Venous thromboembolism in

over 16s: reducing the risk of

hospital-acquired deep vein
thrombosis or pulmonary
embolism

NICE guideline
Published: 21 March 2018
www.nice.org.uk/guidance/ng89

© NICE 2019. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-

rights). Last updated August 2019
Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

Your responsibility
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual needs,
preferences and values of their patients or the people using their service. It is not mandatory to
apply the recommendations, and the guideline does not override the responsibility to make
decisions appropriate to the circumstances of the individual, in consultation with them and their
families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be
applied when individual professionals and people using services wish to use it. They should do so in
the context of local and national priorities for funding and developing services, and in light of their
duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a
way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of implementing
NICE recommendations wherever possible.

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conditions#notice-of-rights). Last updated August 2019 of 43
Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

Contents
Overview ................................................................................................................................................................................ 5

Who is it for? ...................................................................................................................................................................................... 5

Recommendations .............................................................................................................................................................. 6

1.1 Risk assessment ........................................................................................................................................................................ 6

1.2 Giving information and planning for discharge ............................................................................................................ 8

1.3 All patients................................................................................................................................................................................... 10

1.4 Interventions for people with acute coronary syndromes or acute stroke or for acutely ill patients.... 12

1.5 Interventions for people with renal impairment.......................................................................................................... 13

1.6 Interventions for people with cancer ............................................................................................................................... 13

1.7 Interventions for people having palliative care ............................................................................................................ 14

1.8 Interventions for people admitted to critical care ...................................................................................................... 14

1.9 Interventions for people with psychiatric illness......................................................................................................... 15

1.10 Interventions when using anaesthesia.......................................................................................................................... 16

1.11 Interventions for people having orthopaedic surgery ............................................................................................ 16

1.12 Interventions for people having elective spinal surgery or cranial surgery or people with spinal
injury ..................................................................................................................................................................................................... 20

1.13 Interventions for people with major trauma............................................................................................................... 22

1.14 Interventions for people having abdominal, thoracic or head and neck surgery ......................................... 22

1.15 Interventions for people having cardiac or vascular surgery............................................................................... 25

1.16 Interventions for pregnant women and women who gave birth or had a miscarriage or termination
of pregnancy in the past 6 weeks............................................................................................................................................... 27

Terms used in this guideline ......................................................................................................................................................... 28

Putting this guideline into practice ..............................................................................................................................31

Context....................................................................................................................................................................................33

More information............................................................................................................................................................................. 34

Recommendations for research ....................................................................................................................................35

1 Risk assessment ............................................................................................................................................................................ 35

2 Dose strategies for people who are obese ......................................................................................................................... 35

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

3 Direct oral anticoagulants for people with lower limb immobilisation .................................................................. 36

4 Aspirin prophylaxis for people with fragility fractures of the pelvis, hip or proximal femur.......................... 37

5 Duration of prophylaxis for elective total hip replacement surgery ....................................................................... 37

Update information ...........................................................................................................................................................39

Recommendations that have been changed ......................................................................................................................... 39

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

This guideline replaces CG92.

This guideline is the basis of QS3.

Ov
Overview
erview
This guideline covers assessing and reducing the risk of venous thromboembolism (VTE or blood
clots) and deep vein thrombosis (DVT) in people aged 16 and over in hospital. It aims to help
healthcare professionals identify people most at risk and describes treatments and interventions
that can be used to reduce the risk of VTE.

Who is it for?
Healthcare professionals

People going into hospital who are at risk of VTE. This includes people discharged from
hospital, (including from A&E) with lower limb devices such as plaster casts and braces, people
attending hospital for day procedures including cancer treatment and surgery, and pregnant
women admitted to hospital or a midwife-led unit including up to 6 weeks after giving birth,
and their carers

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conditions#notice-of-rights). Last updated August 2019 of 43
Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

Recommendations
People have the right to be involved in discussions and make informed decisions about their
care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or
certainty) of our recommendations, and has information about prescribing medicines (including
off-label use), professional guidelines, standards and laws (including on consent and mental
capacity), and safeguarding.

1.1 Risk assessment

All patients
1.1.1 Assess all patients to identify the risk of venous thromboembolism (VTE) and
bleeding (see recommendation 1.1.2 for all medical patients, 1.1.5 for all surgical
patients, 1.1.9 for all pregnant women and all women who gave birth or had a
miscarriage or termination of pregnancy in the past 6 weeks, 1.8.1 for all people
admitted to the critical care unit and 1.9.1 for all acute psychiatric patients).
[2018]

People admitted to hospital

Medical patients
1.1.2 Assess all medical patients to identify the risk of VTE and bleeding:

As soon as possible after admission to hospital or by the time of the first consultant
review

Using a tool published by a national UK body, professional network or peer-reviewed

journal. The most commonly used risk assessment tool for medical patients is the
Department of Health VTE risk assessment tool[ ]. [2018] 1

1.1.3 Balance the person's individual risk of VTE against their risk of bleeding when
deciding whether to offer pharmacological thromboprophylaxis to medical
patients. [2018]

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

1.1.4 If using pharmacological VTE prophylaxis for medical patients, start it as soon as
possible and within 14 hours of admission, unless otherwise stated in the
population-specific recommendations (see sections 1.4 to 1.9). [2018]

Surgical and tr
trauma
auma patients
1.1.5 Assess all surgical and trauma patients to identify the risk of VTE and bleeding:

As soon as possible after admission to hospital or by the time of the first consultant
review

Using a tool published by a national UK body, professional network or peer-reviewed

journal. The most commonly used risk assessment tool for surgical patients is the
Department of Health VTE risk assessment tool[ ]. [2018] 1

1.1.6 Balance the person's individual risk of VTE against their risk of bleeding when
deciding whether to offer pharmacological thromboprophylaxis to surgical and
trauma patients. [2018]

1.1.7 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 (see sections 1.10 to 1.15). [2018]

Reassessment of risk of VTE and bleeding

1.1.8 Reassess all medical, surgical and trauma patients for risk of VTE and bleeding
at the point of consultant review or if their clinical condition changes. [2018]

Pregnant women and women who ga gavve birth or had a miscarriage

or termination of pregnancy in the past 6 weeks
1.1.9 Assess all women on admission to hospital or a midwife-led unit if they are
pregnant or gave birth, had a miscarriage or had a termination of pregnancy in
the past 6 weeks, to identify their risk of VTE and bleeding. Use a tool published
by a national UK body, professional network or peer-reviewed journal. The most
commonly used risk assessment tool was developed by the Royal College of
Obstetricians and Gynaecologists[ ]. [2018]
2

