Extended Venous Thromboembolism (VTE) Prophylaxis for Surgical Patients undergoing Major Abdominal or Pelvic Surgery for Cancer - NHS Borders

NHS Borders drugs and therapeutics
NHS Borders

Objectives

To provide guidance on the requirement for extended venous thromboembolism (VTE) prophylaxis for surgical patients undergoing major abdominal or pelvic surgery for cancer in NHS Borders.

Scope

Advice for patients having major abdominal, colorectal or pelvic surgery for cancer only.

Audience

Prescribers and clinical teams working in the surgical wards at BGH. BGH pharmacists.

Prescribing considerations

Assessment of required VTE prophylaxis will be completed at the surgical pre-assessment clinic.

Patients admitted as emergencies with a diagnosis of colorectal cancer will have a plan for extended VTE prophylaxis included in “step down” information from ITU.

Patients with complex histories should be discussed with appropriate clinical specialities (e.g mechanical heart valves should be discussed with cardiology and patients with a heparin allergy should be discussed with haematology).

If VTE prophylaxis is withheld or there is deviation from this guidance, the reasons must be documented in the patient’s case notes.

Prescribing guidance for patients not taking anticoagulants

All patients having major abdominal or colorectal surgery for cancer should receive 28 days of prophylaxis dose of enoxaparin if eGFR >30ml/min.**, unless contraindicated

Prophylaxis doses of enoxaparin:

Weight (kg)

Dosage in eGFR ≥ 30ml/min/1.73m2 

<50kg

20mg ONCE daily

50-100kg

40mg ONCE daily

101-150kg

40mg TWICE daily

>150kg

60mg TWICE daily*

Weight (kg)

Dosage if eGFRl 15- 29 ml/min/1.73m2

<50kg

20mg ONCE daily

50-100kg

20mg ONCE daily

101 – 150kg

40mg ONCE daily

>150kg

40mg TWICE daily

Prescribing guidance for patients already prescribed anticoagulants

This advice applies to patients prescribed anticoagulants regularly including warfarin, rivaroxaban, apixaban, dabigatran, edoxaban, any treatment dose low molecular weight heparin

Regular oral anticoagulant drug therapy should restart after the recommended extended prophylaxis period.

Patients who have had their cancer completely excised (macroscopic RO resection, which should be documented in theatre notes) can be changed back to their oral anticoagulant at discharge if they are well. (RO: surgery successfully removed all macroscopically (visible) and all microscopically (tissue samples/margins)

For patients prescribed anticoagulants after recent (within 3 months) stroke, TIA or VTE consider the risks of complications and the risk of delaying cancer surgery. Discuss with surgical team and neurology team. Please note this is a high risk situation – seek advice from haematology.

Patients prescribed oral anticoagulants for the below indications are at increased risk of thrombosis and will require bridging with therapeutic doses of enoxaparin until their usual anticoagulant can be restarted. An anticoagulation plan will be made at the pre-assessment by the anaesthetist, haematology and cardiology teams.

Indications for anticoagulants which increase the risk of thrombosis for patients prescribed anticoagulants:

Indication for anticoagulant

High Risk for thrombosis:

Patients who meet the below criteria are at an increased risk of thrombosis and bridging needs to be considered. 

Venous thrombo- embolism (VTE)
  1. Patient has had VTE in the last three months 1

  2. Patient has previously had VTE whilst on therapeutic anticoagulation

  3. Patient has a target INR > 3.5

Patient with VTE event with underlying high risk medical condition e.g. myeloproliferative disorder

Atrial Fibrillation (AF)
  1. Patient has had stroke or TIA in the last three months1.

  2. Patient has had a previous stroke or TIA (at any time) and three or more of the following risk factors:
    • Hypertension
    • (>140/90 mmHg or on antihypertensives)
    • Age >75 years
    • Diabetes mellitus
    • Severe LV impairment2

Mechanical Heart Valve (MHV)

Discuss with cardiologist

 

Cerebral Vascular Accident or Transient Ischaemic Attack (CVA/TIA)
  1. Patient with/TIA in last 3 months

  2. Patients with previous stroke/TIA and 3 or more of the following:
    • Congestive cardiac failure
    • Hypertension (BP>140/90mmHg or on antihypertensive treatment)
    • Age >75 years
    • Diabetes mellitus

 

Prescribing guidance for patients already prescribed antiplatelets

Patients prescribed including aspirin, clopidogrel, ticagrelor or prasugrel:

Indication/ Clinical situation

Prescribing advice

On single antiplatelet therapy

Prescribe prophylactic dose of enoxaparin as per table 1.

Patients on dual antiplatelet therapy for stents

Discuss with cardiology

Patients prescribed clopidogrel 75mg daily

Changed to aspirin 75mg daily 10 days and then back to clopidogrel 75mg daily after extended treatment with enoxaparin is completed. Patients who cannot have aspirin have clopidogrel recommenced post operative and do NOT receive extended prophylaxis with enoxaparin.

Stroke patients

Avoid surgery within 3 months of event. Discuss with stroke team/neurology/surgical team to consider risk to patient from potentially delaying surgery.

Discharge letter

Requires plan for reintroduction of antiplatelets once post operative extended

 

 

Discharge VTE prophylaxis requirements

Patients should be taught to self-administer (or carer taught to administer), where possible.

Alternatively, ward nursing staff should confirm that community nurses can administer and then enoxaparin should be prescribed on a community prescription chart by ward medical staff on discharge from hospital.

On discharge from the BGH patients will receive a supply of enoxaparin to complete their treatment. This should be dispensed by BGH pharmacy. The ward will have a stock of over-labelled enoxaparin which may be used out of hours.

Editorial Information

Last reviewed: 01/05/2026

Next review date: 31/05/2029

Author(s): Harvey, K.

Version: v6.0

Co-Author(s): McKaig, R, Pal, K.

Approved By: NHS Borders Anticoagulation Committee

Reviewer name(s): Harvey, K.

References

Previous guideline

SPC for Inhixa

NHS Lothian anticoagulation guidelines