Venous thromboembolism prophylaxis — Viva

Viva Stems

1. How do you stratify this patient's VTE risk, and what prophylaxis does major abdominal cancer surgery warrant? Major cancer surgery is very-high risk: plan pharmacological prophylaxis plus IPC with early mobilisation, and extended prophylaxis for at least 28 days — a five-study review (2936 patients) found extended LMWH and DOAC courses each reduced VTE versus no extended course with no major-bleeding difference.^[2]

2. How do you time the epidural insertion and removal around prophylactic LMWH? At trough effect for both — insertion and removal are equal-risk moments. Confirm the drug, dose intensity and renal function against the current ASRA table; never improvise intervals.^[1]

3. The patient develops new back pain and leg weakness on day one with the epidural in situ. What do you do? Treat as spinal epidural haematoma until proven otherwise: stop the anticoagulant pathway carefully, arrange urgent MRI, call the spine team. The window to prevent permanent paraplegia is hours.^[1]

4. When would you choose mechanical prophylaxis alone? Active bleeding, severe thrombocytopenia, coagulopathy, recent intracranial or spinal bleed — bridge with IPC and convert to pharmacological once safe.^[1]

5. What is the commonest systems error with epidural catheters and LMWH? A routine prophylactic dose given too soon after catheter removal. Write the last dose, removal time and next dose on the chart so a short interval looks visibly wrong.^[1]