1.1.10 Reassess risk of VTE and bleeding, and assess the need for thromboprophylaxis
for all women:

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

within 6 hours of giving birth, having a miscarriage or having a termination of

pregnancy or

if their clinical condition changes and they:

are pregnant or

gave birth, had a miscarriage or had a termination of pregnancy within the past
6 weeks. [2018]

1.2 Giving information and planning for discharge

1.2.1 On admission ensure that people understand the reason for having a risk
assessment for VTE and bleeding. [2018]

1.2.2 For people admitted to hospital who are at increased risk of VTE, give them and
their family members or carers (as appropriate) verbal and written information
on the following before offering VTE prophylaxis:

the person's risks and possible consequences of VTE

the importance of VTE prophylaxis and its possible side effects – for example,
pharmacological prophylaxis can increase bleeding risk

the correct use of VTE prophylaxis – for example, anti-embolism stockings,

intermittent pneumatic compression

how people can reduce their risk of VTE (such as keeping well hydrated and, if possible,
exercising and becoming more mobile). [2018]

1.2.3 Be aware that heparins are of animal origin and this may be of concern to some
people[ ]. Discuss the alternatives with people who have concerns about using
3

animal products, after discussing their suitability, advantages and disadvantages

with the person. [2018]

1.2.4 As part of the discharge plan, give patients and their family members or carers
(as appropriate) verbal and written information on:

the signs and symptoms of deep vein thrombosis (DVT) and pulmonary embolism

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

how people can reduce their risk of VTE (such as keeping well hydrated and, if possible,
exercising and becoming more mobile)

the importance of seeking help if DVT, pulmonary embolism or other adverse events
are suspected. [2018]

1.2.5 Give people discharged with VTE prophylaxis and their family members or
carers (as appropriate) verbal and written information on:

the importance of using VTE prophylaxis correctly (including the correct

administration and disposal of pharmacological prophylaxis)

the importance of continuing treatment for the recommended duration

the signs and symptoms of adverse events related to VTE prophylaxis

the importance of seeking help and who to contact if people have problems using VTE
prophylaxis. [2018]

1.2.6 Ensure that people who are discharged with anti-embolism stockings:

understand the benefits of wearing them

understand the importance of wearing them correctly

understand the need to remove them daily for hygiene purposes

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 if there is a problem – for example, skin marking, blistering or
discolouration, particularly over the heels and bony prominences

know who to contact if there is a problem

know when to stop wearing them. [2018]

1.2.7 Ensure that people 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. [2018]

1.2.8 Notify the person's GP if the person has been discharged with pharmacological
and/or mechanical VTE prophylaxis to be used at home. [2018]

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

1.3 All patients

Mechanical proph
prophylaxis
ylaxis
1.3.1 Do not offer anti-embolism stockings to people 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 anti-embolism stockings may cause damage – for
example, fragile 'tissue paper' skin, dermatitis, gangrene or recent skin graft

known allergy to material of manufacture

severe leg oedema

major limb deformity or unusual leg size or shape preventing correct fit.

Use caution and clinical judgement when applying anti-embolism stockings over
venous ulcers or wounds. [2010, amended 2018]

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

1.3.3 Ensure that people who develop oedema or postoperative swelling have their
legs re-measured and anti-embolism stockings refitted. [2010]

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

1.3.5 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 Standard BS 661210:2018 Specification for
graduated compression hosiery, anti-embolism hosiery and graduated support
hosiery.) [2010]

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

1.3.6 Encourage people to wear their anti-embolism stockings day and night until
they no longer have significantly reduced mobility. [2010]

1.3.7 Remove anti-embolism stockings daily for hygiene purposes and to inspect skin
condition. In people with a significant reduction in mobility, poor skin integrity
or any sensory loss, inspect the skin 2 or 3 times a day, particularly over the
heels and bony prominences. [2010]

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

1.3.9 Stop 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 person experiences pain or discomfort. If suitable, offer intermittent
pneumatic compression as an alternative. [2010, amended 2018]

1.3.10 Do not offer intermittent pneumatic compression to people with a known

allergy to the material of manufacture. [2010, amended 2018]

1.3.11 Advise the person to wear their device for as much time as possible. [2010,
amended 2018]

Pharmacological proph
prophylaxis
ylaxis
1.3.12 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
guideline. At the time of publication (March 2018), 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. [2018]

All surgery
1.3.13 Advise people 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]

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

Nursing care: early mobilisation and h

hyydr
dration
ation
1.3.14 Encourage people to mobilise as soon as possible. [2010]

1.3.15 Do not allow people to become dehydrated unless clinically indicated. [2010]

People using antiplatelet agents

1.3.16 Consider VTE prophylaxis for people who are having antiplatelet agents for
other conditions and whose risk of VTE outweighs their risk of bleeding. Take
into account the risk of bleeding and of comorbidities such as arterial
thrombosis.

If the risk of VTE outweighs the risk of bleeding, consider pharmacological VTE
prophylaxis based on their condition or procedure.

If the risk of bleeding outweighs the risk of VTE, consider mechanical VTE prophylaxis.
[2018]

People using anticoagulation ther

therap
apyy
1.3.17 Consider VTE prophylaxis for people at increased risk of VTE who are
interrupting anticoagulant therapy. [2018]

1.4 Interv
Interventions
entions for people with acute coronary
syndromes or acute strok
stroke
e or for acutely ill patients
Acute coronary syndromes
1.4.1 Be aware that people receiving anticoagulant drugs as part of their treatment
for an acute coronary syndrome do not usually need VTE prophylaxis. See also
recommendation 1.3.17. [2018]

Acute strok
stroke
e patients
1.4.2 Do not offer anti-embolism stockings for VTE prophylaxis to people who are
admitted for acute stroke. [2010, amended 2018]

1.4.3 Consider intermittent pneumatic compression for VTE prophylaxis for people

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

who are immobile and admitted with acute stroke. If using, start it within 3 days
of acute stroke. [2018]

1.4.4 Explain to the person admitted with acute stroke and their family members or
carers (as appropriate) that intermittent pneumatic compression:

reduces the risk of DVT and may increase their chances of survival

will not help them recover from stroke, and there may be an associated increased risk
of surviving with severe disability. [2018]

1.4.5 When using intermittent pneumatic compression for people who are admitted
with acute stroke, provide it for 30 days or until the person is mobile or
discharged, whichever is sooner. [2018]

Acutely ill medical patients

1.4.6 Offer pharmacological VTE prophylaxis for a minimum of 7 days to acutely ill
medical patients whose risk of VTE outweighs their risk of bleeding:

Use LMWH[ ] as first-line treatment.

