 hours after surgery.

      Continue pharmacological VTE prophylaxis for 28–35 days, according to the summary of product characteristics for the individual agent being used. [2010]

1.5.16 Fondaparinux sodium is not recommended for use preoperatively for patients undergoing hip fracture surgery. If it has been used preoperatively it should be stopped 24 hours before surgery and restarted 6 hours after surgical closure, provided haemostasis has been established and there is no risk of bleeding (see box 2). [2010]

Other orthopaedic surgery

1.5.17 Consider offering combined VTE prophylaxis with mechanical and pharmacological methods to patients having orthopaedic surgery (other than hip replacement, knee replacement or hip fracture surgery) based on an assessment of risks (see section 1.1) and after discussion with the patient.

  • Start mechanical VTE prophylaxis at admission. Choose one of the following, based on individual patient factors:

    • anti‑embolism stockings (thigh or knee length), used with caution (see recommendations 1.3.2–1.3.11)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • Start pharmacological VTE prophylaxis 6–12 hours after surgery. Choose one of:

    • LMWH

    • UFH (for patients with severe renal impairment or established renal failure).

      Continue pharmacological VTE prophylaxis until the patient no longer has significantly reduced mobility. [2010]

1.5.18 Do not routinely offer VTE prophylaxis to patients undergoing upper limb surgery. If a patient is assessed to be at increased risk of VTE (see section 1.1), refer to recommendation 1.5.17. [2010]

Vascular

1.5.19 Offer VTE prophylaxis to patients undergoing vascular surgery who are not having other anticoagulant therapy and are assessed to be at increased risk of VTE (see section 1.1). If peripheral arterial disease is present, seek expert opinion before fitting anti‑embolism stockings.

  • Start mechanical VTE prophylaxis at admission. Choose any one of:

    • anti‑embolism stockings (thigh or knee length)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • Add pharmacological VTE prophylaxis for patients who have a low risk of major bleeding, taking into account individual patient factors and according to clinical judgement. Choose one of:

    • LMWH

    • UFH (for patients with severe renal impairment or established renal failure).

      Continue pharmacological VTE prophylaxis until the patient no longer has significantly reduced mobility (generally 5–7 days). [2010]

Day surgery

1.5.20 Offer VTE prophylaxis to patients undergoing day surgery who are assessed to be at increased risk of VTE (see section 1.1).

  • Start mechanical VTE prophylaxis at admission. Choose any one of:

    • anti‑embolism stockings (thigh or knee length)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • Add pharmacological VTE prophylaxis for patients who have a low risk of major bleeding, taking into account individual patient factors and according to clinical judgement. Choose any one of:

    • fondaparinux

    • LMWH

    • UFH (for patients with severe renal impairment or established renal failure).

      If the patient is expected to have significantly reduced mobility after discharge, continue pharmacological VTE prophylaxis, generally for 5–7 days. [2010]

Other surgical patients

1.5.21 Offer VTE prophylaxis to patients undergoing surgery other than that covered in recommendations 1.5.6–1.5.20 who are assessed to be at increased risk of VTE (see section 1.1).

  • Start mechanical VTE prophylaxis at admission. Choose any one of:

    • anti‑embolism stockings (thigh or knee length)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • Add pharmacological VTE prophylaxis for patients who have a low risk of major bleeding, taking into account individual patient factors and according to clinical judgement. Choose one of:

    • LMWH

    • UFH (for patients with severe renal impairment or established renal failure).

      Continue pharmacological VTE prophylaxis until the patient no longer has significantly reduced mobility (generally 5–7 days). [2010]

1.6 Other patient groups

Major trauma

1.6.1 Offer combined VTE prophylaxis with mechanical and pharmacological methods to patients with major trauma. Regularly reassess the patient's risks of VTE and bleeding.

