VTE prophylaxis after cancer surgery — OSCE prescribing station

The stem

Mrs Odeh is on day 0 after a laparoscopic anterior resection for rectal cancer. She had a general anaesthetic with a spinal, which was performed at 08:00 today. She is back on the ward at 16:00 and has no bleeding concerns. Prescribe her venous thromboembolism prophylaxis.

Patient details

Patient: Mrs Nadia Odeh, 66 years
Weight: 82 kg, body mass index 32
Allergies: None known
Haemoglobin: 118 g/L
Platelets: 245 ×10⁹/L
eGFR: 78 mL/min/1.73 m²
Risk factors: Active cancer, major pelvic surgery, age over 60, obesity

Drug chartTo write

Drug (generic name)	Dose	Route	How often / rate	Notes

Write the drug, dose, route and frequency, and sign every entry.

The examiner’s questions

Question 1Prescribe her VTE prophylaxis.Show the model answer

Drug (generic name)	Dose	Route	How often / rate	Notes
Enoxaparin	40 mg	Subcutaneous	Once daily at 18:00	Start this evening; continue for 28 days after surgery
Anti-embolism stockings or intermittent pneumatic compression	–	Both legs	Continuously	Until she is fully mobile

Any low-molecular-weight heparin in your local formulary is acceptable, at its prophylactic dose.

Question 2Why does she need 28 days of treatment?Show the model answer

Major abdominal or pelvic surgery for cancer carries a risk of clot that lasts weeks after discharge. NICE recommends extended prophylaxis for 28 days after such surgery. Teach her or a relative to give the injections, or arrange community nursing.

Question 3What would make you change the dose or hold it?Show the model answer

An eGFR below 30 needs a reduced dose, 20 mg of enoxaparin once daily, or unfractionated heparin. Very high body weight may need a higher dose by local protocol. Hold it for active bleeding, platelets below about 75 ×10⁹/L, or an uncontrolled bleeding risk, and use mechanical methods alone. Check stockings are not used if she has peripheral arterial disease or a leg ulcer.

Question 4She has an epidural catheter instead of a spinal. What timing rules apply?Show the model answer

Leave at least 12 hours after a prophylactic dose before the catheter is removed, and give the next dose no sooner than 4 hours after removal. Agree the plan with the anaesthetist.

After you answerThe teaching pointShow

Every surgical patient has a VTE risk assessment on admission and again within 24 hours, and whenever their condition changes. A prescription without a risk assessment is incomplete.

The patients are written for teaching and are not real. Doses are typical adult doses; always check the current formulary and your hospital’s guidelines before prescribing.