4

If LMWH[ ] is contraindicated, use fondaparinux sodium[ ]. [2018]

4 5

1.5 Interv
Interventions
entions for people with renal impairment
1.5.1 If using pharmacological VTE prophylaxis for people with renal impairment,
choose either LMWH[ ] or unfractionated heparin (UFH). [2018]
4

1.5.2 If needed, reduce the dose of LMWH[ ] and UFH for people with renal
4

impairment. Base the decision on multidisciplinary or senior opinion, or locally

agreed protocols. [2018]

1.6 Interv
Interventions
entions for people with cancer
1.6.1 Do not offer VTE prophylaxis to people with cancer who are receiving cancer-
modifying treatments such as radiotherapy, chemotherapy or immunotherapy
and who are mobile, except as outlined in recommendations 1.6.2 and 1.6.3,
unless they are also at increased risk of VTE because of something other than
the cancer. [2018]

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

1.6.2 Consider pharmacological VTE prophylaxis for people with myeloma who are
receiving chemotherapy with thalidomide, pomalidomide or lenalidomide with
steroids. Choose either:

aspirin[ ] (75 or 150 mg) or

6

LMWH[ ]. [2018]
4

1.6.3 Consider pharmacological VTE prophylaxis with LMWH[ ] for people with4

pancreatic cancer who are receiving chemotherapy. [2018]

1.6.4 If giving VTE prophylaxis to people with cancer (see recommendations 1.6.2
and 1.6.3), continue for as long as they are receiving chemotherapy. [2018]

1.7 Interv
Interventions
entions for people ha
having
ving palliativ
palliativee care
1.7.1 Consider pharmacological VTE prophylaxis for people who are having palliative
care. Take into account temporary increases in thrombotic risk factors, risk of
bleeding, likely life expectancy and the views of the person and their family
members or carers (as appropriate):

Use LMWH[ ] as first-line treatment.

4

If LMWH[ ] is contraindicated, use fondaparinux sodium[ ]. [2018]

4 5

1.7.2 Do not offer VTE prophylaxis to people in the last days of life. [2018]

1.7.3 For recommendations on shared decision-making in the last days of life, see the
NICE guideline on care of dying adults in the last days of life. [2018]

1.7.4 Review VTE prophylaxis daily for people who are having palliative care, taking
into account the views of the person, their family members or carers (as
appropriate) and the multidisciplinary team. [2018]

1.8 Interv
Interventions
entions for people admitted to critical care
1.8.1 Assess all people admitted to the critical care unit for risk of VTE and bleeding.
[2018]

1.8.2 Provide LMWH[ ] to people admitted to the critical care unit if pharmacological
4

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

VTE prophylaxis is not contraindicated. For people with renal impairment, see
recommendations 1.5.1 and 1.5.2. [2018]

1.8.3 Consider mechanical VTE prophylaxis for people admitted to the critical care
unit if pharmacological prophylaxis is contraindicated based on their condition
or procedure. [2018]

1.8.4 If using mechanical VTE prophylaxis for people admitted to the critical care unit,
start it on admission and continue until the person no longer has reduced
mobility relative to their normal or anticipated mobility. [2018]

1.8.5 Reassess VTE and bleeding risk daily for people in critical care units. [2018]

1.8.6 Assess VTE and bleeding risk more than once a day in people admitted to the
critical care unit if the person's condition is changing rapidly. [2018]

1.9 Interv
Interventions
entions for people with psy
psychiatric
chiatric illness
1.9.1 Assess all acute psychiatric patients to identify their risk of VTE and bleeding:

As soon as possible after admission to hospital or by the time of the first consultant
review

Using a tool published by a national UK body, professional network or peer-reviewed

journal. The most commonly used risk assessment tool for hospital patients is the
Department of Health VTE risk assessment tool[ ]. [2018] 1

1.9.2 Reassess all people admitted to an acute psychiatric ward for risk of VTE and
bleeding at the point of consultant review or if their clinical condition changes.
[2018]

1.9.3 Consider pharmacological VTE prophylaxis with LMWH[ ] for people admitted
4

to an acute psychiatric ward whose risk of VTE outweighs their risk of bleeding.
[2018]

1.9.4 Consider pharmacological VTE prophylaxis with fondaparinux sodium[ ] if 5

LMWH[ ] is contraindicated for people admitted to an acute psychiatric ward

4

whose risk of VTE outweighs their risk of bleeding. [2018]

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

1.9.5 Continue pharmacological VTE prophylaxis for people admitted to an acute

psychiatric ward until the person is no longer at increased risk of VTE. [2018]

1.10 Interv
Interventions
entions when using anaesthesia
1.10.1 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. [2010]

1.10.2 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. [2010]

1.10.3 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. [2010]

1.11 Interv
Interventions
entions for people ha
having
ving orthopaedic
surgery
Lower limb immobilisation
1.11.1 Consider pharmacological VTE prophylaxis with LMWH[ ] or fondaparinux4

sodium[ ] for people with lower limb immobilisation whose risk of VTE outweighs
5

their risk of bleeding. Consider stopping prophylaxis if lower limb

immobilisation continues beyond 42 days. [2018]

Fragility fr
fractures
actures of the pelvis, hip and pro
proximal
ximal femur
1.11.2 Offer VTE prophylaxis for a month to people with fragility fractures of the
pelvis, hip or proximal femur if the risk of VTE outweighs the risk of bleeding.
Choose either:

LMWH[ ], starting 6–12 hours after surgery or

4

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

fondaparinux sodium[ ], starting 6 hours after surgery, providing there is low risk of
5

bleeding. [2018]

1.11.3 Consider pre-operative VTE prophylaxis for people with fragility fractures of
the pelvis, hip or proximal femur if surgery is delayed beyond the day after
admission. Give the last dose no less than 12 hours before surgery for LMWH[ ] 4

or 24 hours before surgery for fondaparinux sodium[ ]. [2018] 5

1.11.4 Consider intermittent pneumatic compression for people with fragility fractures
of the pelvis, hip or proximal femur at the time of admission if pharmacological
prophylaxis is contraindicated. Continue until the person no longer has
significantly reduced mobility relative to their normal or anticipated mobility.
[2018]

Electiv
Electivee hip replacement
1.11.5 Offer VTE prophylaxis to people undergoing elective hip replacement surgery
whose risk of VTE outweighs their risk of bleeding. Choose any one of:

LMWH[ ] for 10 days followed by aspirin[ ] (75 or 150 mg) for a further 28 days.
4 6

LMWH[ ] for 28 days combined with anti-embolism stockings (until discharge).

4

Rivaroxaban[ ], within its marketing authorisation, is recommended as an option for the

7

prevention of venous thromboembolism in adults having elective total hip replacement

surgery or elective total knee replacement surgery. [This text is from rivaroxaban for
the prevention of venous thromboembolism after total hip or total knee replacement
in adults (NICE technology appraisal guidance 170).] [2018]

1.11.6 Consider one of the following if none of the options in recommendation 1.11.5
can be used:

Apixaban[ ] is recommended as an option for the prevention of venous

8

thromboembolism in adults after elective hip or knee replacement surgery. [This text is
from apixaban for the prevention of venous thromboembolism after total hip or knee
replacement in adults (NICE technology appraisal guidance 245).]

