Page 15 - HPB Handbook - May 30 2022 (Flipbook) v2

Page 15 of 22

Except when contra-indicated, all patients should be prescribed heparin 5000 units sc to be given with premedication. Post
op, the patient should receive enoxaparin, 40 mg sc daily until discharge. The enoxaparin dose may be modified on account
of patient’s weight.

Discharge DVT Prophylaxis
It is a unit policy that all patients with confirmed malignant cases who have had major abdominal cancer surgery to
be anticoagulated for 28 days postop: the first portion in hospital on Enoxaparin, (or Heparin if indicated) and the
balance at home on oral Pradaxa, (Dabigatran). This means that most patients will require a discharge plan for receiving
Pradaxa at home at a normal dose of 220mg per day. This drug is paid for by the patient so please let the charge nurse or staff
know if there is a financial concern; there are free alternatives.

VTE Prophylaxis at DISCHARGE for Hepatobiliary Patients with dabigatran [Pradaxa]

Dabigatran Dabigatran
Parameter 150 mg ONCE daily 220 mg ONCE daily

Indication Major HPB surgery Major HPB surgery with malignancy
with malignancy

Creatinine Clearance Less than 30 mL/min 30 to 50 mL/min Greater than 50 mL/min

Age 75 years or older 74 years or younger

Severe risk of bleeding
Contraindications -active peptic ulcer disease
-extensive cerebral infarct within last 6
months
Strong P-glycoprotein inhibitors
-ketoconazole
Therapeutic anticoagulation
•warfarin
•LMWH
Antiplatelet Therapy Antiplatelet Therapy Acetylsalicylic acid
Caution Use Acetylsalicylic acid 81mg
®
81mg clopidogrel[Plavix ]
®
clopidogrel[Plavix ] prasugrel [Effient ]
®
prasugrel [Effient ] ticagrelor [Brilinta ]
®
®
ticagrelor [Brilinta ]
®

Patients on triple therapy (ASA + antiplatelet + dabigatran) will be
assessed on a case by case basis
P-glycoprotein inhibitors
[e.g. verapamil, quinidine,
amiodarone, itraconazole,
tacrolimus, cyclosporin,
ritonavir, saquinavir,
nelfinavir]
Patients with multiple risk factors for bleeds will be assessed on a case by case basis

Prescribe As 150 mg ONCE daily x ___ 220 mg ONCE daily x ___ days for VTE
days for VTE prophylaxis prophylaxis [until POD # 28]. No repeats.
[until POD # 28]. No
repeats.

Do NOT use Limited Use Code for Atrial Fibrillation.

Dose reduction to dabigatran 150 mg daily should be considered for the elderly, reduced renal function and multiple antiplatelet uses. See unit pharmacist for any dose
related questions. It should also be noted on the discharge summary that Pradaxa /Dabigatran should not be refilled so that the GPs are not automatically doing so.

Pulmonary Embolism
You will see more patients with pulmonary embolism in the surgical than the medical units.