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Low Risk | No VTE risk factors, or ambulatory pt w/ expected LOS ≤2 days, or undergoing minor/same-day surg (<45min OR time)
Use nonpharmacologic VTE prophylaxis, document ambulation for low-risk1 pt - Use graduated compression stockings, TED hose, or pneumatic/BL sequential compression devices
- Document ambulation q shift
- Reassess VTE risk level routinely, upon transfer, & pre-discharge
Footnotes 1 Low-risk: ambulatory pt w/ expected LOS ≤2 days or pt undergoing minor/same-day surg (<45min OR time), or pt w/ none of these VTE risk factors:
• Pt features: age >40, BMI >30, hospitalized for surg/acute illness, immobility (confined to bed/chair), central venous catheter
• Hx: hx DVT or PE, family hx DVT or PE (1st-deg relative), hx ischemic stroke w/ paresis, hx recent major surg (≤3mo)
• CV: MI (<3mo), CHF (NYHA Class III or IV), venous stasis/varicose veins
• Pulm: lung dz (acute or chronic)
• Renal: dehydration (>10% body wt), nephrotic syndrome
• GI: inflammatory bowel dz
• ID: sepsis
• Rheum: rheumatic dz (active)
• Heme/Onc: hypercoagulable state, sickle cell dz, malignancy (active), myeloproliferative disorder
• Gyn: pregnant or postpartum (<1mo), estrogen-based tx (OCP, HRT)
Prevention of Venous Thromboembolism: 7th ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S.
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Intermed-to-High Risk → Very High Risk | Any VTE risk factor(s): excludes ambulatory pts w/ expected LOS ≤2 days & pts undergoing minor/same-day surg (<45min OR time)
Intermed-to-High Risk | none of: acute ischemic stroke, acute spinal cord injury, multiple major trauma, abdominal/pelvic surgery for CA, orthopedic pt (elective hip/knee arthroplasty, or fx hip/pelvis/severe leg) Use pharmacologic VTE prophylaxis, barring contraindications, for intermed-to-high1 risk pt - Assess absolute contraindications to pharmacologic tx (spine surg; active hemorrhage; or w/in past mo hemorrhage d/t severe head/spinal cord trauma) & relative2 contraindications
- If pharmacologic prophylaxis contraindicated, use mechanical (graduated compression stockings/TED hose or pneumatic/BL sequential compression device) & document ambulation q shift
Start/continue pharmacologic options: - Enoxaparin 40 mg SQ q24h
- Heparin: 5000 units SQ q8h or 7500 units SQ q12h; or if >75 yo, use 5000 units SQ q12h
- Fondaparinux 2.5 mg SQ q24h
- Any therapeutic anticoagulation
Reassess VTE risk level & contraindications: routinely, upon transfer, & pre-discharge Footnotes 1 Intermed-to-high risk: pt w/ any of these VTE risk factors (excludes ambulatory pt w/ expected LOS ≤2 days or pt undergoing minor/same-day surg <45min OR time):
• Pt features: age >40, BMI >30, hospitalized for surg/acute illness, immobility (confined to bed/chair), central venous catheter
• Hx: hx DVT or PE, family hx DVT or PE (1st-deg relative), hx ischemic stroke w/ paresis, hx recent major surg (≤3mo)
• CV: MI (<3mo), CHF (NYHA Class III or IV), venous stasis/varicose veins
• Pulm: lung dz (acute or chronic)
• Renal: dehydration (>10% body wt), nephrotic syndrome
• GI: inflammatory bowel dz
• ID: sepsis
• Rheum: rheumatic dz (active)
• Heme/Onc: hypercoagulable state, sickle cell dz, malignancy (active), myeloproliferative disorder
• Gyn: pregnant or postpartum (<1mo), estrogen-based tx (OCP, HRT)
2 Relative contraindications to pharmacologic VTE prophylaxis
• Intracranial hemorrhage w/in 1y
• GI hemorrhage w/in 1mo
• GU hemorrhage w/in 1mo
• Craniotomy w/in 2wk
• Intraocular surg w/in 2wk
• Epidural catheter: insertion w/in 12h or removal w/in 4h
• Post-op bleeding concerns
• Intracranial lesion/neoplasm (active)
• Hypertensive urgency/emergency
• Thrombocytopenia (plts <50 K/mcL) or falling plt count
• Coagulopathy (INR >2 or PT >18)
• End-stage liver dz
Very High Risk | any of: acute ischemic stroke, acute spinal cord injury, multiple major trauma, abdominal/pelvic surgery for CA, orthopedic pt (elective hip/knee arthroplasty, or fx hip/pelvis/severe leg) Combine mechanical + pharmacologic VTE prophylaxis (barring contraindications) for very high risk1 pt - Assess absolute contraindications to pharmacologic tx (spine surg; active hemorrhage; or w/in past mo hemorrhage d/t severe head/spinal cord trauma) & relative2 contraindications
- Use mechanical prophylaxis (graduated compression stockings/TED hose or pneumatic/BL sequential compression device) & document ambulation q shift
Combine mechanical w/ pharmacologic options: - Enoxaparin: 40 mg SQ q24h or 30 mg SQ bid
- Fondaparinux 2.5 mg SQ q24h
- Warfarin w/ INR >2, or any therapeutic anticoagulation
Reassess VTE risk level & contraindications: routinely, upon transfer, & pre-discharge Footnotes 1 Very high risk: pt w/ any of these (excludes ambulatory pt w/ expected LOS ≤2 days or pt undergoing minor/same-day surg <45 min OR time):
• Acute ischemic stroke
• Acute spinal cord injury
• Multiple major trauma
• Abdominal or pelvic surgery for CA
• Orthopedic pts: elective hip or knee arthroplasty; hip, pelvis, or severe leg fracture
2 Relative contraindications to pharmacologic VTE prophylaxis
• Intracranial hemorrhage w/in 1y
• GI hemorrhage w/in 1mo
• GU hemorrhage w/in 1mo
• Craniotomy w/in 2wk
• Intraocular surg w/in 2wk
• Epidural catheter: insertion w/in 12h or removal w/in 4h
• Post-op bleeding concerns
• Intracranial lesion/neoplasm (active)
• Hypertensive urgency/emergency
• Thrombocytopenia (plts <50 K/mcL) or falling plt count
• Coagulopathy (INR >2 or PT >18)
• End-stage liver dz
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