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Dabigatran etexilate[ ], within its marketing authorisation, is recommended as an

9

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. [This text is from dabigatran etexilate for the prevention of
venous thromboembolism after hip or knee replacement surgery in adults (NICE
technology appraisal guidance 157).] [2018]

1.11.7 Consider anti-embolism stockings until discharge from hospital if

pharmacological interventions are contraindicated in people undergoing
elective hip replacement surgery. [2018]

Electiv
Electivee knee replacement
1.11.8 Offer VTE prophylaxis to people undergoing elective knee replacement surgery
whose VTE risk outweighs their risk of bleeding. Choose any one of:

Aspirin[ ] (75 or 150 mg) for 14 days.

6

LMWH[ ] for 14 days combined with anti-embolism stockings until discharge.

4

Rivaroxaban[ ], within its marketing authorisation, is recommended as an option for the

7

prevention of venous thromboembolism in adults having elective total hip replacement

surgery or elective total knee replacement surgery. [This text is from rivaroxaban for
the prevention of venous thromboembolism after total hip or total knee replacement
in adults (NICE technology appraisal guidance 170).] [2018]

1.11.9 Consider one of the following if none of the options in recommendation 1.11.8
can be used:

Apixaban[ ] is recommended as an option for the prevention of venous

8

thromboembolism in adults after elective hip or knee replacement surgery. [This text is
from apixaban for the prevention of venous thromboembolism after total hip or knee
replacement in adults (NICE technology appraisal guidance 245).]

Dabigatran etexilate[ ], within its marketing authorisation, is recommended as an

9

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. [This text is from dabigatran etexilate for the prevention of
venous thromboembolism after hip or knee replacement surgery in adults (NICE
technology appraisal guidance 157).] [2018]

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
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1.11.10 Consider intermittent pneumatic compression if pharmacological prophylaxis is

contraindicated in people undergoing elective knee replacement surgery.
Continue until the person is mobile. [2018]

Non-arthroplasty orthopaedic knee surgery

1.11.11 Be aware that VTE prophylaxis is generally not needed for people undergoing
arthroscopic knee surgery where:

total anaesthesia time is less than 90 minutes and

the person is at low risk of VTE. [2018]

1.11.12 Consider LMWH[ ] 6–12 hours after surgery for 14 days for people undergoing
4

arthroscopic knee surgery if:

total anaesthesia time is more than 90 minutes or

the person's risk of VTE outweighs their risk of bleeding. [2018]

1.11.13 Consider VTE prophylaxis for people undergoing other knee surgery (for
example, osteotomy or fracture surgery) whose risk of VTE outweighs their risk
of bleeding. [2018]

Foot and ankle orthopaedic surgery

1.11.14 Consider pharmacological VTE prophylaxis for people undergoing foot or ankle
surgery:

that requires immobilisation (for example, arthrodesis or arthroplasty); consider

stopping prophylaxis if immobilisation continues beyond 42 days (see
recommendation 1.11.1) or

when total anaesthesia time is more than 90 minutes or

the person's risk of VTE outweighs their risk of bleeding. [2018]

Upper limb orthopaedic surgery

1.11.15 Be aware that VTE prophylaxis is generally not needed if giving local or regional
anaesthetic for upper limb surgery. [2018]

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
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1.11.16 Consider VTE prophylaxis for people undergoing upper limb surgery if the
person's total time under general anaesthetic is over 90 minutes or where their
operation is likely to make it difficult for them to mobilise. [2018]

1.12 Interv
Interventions
entions for people ha
having
ving electiv
electivee spinal
surgery or cr
cranial
anial surgery or people with spinal injury
Electiv
Electivee spinal surgery
1.12.1 Offer mechanical VTE prophylaxis on admission to people undergoing elective
spinal surgery. Choose either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue for 30 days or until the person is mobile or discharged, whichever is sooner.
[2018]

1.12.2 Consider adding pharmacological VTE prophylaxis with LMWH[ ] for people 4

undergoing elective spinal surgery whose risk of VTE outweighs their risk of
bleeding, taking into account individual patient and surgical factors (major or
complex surgery) and according to clinical judgement. [2018]

1.12.3 If using LMWH[ ] for people undergoing elective spinal surgery, start giving it
4

24–48 hours postoperatively according to clinical judgement, taking into

account patient characteristics and surgical procedure. Continue for 30 days or
until the person is mobile or discharged, whichever is sooner. [2018]

1.12.4 If needed, start LMWH[ ] earlier than 24 hours after the operation for people
4

undergoing elective spinal surgery. Base the decision on multidisciplinary or

senior opinion, or a locally agreed protocol. [2018]

Cr
Cranial
anial surgery
1.12.5 Consider mechanical VTE prophylaxis for people undergoing cranial surgery.
[2018]

1.12.6 If using mechanical VTE prophylaxis for people undergoing cranial surgery, start

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

it on admission. Choose either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue for 30 days or until the person is mobile or discharged, whichever is sooner.
[2018]

1.12.7 Consider adding pre-operative pharmacological VTE prophylaxis with LMWH[ ]. 4

Give the last dose no less than 24 hours before surgery for people undergoing
cranial surgery whose risk of VTE outweighs their risk of bleeding. [2018]

1.12.8 Consider adding pharmacological VTE prophylaxis with LMWH[ ], starting 4

24–48 hours after surgery for people undergoing cranial surgery whose risk of
VTE outweighs their risk of bleeding. Continue for a minimum of 7 days. [2018]

1.12.9 If needed, start LMWH[ ] earlier than 24 hours after the operation for people
4

undergoing cranial surgery. Base the decision on multidisciplinary or senior

opinion, or a locally agreed protocol. [2018]

1.12.10 Do not offer pharmacological VTE prophylaxis to people with ruptured cranial
vascular malformations (for example, brain aneurysms) or people with
intracranial haemorrhage (spontaneous or traumatic) until the lesion has been
secured or the condition has stabilised. [2018]

Spinal injury
1.12.11 Consider mechanical VTE prophylaxis on admission for people with spinal
injury. Choose either:

anti-embolism stockings (only in a specialist spinal injury unit and after

multidisciplinary team discussion) or

intermittent pneumatic compression. [2018, amended 2019]

1.12.12 Reassess risk of bleeding 24 hours after initial admission in people with spinal
injury. [2018]

1.12.13 Consider adding pharmacological VTE prophylaxis with LMWH[ ] 24 hours after 4

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
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initial admission for people with spinal injury who are not having surgery in the
next 24–48 hours, if the benefit of reducing the risk of VTE outweighs the risk of
bleeding. [2018]

