Balancing VTE Risk against Early Post-Operative Bleeding Risks

Patients with haemorrhage due to traumatic brain injury (TBI) are at increased risk of developing VTE. However there is also a risk of progression of the haemorrhage which creates a dilemma in early post-injury period i.e. anticoagulant prophylaxis for VTE can increase the risk of haemorrhage thus potentially increasing the risk of further brain injury.

Typically, for patients who have experienced polytrauma and where there has been no haemorrhage, anticoagulant prophylaxis to prevent DVT is recommended.

Currently there is no proven research advantage with regard to either providing or withholding anticoagulant prophylaxis for VTE prevention in the 24 hours following TBI where there has been haemorrhage.

The risk/benefit ratio in treating VTE needs to account for:

  • Pre-existing bleeding potential (e.g. if history of pre-existing alcohol misuse, liver disease or coagulopathy).
  • Pre-existing cardiac, respiratory or haematological indications for long term anticoagulation.
  • Pre-existing medical conditions contributing to VTE risk (e.g. thrombophilia, neoplasia, autoimmune disorders).

Current NICE Guidelines recommend that for neurological patients in general:458919445-guidelines

  • “VTE prophylaxis should be offered to patients undergoing cranial or spinal surgery who are assessed to be at increased risk of VTE using one of anti embolism stockings, foot impulse devices or intermittent pneumatic compression devices until the patient no longer has significantly reduced mobility.”
  • “Consideration of pharmacological prophylaxis is recommended for patients who have a low risk of major bleeding, based on clinical assessment of individual patient factors and continuation recommended until the patient no longer has significantly reduced mobility (generally 5–7 days).”
  • “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.”

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