What are the key steps in the VTE prophylaxis care pathway?
- Assess level of mobility, VTE and bleeding risk
- Balance risks of VTE and bleeding and prescribe as appropriate
- Reassess within 24 hours and when clinical situation changes
List some patient specific risk factors for VTE
- Active cancer
- Age >60
- Dehydration
- Thrombophillia
- 1 or more medical co-morbidities
- HRT or OCP
- Pregnancy /
List some admission specific risk factors for VTE
- Large decrease in mobility >3 days
- Time for anaesthetic and surgery >90 minutes
- Surgery of pelvis or lower limb
- THR / TKR
- Hip fracture
- Critical care admission
List some patient specific risk factors for bleeding
- Active bleeding
- Acquired bleeding disorder (liver disease)
- Anticoagulant use
- Thrombocytopenia
- Inherited bleeding disorders
List some admission specific risk factors for bleeding
- Neuro / eye/ spinal surgery
- Procedure associated with increased bleeding risk
- Lumbar puncture / epidural
- Spinal anaesthetic 4 hours prior or expected in the next 12 hours
What are the two main types of VTE prophylaxis?
- Mechanical (Anti-embolism stockings or IPC)
- Pharmacological (LMWH or unfractionated heparin for severe renal impairment)
What general precautions can be taken to avoid VTE?
- Patient education
- Avoid dehydration (unless clinically indicated)
- Encourage patients to mobilise ASAP
What can be considered to prevent VTE in patients in whom mechanical and pharmacological prophylaxis in contraindicated?
IVC filter - prevents emboli from clots in the legs travelling to the lungs and causing PE.
What 4 factors determine whether a patient receives prophylactic antibiotics?
- Patient’s risk of surgical site infection
- Potential severity of the consequences of an SSI in the patient
- Likely effectiveness of prophylaxis in the individual circumstances
- Potential consequences of antibiotic use for the patient (E.g. C. Dif risk)
By what route are prophylactic antibiotics usually given ?
Are there any specific exceptions?
IV administration.
Some special surgeries have specific routes E.g. eyes
When should prophylactic antibiotics be administered?
Within 60 minutes prior to skin incision. A single, standard, therapeutic dose is usually sufficient.
List some patient specific risk factors for surgical site infection
- Extremes of age
- Poor nutritional state
- Obesity
- Diabetes mellitus
- Smoking
- Co- existing infection elsewhere
- Bacterial colonisation
- Immunosuppression
- Prolonged post op stay
List some operation specific risk factors
- Length of surgical scrub
- Pre-operative shaving
- Skin antisepsis
- Length of operation
- Antimicrobial prophylaxis status
- Surgical drains left in situ
- Post operative hypothermia
What type of antibiotic would be used for prophylaxis in high risk surgery MRSA patients?
Glycopeptide
Are there any surgical complications where a second dose of prophylactic antibiotics would need to be administered?
Major intraoperative blood loss - consider additional prophylaxis after fluid replacement