1.12.14 Continue VTE prophylaxis in people with spinal injury for 30 days or until the
person is mobile or discharged, whichever is sooner. [2018]

1.13 Interv
Interventions
entions for people with major tr
trauma
auma
1.13.1 Offer mechanical VTE prophylaxis with intermittent pneumatic compression on
admission to people with serious or major trauma. Continue until the person no
longer has significantly reduced mobility relative to their normal or anticipated
mobility. [2018]

1.13.2 Reassess risk of VTE and bleeding in people with serious or major trauma
whenever their clinical condition changes and at least daily. [2018]

1.13.3 Consider pharmacological VTE prophylaxis for people with serious or major
trauma as soon as possible after the risk assessment when the risk of VTE
outweighs the risk of bleeding. Continue for a minimum of 7 days. [2018]

1.14 Interv
Interventions
entions for people ha
having
ving abdominal, thor
thoracic
acic
or head and neck surgery
Abdominal surgery
1.14.1 Offer VTE prophylaxis to people undergoing abdominal (gastrointestinal,
gynaecological, urological) surgery who are at increased risk of VTE. For people
undergoing bariatric surgery, follow recommendations 1.14.5–1.14.7. [2018]

1.14.2 Start mechanical VTE prophylaxis on admission for people undergoing

abdominal surgery. Choose either:

anti-embolism stockings or

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
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intermittent pneumatic compression.

Continue until the person no longer has significantly reduced mobility relative to their
normal or anticipated mobility. [2018]

1.14.3 Add pharmacological VTE prophylaxis for a minimum of 7 days for people
undergoing abdominal surgery whose risk of VTE outweighs their risk of
bleeding, taking into account individual patient factors and according to clinical
judgement. Choose either:

LMWH[ ]or4

fondaparinux sodium[ ]. [2018]

5

1.14.4 Consider extending pharmacological VTE prophylaxis to 28 days

postoperatively for people who have had major cancer surgery in the abdomen.
[2018]

Bariatric surgery
1.14.5 Offer VTE prophylaxis to people undergoing bariatric surgery. [2018]

1.14.6 Start mechanical VTE prophylaxis on admission for people undergoing bariatric
surgery. Choose either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue until the person no longer has significantly reduced mobility relative to their
normal or anticipated mobility. [2018]

1.14.7 Add pharmacological VTE prophylaxis for people undergoing bariatric surgery
for a minimum of 7 days for people whose risk of VTE outweighs their risk of
bleeding. Choose either:

LMWH[ ]or4

fondaparinux sodium[ ]. [2018]

5

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
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Thor
Thoracic
acic surgery
1.14.8 Consider VTE prophylaxis for people undergoing thoracic surgery who are at
increased risk of VTE. [2018]

1.14.9 Start mechanical VTE prophylaxis on admission for people undergoing thoracic
surgery. Choose either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue until the person no longer has significantly reduced mobility relative to their
normal or anticipated mobility. [2018]

1.14.10 Consider adding pharmacological VTE prophylaxis for people undergoing

thoracic surgery for a minimum of 7 days to people whose risk of VTE outweighs
their risk of bleeding:

Use LMWH[ ] as first-line treatment.

4

If LMWH[ ] is contraindicated, use fondaparinux sodium5. [2018]

4

Head and neck surgery

Or
Oral
al and maxillofacial surgery
1.14.11 Consider pharmacological VTE prophylaxis with LMWH[ ] for a minimum of
4

7 days for people undergoing oral or maxillofacial surgery whose risk of VTE
outweighs their risk of bleeding. [2018]

1.14.12 Consider mechanical VTE prophylaxis on admission for people undergoing oral
or maxillofacial surgery who are at increased risk of VTE and high risk of
bleeding. Choose either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue until the person no longer has significantly reduced mobility relative to their
normal or anticipated mobility. [2018]

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
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ENT surgery
1.14.13 Consider pharmacological VTE prophylaxis with LMWH[ ] for a minimum of
4

7 days for people undergoing ears, nose or throat (ENT) surgery whose risk of
VTE outweighs their risk of bleeding. [2018]

1.14.14 Consider mechanical VTE prophylaxis on admission for people undergoing ENT
surgery who are at increased risk of VTE and high risk of bleeding. Choose
either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue until the person no longer has significantly reduced mobility relative to their
normal or anticipated mobility. [2018]

1.15 Interv
Interventions
entions for people ha
having
ving cardiac or vascular
surgery
Cardiac surgery
1.15.1 Consider mechanical VTE prophylaxis on admission for people who are
undergoing cardiac surgery who are at increased risk of VTE. Choose either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue until the person no longer has significantly reduced mobility relative to their
normal or anticipated mobility. [2018]

1.15.2 Consider adding pharmacological VTE prophylaxis for a minimum of 7 days for
people who are undergoing cardiac surgery and are not having other
anticoagulation therapy:

Use LMWH[ ] as first-line treatment.

4

If LMWH[ ] is contraindicated, use fondaparinux sodium[ ]. [2018]

4 5

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
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Vascular surgery
Open vascular surgery or endo
endovascular
vascular aneurysm repair
1.15.3 Consider pharmacological VTE prophylaxis with LMWH[ ] for a minimum of
4

7 days for people who are undergoing open vascular surgery or major
endovascular procedures, including endovascular aneurysm repair whose risk of
VTE outweighs their risk of bleeding. [2018]

1.15.4 Consider mechanical VTE prophylaxis on admission for people who are
undergoing open vascular surgery or major endovascular procedures, including
endovascular aneurysm repair, if pharmacological prophylaxis is
contraindicated. Choose either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue until the person no longer has significantly reduced mobility relative to their
normal or anticipated mobility. [2018]

Lower limb amputation

1.15.5 Consider pharmacological VTE prophylaxis with LMWH[ ] for a minimum of
4

7 days for people who are undergoing lower limb amputation whose risk of VTE
outweighs their risk of bleeding. [2018]

1.15.6 Consider mechanical VTE prophylaxis with intermittent pneumatic compression

on the contralateral leg, on admission, for people who are undergoing lower
limb amputation and if pharmacological prophylaxis is contraindicated. [2018]

1.15.7 For people undergoing lower limb amputation, continue mechanical VTE
prophylaxis until the person no longer has significantly reduced mobility relative
to their anticipated mobility. [2018]

Varicose vvein
ein surgery
1.15.8 Be aware that VTE prophylaxis is generally not needed for people undergoing
varicose vein surgery where:

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total anaesthesia time is less than 90 minutes and

the person is at low risk of VTE. [2018]