  • Start mechanical VTE prophylaxis at admission or as early as clinically possible. Choose any one of:

    • anti‑embolism stockings (thigh or knee length), used with caution (see recommendations 1.3.2–1.3.11)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • If the benefits of reducing the risk of VTE outweigh the risks of bleeding (see box 2) and the bleeding risk has been established as low, add pharmacological VTE prophylaxis. Choose one of:

    • LMWH

    • UFH (for patients with severe renal impairment or established renal failure).

      Continue pharmacological VTE prophylaxis until the patient no longer has significantly reduced mobility. [2010]

Spinal injury

1.6.2 Offer combined VTE prophylaxis with mechanical and pharmacological methods to patients with spinal injury. Regularly reassess the patient's risks of VTE and bleeding.

  • Start mechanical VTE prophylaxis at admission or as early as clinically possible. Choose any one of:

    • anti‑embolism stockings (thigh or knee length), used with caution (see recommendations 1.3.2–1.3.11)

    • foot impulse devices

    • intermittent pneumatic compression devices (thigh or knee length).

      Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced mobility.

  • If the benefits of reducing the risk of VTE outweigh the risks of bleeding (see box 2) and the bleeding risk has been established as low, add pharmacological VTE prophylaxis. Choose one of:

    • LMWH

    • UFH (for patients with severe renal impairment or established renal failure).

      Continue pharmacological VTE prophylaxis until the patient no longer has significantly reduced mobility. [2010]

Lower limb plaster casts

1.6.3 Consider offering pharmacological VTE prophylaxis to patients with lower limb plaster casts after evaluating the risks (see section 1.1) and benefits based on clinical discussion with the patient. Offer LMWH (or UFH for patients with severe renal impairment or established renal failure) until lower limb plaster cast removal. [2010]

Pregnancy and up to 6 weeks post partum

1.6.4 Consider offering pharmacological VTE prophylaxis with LMWH (or UFH for patients with severe renal impairment or established renal failure) to women who are pregnant or have given birth within the previous 6 weeks who are admitted to hospital but are not undergoing surgery, and who have one or more of the following risk factors:

  • expected to have significantly reduced mobility for 3 or more days

  • active cancer or cancer treatment

  • age over 35 years

  • critical care admission

  • dehydration

  • excess blood loss or blood transfusion

  • known thrombophilias

  • obesity (pre‑pregnancy or early pregnancy BMI over 30 kg/m2)

  • one or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions)

  • personal history or a first‑degree relative with a history of VTE

  • pregnancy‑related risk factor (such as ovarian hyperstimulation, hyperemesis gravidarum, multiple pregnancy or pre‑eclampsia)

  • varicose veins with phlebitis. [2010]

1.6.5 Consider offering combined VTE prophylaxis with mechanical methods and LMWH (or UFH for patients with severe renal impairment or established renal failure) to women who are pregnant or have given birth within the previous 6 weeks who are undergoing surgery, including caesarean section. [2010]

1.6.6 Offer mechanical and/or pharmacological VTE prophylaxis to women who are pregnant or have given birth within the previous 6 weeks only after assessing the risks and benefits and discussing these with the woman and with healthcare professionals who have knowledge of the proposed method of VTE prophylaxis during pregnancy and post partum. Plan when to start and stop pharmacological VTE prophylaxis to minimise the risk of bleeding. [2010]

Critical care

1.6.7 Assess all patients on admission to the critical care unit for their risks of VTE (see section 1.1) and bleeding (see box 2). Reassess patients' risks of VTE and bleeding daily and more frequently if their clinical condition is changing rapidly. [2010]

1.6.8 Offer VTE prophylaxis to patients admitted to the critical care unit according to the reason for admission, taking into account:

  • any planned interventions

  • the use of other therapies that may increase the risk of complications. [2010]

1.6.9 Review decisions about VTE prophylaxis for patients in critical care daily and more frequently if their clinical condition is changing rapidly. Take into account the known views of the patient, comments from their family and/or carers and the multidisciplinary team. [2010]

Patients already having antiplatelet agents or anticoagulation on admission or needing them for treatment

1.6.10 Consider offering additional mechanical or pharmacological VTE prophylaxis to patients who are having antiplatelet agents to treat other conditions and who are assessed to be at increased risk of VTE (see section 1.1). Take into account the risk of bleeding (see box 2) and of comorbidities such as arterial thrombosis.