1.15.9 Consider pharmacological VTE prophylaxis with LMWH[ ], starting 6–12 hours
4

after surgery and continuing for 7 days for people undergoing varicose vein
surgery if:

total anaesthesia time is more than 90 minutes or

the person's risk of VTE outweighs their risk of bleeding. [2018]

1.15.10 Consider mechanical VTE prophylaxis with anti-embolism stockings, on

admission, for people undergoing varicose vein surgery:

who are at increased risk of VTE and

if pharmacological prophylaxis is contraindicated. [2018]

1.15.11 If using anti-embolism stockings for people undergoing varicose vein surgery,
continue until the person no longer has significantly reduced mobility relative to
their normal or anticipated mobility. [2018]

1.16 Interv
Interventions
entions for pregnant women and women who
ga
gavve birth or had a miscarriage or termination of
pregnancy in the past 6 weeks
1.16.1 Consider LMWH[ ] for all women who are admitted to hospital or a midwife-led
4

unit if they are pregnant or gave birth, had a miscarriage or had a termination of
pregnancy in the past 6 weeks, and whose risk of VTE outweighs their risk of
bleeding. [2018]

1.16.2 Do not offer VTE prophylaxis to women admitted to hospital or a midwife-led

unit who are in active labour. [2018]

1.16.3 Stop pharmacological VTE prophylaxis when women are in labour. [2018]

1.16.4 If using LMWH[ ] in pregnant women, start it as soon as possible and within
4

14 hours of the risk assessment being completed and continue until the woman
is no longer at increased risk of VTE or until discharge from hospital or the

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
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midwife-led unit. [2018]

1.16.5 If using LMWH[ ] in women who gave birth or had a miscarriage or termination
4

of pregnancy, start 4–8 hours after the event unless contraindicated and
continue for a minimum of 7 days. [2018]

1.16.6 Consider combined prophylaxis with LMWH[ ] plus mechanical prophylaxis for
4

pregnant women or women who gave birth or had a miscarriage or termination

of pregnancy in the past 6 weeks and who are likely to be immobilised, or have
significantly reduced mobility relative to their normal or anticipated mobility for
3 or more days after surgery, including caesarean section:

Use intermittent pneumatic compression as first-line treatment.

If intermittent pneumatic compression is contraindicated, use anti-embolism

stockings.

Continue until the woman no longer has significantly reduced mobility relative to her
normal or anticipated mobility or until discharge from hospital. [2018]

Terms used in this guideline

Admission
Admission in the context of this guideline refers to admission as an inpatient, where a bed is
provided for 1 or more nights, or admission as a day patient, where a bed is provided for a
procedure including surgery or chemotherapy but not for an overnight stay.

Discharge
Discharge in the context of this guideline refers to discharge from hospital as an inpatient or after a
day procedure.

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 DVT 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,

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

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.

Lower limb immobilisation

Any clinical decision taken to manage the affected limb in a way that would prevent normal weight-
bearing status or use of that limb, or both.

Renal impairment
People with an estimated glomerular filtration rate (eGFR) of less than 30 ml/min/1.73 m2. For
more detailed information on renal impairment, see NICE's guideline on chronic kidney disease in
adults.

Significantly reduced mobility

People who are bed bound, unable to walk unaided or likely to spend a substantial proportion of
their day in bed or in a chair.

[1]
Reproduced with the permission of the Department of Health and Social Care under the Open
Government Licence.

[2]
Reproduced from: Royal College of Obstetricians and Gynaecologists. Reducing the risk of
venous thromboembolism during pregnancy and the puerperium. Green-top Guideline No. 37a.
London: RCOG, 2015, with the permission of the Royal College of Obstetricians and
Gynaecologists.

[3]
See Religion or belief: a practical guide for the NHS.

[4]
At the time of publication (March 2018), LMWH 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.

[5]
At the time of publication (March 2018), fondaparinux sodium did not have a UK marketing

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conditions#notice-of-rights). Last updated August 2019 of 43
Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

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.

[6]
At the time of publication (March 2018), aspirin did not have a UK marketing authorisation 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.

[7]
At the time of publication (March 2018), rivaroxaban 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.

[8]
At the time of publication (March 2018), apixaban 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.

[9]
At the time of publication (March 2018), dabigatran etexilate 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.

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

Putting this guideline into pr

practice
actice
NICE has produced tools and resources to help you put this guideline into practice.

Putting recommendations into practice can take time. How long may vary from guideline to
guideline, and depends on how much change in practice or services is needed. Implementing change
is most effective when aligned with local priorities.

Changes recommended for clinical practice that can be done quickly – like changes in prescribing
practice – should be shared quickly. This is because healthcare professionals should use guidelines
to guide their work – as is required by professional regulating bodies such as the General Medical
and Nursing and Midwifery Councils.

Changes should be implemented as soon as possible, unless there is a good reason for not doing so
(for example, if it would be better value for money if a package of recommendations were all
implemented at once).

Different organisations may need different approaches to implementation, depending on their size
and function. Sometimes individual practitioners may be able to respond to recommendations to
improve their practice more quickly than large organisations.

Here are some pointers to help organisations put NICE guidelines into practice:

1. Raise aawareness
wareness through routine communication channels, such as email or newsletters, regular
meetings, internal staff briefings and other communications with all relevant partner organisations.
Identify things staff can include in their own practice straight away.

2. Identify a lead with an interest in the topic to champion the guideline and motivate others to
support its use and make service changes, and to find out any significant issues locally.

3. Carry out a baseline assessment against the recommendations to find out whether there are
gaps in current service provision.

4. Think about what data yyou

ou need to measure impro
improvvement and plan how you will collect it. You
may want to work with other health and social care organisations and specialist groups to compare
current practice with the recommendations. This may also help identify local issues that will slow or
prevent implementation.

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

5. De
Devvelop an action plan
plan, with the steps needed to put the guideline into practice, and make sure it
is ready as soon as possible. Big, complex changes may take longer to implement, but some may be
quick and easy to do. An action plan will help in both cases.

6. For vvery
ery big changes include milestones and a business case, which will set out additional costs,
savings and possible areas for disinvestment. A small project group could develop the action plan.
The group might include the guideline champion, a senior organisational sponsor, staff involved in
the associated services, finance and information professionals.

7. Implement the action plan with oversight from the lead and the project group. Big projects may
also need project management support.

8. Re
Review
view and monitor how well the guideline is being implemented through the project group.
Share progress with those involved in making improvements, as well as relevant boards and local
partners.

NICE provides a comprehensive programme of support and resources to maximise uptake and use
of evidence and guidance. See our into practice pages for more information.

Also see Leng G, Moore V, Abraham S, editors (2014) Achieving high quality care – practical
experience from NICE. Chichester: Wiley.

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

Conte
Context
xt
Hospital-acquired venous thromboembolism (VTE), also known as hospital-acquired or hospital-
associated thrombosis (HAT), covers all VTE that occurs in hospital and within 90 days after a
hospital admission. It is a common and potentially preventable problem. VTE most frequently
occurs in the deep veins of the legs or pelvis (a deep vein thrombosis [DVT]). If it dislodges and
travels to the lungs, it is called a pulmonary embolism, which in some cases can be fatal.

Hospital-acquired VTE accounts for thousands of deaths annually in the NHS, and fatal pulmonary
embolism remains a common cause of in-hospital mortality. HAT accounts for 50–60% of all VTE
seen. In 2013–14, there were around 24,700 admissions for pulmonary embolism and 19,400 for
DVT in England. In 2013 in England and Wales, there were 2,191 deaths recorded as due to
pulmonary embolism and 2,816 due to DVT. Treatment of non-fatal symptomatic VTE and related
long-term morbidities is associated with a considerable cost to the health service.

People admitted to hospital or mental health units have varying risk factors for VTE. The spectrum
of VTE risk is broad, and understanding the scale of the problem has led to a paradigm shift in
preventing and managing VTE in the NHS. In particular, patients now undergo VTE risk assessment
as a routine event in all NHS care pathways. By July 2013, 96% of adult admissions to NHS-funded
acute care hospitals were risk assessed for VTE compared with less than 50% of patients in
July 2010.

VTE prophylaxis has been shown to reduce the incidence of DVT. It includes mechanical methods
(such as anti-embolism stockings and intermittent pneumatic compression devices), and
pharmacological treatments (such as heparin and other anticoagulant drugs).

This guideline is about reducing the risk of VTE in over 16s admitted to or treated as day
procedures in hospitals. It provides recommendations on the most clinically and cost-effective
measures to reduce the risk of VTE, while considering the potential risks of the various VTE
prophylaxis options and patient preferences. It highlights the importance of risk assessment for
VTE and for bleeding for all people being admitted and of clinical judgement in deciding on a
prophylaxis strategy for each person at risk.

The 2018 update takes into account newer evidence and newer therapies and has been made more
relevant for specific groups such as surgical sub-specialities, people with mental health conditions
and pregnant women.

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

More information
You can also see this guideline in the NICE Pathway on venous thromboembolism.
To find out what NICE has said on topics related to this guideline, see our web page on embolism
and thrombosis.
See also the guideline committee's discussion and the evidence reviews (in the full guideline),
and information about how the guideline was developed, including details of the committee.

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

Recommendations for research

The guideline committee has made the following recommendations for research. The committee's
full set of research recommendations is detailed in the full guideline.

1 Risk assessment
What is the accuracy of individual risk assessment tools in predicting the risk of venous
thromboembolism (VTE) and risk of bleeding in people admitted to hospital?

Wh
Whyy this is important
Risk assessment is a mandatory for all people admitted or having day procedures in hospital. Since
2010, the National VTE Risk Assessment Tool has been widely used in the NHS to assess a person's
risk of VTE. This tool has not been validated or tested against other tools to evaluate its diagnostic
accuracy or effectiveness at correctly identifying people at risk of VTE. There is concern that the
tool may not accurately identify those who are most likely to get VTE.

According to national figures, over 70% of medical patients in the UK have prophylaxis when the
national tool has been used, with some trusts offering prophylaxis to over 90% of medical patients.
Around 40% of medical patients have prophylaxis in largely US-based populations when other tools
are used (although this may partially relate to different indications for hospital admission). It is not
known if this means that the national tool identifies too many people or the other tools do not
identify enough. The potential impact of giving unnecessary prophylaxis is that people may be at
increased risk of bleeding and discomfort through repeated injections. There is also the potential
for reducing the cost of thromboprophylaxis by better defining 'at risk' populations, so that the
number of those given thromboprophylaxis is reduced.

2 Dose str
strategies
ategies for people who are obese
What is the clinical and cost effectiveness of weight-based dose-adjustment strategies of low-
molecular-weight heparin (LMWH) compared with fixed-dose strategies of LMWH for preventing
VTE in people who are very obese (BMI over 35) who are admitted to hospital or having day
procedures (including surgery and chemotherapy)?

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

Wh
Whyy this is important
Obesity is on the rise in England. The prevalence of obesity increased by 11% between 1993 and
2014 (15% in 1993 and 26% in 2014), which has resulted in more obese people being admitted to
hospital. Obesity may as much as double a person's risk of developing hospital-acquired VTE,
therefore most obese people will need prophylaxis. There is much uncertainty about what dose to
use and the clinical and cost effectiveness of using weight-based dose-adjustment versus fixed-
dose strategies. In current practice, a higher than usual dose is given but this may not be necessary,
especially if the person has obesity-related liver disease. Several studies have reported
effectiveness in terms of biological measures rather than clinical outcomes such as deep vein
thrombosis (DVT) and bleeding events. It is important that there is a clearer understanding of the
effects that different dose strategies can have in terms of clinical outcomes. This is because they
can directly influence the quality of life of obese people admitted to hospital and help inform
clinical decisions on patient care.

3 Direct or
oral
al anticoagulants for people with lower limb
immobilisation
What is the clinical and cost effectiveness of direct oral anticoagulants for preventing VTE in
people with lower limb immobilisation?

Wh
Whyy this is important
The Computerized registry of patients with venous thromboembolism (RIETE) study, a multicentre
prospective cohort study of 30,886 patients with acute VTE, estimated that 5.7% of VTE events
were associated with lower limb immobilisation for non-major orthopaedic surgery. Estimates of
DVT risk in people with lower limb immobilisation, based on meta-analyses of trials comparing
chemothromboprophylaxis with placebo, range between approximately 4% and 40%. Given that
lower limb immobilisation following trauma or non-major orthopaedic surgery is so common, the
consequent burden of disease from VTE from this cause in the whole population is very
considerable. For example, the annual incidence of ankle fracture is 187 per 100,000, translating to
over 120,000 incident fractures per year in the UK. If 10% of these fractures are complicated by
VTE, then we might expect approximately 12,000 events per year only related to immobilisation
following ankle trauma.

Despite this burden of ill-health, no randomised studies comparing modern anticoagulants that are
available in oral preparations (perhaps more suitable for outpatient treatments) with established
treatments such as LMWH or fondaparinux were identified in the evidence review. The committee

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

were unable to make a recommendation to consider oral anticoagulants for this patient group given
this lack of evidence.

4 Aspirin proph
prophylaxis
ylaxis for people with fr
fragility
agility fr
fractures
actures
of the pelvis, hip or pro
proximal
ximal femur
What is the clinical and cost effectiveness of aspirin alone versus other pharmacological and/or
mechanical prophylaxis strategies (alone or in combination) for people with fragility fractures of
the pelvis, hip or proximal femur?