  • If the risk of VTE outweighs the risk of bleeding, consider offering pharmacological VTE prophylaxis according to the reason for admission.

  • If the risk of bleeding outweighs the risk of VTE, offer mechanical VTE prophylaxis. [2010]

1.6.11 Do not offer additional pharmacological or mechanical VTE prophylaxis to patients who are taking vitamin K antagonists and who are within their therapeutic range, providing anticoagulant therapy is continued. [2010]

1.6.12 Do not offer additional pharmacological or mechanical VTE prophylaxis to patients who are having full anticoagulant therapy (for example, fondaparinux sodium, LMWH or UFH). [2010]

1.7 Patient information and planning for discharge

Patient information

1.7.1 Be aware that heparins are of animal origin and this may be of concern to some patients[9]. For patients who have concerns about using animal products, consider offering synthetic alternatives based on clinical judgement and after discussing their suitability, advantages and disadvantages with the patient. [2010]

1.7.2 Before starting VTE prophylaxis, offer patients and/or their families or carers verbal and written information on:

  • the risks and possible consequences of VTE

  • the importance of VTE prophylaxis and its possible side effects

  • the correct use of VTE prophylaxis (for example, anti‑embolism stockings, foot impulse or intermittent pneumatic compression devices).

  • how patients can reduce their risk of VTE (such as keeping well hydrated and, if possible, exercising and becoming more mobile). [2010]

Planning for discharge

1.7.3 As part of the discharge plan, offer patients and/or their families or carers verbal and written information on:

  • the signs and symptoms of deep vein thrombosis and pulmonary embolism

  • the correct and recommended duration of use of VTE prophylaxis at home (if discharged with prophylaxis)

  • the importance of using VTE prophylaxis correctly and continuing treatment for the recommended duration (if discharged with prophylaxis)

  • the signs and symptoms of adverse events related to VTE prophylaxis (if discharged with prophylaxis)

  • the importance of seeking help and who to contact if they have any problems using the prophylaxis (if discharged with prophylaxis)

  • the importance of seeking medical help and who to contact if deep vein thrombosis, pulmonary embolism or other adverse events are suspected. [2010]

1.7.4 Ensure that patients who are discharged with anti‑embolism stockings:

  • understand the benefits of wearing them

  • understand the need for daily hygiene removal

  • are able to remove and replace them, or have someone available who will be able to do this for them

  • know what to look for, such as skin marking, blistering or discolouration, particularly over the heels and bony prominences

  • know who to contact if there is a problem. [2010]

1.7.5 Ensure that patients who are discharged with pharmacological and/or mechanical VTE prophylaxis are able to use it correctly, or have arrangements made for someone to be available who will be able to help them. [2010]

1.7.6 Notify the patient's GP if the patient has been discharged with pharmacological and/or mechanical VTE prophylaxis to be used at home. [2010]



[5] Prescribers should consult the summary of product characteristics for the pharmacological VTE prophylaxis being used or planned for further details.

[6] At the time of publication (June 2015) some types of LMWH do not have UK marketing authorisation for VTE prophylaxis in medical patients. Prescribers should consult the summary of product characteristics for the individual LMWH. Informed consent for off‑label use should be obtained and documented.

[7] In line with 'Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults' (NICE technology appraisal guidance 157), dabigatran etexilate, within its marketing authorisation, is recommended as an option for the primary prevention of venous thromboembolic events in adults who have undergone elective total hip replacement surgery or elective total knee replacement surgery.

[8] In line with 'Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults' (NICE technology appraisal guidance 170), rivaroxaban, within its marketing authorisation, is recommended as an option for the prevention of venous thromboembolism in adults having elective total hip replacement surgery or elective total knee replacement surgery.

  • National Institute for Health and Care Excellence (NICE)