Wh
Whyy this is important
Fragility fractures are the greatest burden of musculoskeletal disease in hospitals in the UK. There
are approximately 70,000 fragility hip fractures per year in England alone leading to 1.5 million bed
days being used each year, which equates with the continuous occupation of over 4,000 NHS beds.

Current evidence supports a recommendation for prophylaxis with LMWH or fondaparinux. Both
involve a subcutaneous injection for 28 days requiring either self-injection at home or a community
nurse attending to deliver the injection. Patient adherence to treatment may be improved with an
oral rather than injectable treatment.

A large but controversially reported trial suggests that aspirin may be at least as effective as
currently recommended treatments. However, because of methodological and reporting
limitations, the evidence for the effectiveness of aspirin alone is not clear. There is potentially a
large cost saving if aspirin is clinically effective because it is very inexpensive.

5 Dur
Duration
ation of proph
prophylaxis
ylaxis for electiv
electivee total hip
replacement surgery
What is the clinical and cost effectiveness of standard versus extended duration pharmacological
prophylaxis for preventing VTE in people undergoing elective total hip replacement surgery?

Wh
Whyy this is important
In 2015, there were 84,462 hip replacements in England, Wales and Northern Ireland. The current
recommended duration of prophylaxis is 28 days in the elective total hip replacement population.
This extended duration of prophylaxis is based on few, small and older trials. The quality of the
evidence supporting extended duration prophylaxis is very low. Modern pharmaceutical trials of

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

newer interventions use extended duration prophylaxis based on these historical data, with the
added incentive of more expensive prophylaxis strategies. There is a large potential cost saving if a
shorter duration of prophylaxis is as clinically effective, given the considerable cost of prophylaxis
and the number of people for whom it is prescribed.

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

Update information
August 2019: Recommendation 1.12.11 was amended to clarify when anti-embolism stockings can
be used for VTE prophylaxis for people with spinal injury.

March 2018: This guideline is an update of NICE guideline CG92 (published January 2010) and
replaces it.

New recommendations have been added on the risk assessment for venous thromboembolism
(VTE) and reducing the risk of VTE.

Recommendations are marked as [2018, amended 2019], [2018]

[2018], [2010, amended 2018] or
[2010]
[2010].
[2018, amended 2019] indicates that the evidence was reviewed in 2018, but changes were
made to the recommendation wording in 2019 that changed the meaning.
[2018] indicates that the evidence was reviewed and the recommendation was added, updated
or unchanged in 2018.
[2010, amended 2018] indicates that the evidence was reviewed in 2010, but changes were
made to the recommendation wording in 2018 that changed the meaning.
[2010] indicates that the evidence was reviewed in 2010.

Recommendations that ha
havve been changed
Amended recommendation wording ((change
change to meaning)
Recommendation in 2010 Recommendation in
Reason for change
guideline current guideline

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

1.3.2 Do not offer anti- 1.3.1 Do not offer anti-

embolism stockings to embolism stockings to
patients who have: people who have:

suspected or proven suspected or proven

peripheral arterial peripheral arterial
disease disease

peripheral arterial bypass peripheral arterial

grafting bypass grafting

peripheral neuropathy or peripheral neuropathy

other causes of sensory or other causes of
impairment sensory impairment

any local conditions in any local conditions in

which stockings may which anti-embolism
cause damage, for stockings may cause
example fragile 'tissue damage for example,
paper' skin, dermatitis, fragile 'tissue paper'
Minor edits to clarify meaning.
gangrene or recent skin skin, dermatitis,
graft gangrene or recent skin
graft
known allergy to material
of manufacture known allergy to
material of manufacture
cardiac failure
severe leg oedema
severe leg oedema or
pulmonary oedema from major limb deformity or
congestive heart failure unusual leg size or
shape preventing
unusual leg size or shape
correct fit.
major limb deformity
Use caution and clinical
preventing correct fit.
judgement when applying
Use caution and clinical anti-embolism stockings
judgement when applying over venous ulcers or
anti-embolism stockings wounds. [2010, amended
over venous ulcers or 2018]

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

wounds. [2010]

'Discontinue' was changed to 'stop'

for plain English purposes, and
1.3.9 Stop the use of anti-
1.3.9 Discontinue the use of 'patient' changed to 'person'.
embolism stockings if
anti-embolism stockings if The words 'foot impulse' and
there is marking, blistering
there is marking, blistering 'devices' were deleted from
or discolouration of the
or discolouration of the skin, recommendations because the
skin, particularly over the
particularly over the heels guideline committee noted that the
heels and bony
and bony prominences, or if term 'intermittent pneumatic
prominences, or if the
the patient experiences pain compression' covers both sleeves
person experiences pain or
or discomfort. If suitable, applied to the legs and garments
discomfort. If suitable,
offer a foot impulse or wrapped around the foot. The
offer intermittent
intermittent pneumatic options are considered equal in the
pneumatic compression as
compression device as an recommendations. The guideline
an alternative. [2010,
alternative. [2010] committee left it to clinicians to
amended 2018]
decide which were the most
suitable.

The words 'foot impulse' and

'devices' were deleted from
recommendations because the
1.3.12 Do not offer foot guideline committee noted that the
1.3.10 Do not offer
impulse or intermittent term 'intermittent pneumatic
intermittent pneumatic
pneumatic compression compression' covers both sleeves
compression to people
devices to patients with a applied to the legs and garments
with a known allergy to the
known allergy to the wrapped around the foot. The
material of manufacture.
material of manufacture. options are considered equal in the
[2010, amended 2018]
[2010] recommendations. The guideline
committee left it to clinicians to
decide which were the most
suitable.

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

1.3.13 Encourage patients

on the ward who have foot
impulse or intermittent
1.3.11 Advise the person
pneumatic compression
to wear their device for as
devices to use them for as Edited to simplify wording.
much time as possible.
much of the time as is
[2010, amended 2018]
possible and practical, both
when in bed and when
sitting in a chair. [2010]

'Stroke' was changed to 'acute

1.4.2 Do not offer anti- stroke' to make it clear the
1.4.2 Do not offer anti-
embolism stockings for recommendation is about someone
embolism stockings for VTE
VTE prophylaxis to people currently experiencing a stroke or
prophylaxis to patients who
who are admitted for acute having treatment for stroke, not
are admitted for stroke.
stroke. [2010, amended people receiving rehabilitation
[2010]
2018] treatments for stroke. 'Patients' was
changed to 'people'.

Minor changes since publication

December 2019: In recommendation 1.3.5 the British Standardsfor anti-embolism hosiery were
updated because BS 6612 and BS 7672 have been withdrawn.

April 2018: Cross-references to recommendations were corrected.

ISBN: 978-1-4731-2871-2

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or
pulmonary embolism (NG89)

Accreditation

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