06. DVT : PE prophylaxis

General

  • Assess risk for hospital acquired VTE at time of admission, change in level of care, and discharge.
  • Educate patients about signs and symptoms of VTE, as well as VTE prophylaxis.
  • Ambulate patients early and frequently - set daily activity goals.
     

Medical (Non-Surgical) Patients

  • ICU patients: Unless contraindicated, most patients should receive pharmacologic prophylaxis.
  • Non-ICU patients: Several risk stratification models for hospital acquired VTE exist, including the Padua Score, the Improve Score, and the Geneva Score. Choose one to guide decision for VTE prophylaxis.
    • Pauda score ≥ 4 → 11% risk VTE without prophylaxis; pharmacologic VTE prophylaxis recommended (some recommend cut off of ≥3).
    • Improve score ≥ 3-4 → 7-11% risk of VTE; pharmacologic VTE prophylaxis recommended.
    • Geneva Score ≥ 3 → ~3.5% risk of VTE; pharmacologic VTE prophylaxis recommended.

Surgical Patients

  • VTE prophylaxis for surgical patients is based on baseline patient risk factors, surgical procedure, and bleeding risk.
  • Step 1: Caprini score - estimates patient and surgical risk of VTE.
  • Step 2: Estimate bleeding risk - No clear risk stratification model, but grossly estimated based on the following patient factors:
    • Bleeding as indication for surgery
    • Intracranial hemorrhage
    • Moderate or severe coagulopathy, including cirrhosis
    • Bleeding diathesis
    • Thrombocytopenia
  • Step 3: Follow algorithms summarized below

 

 

 

 

 

*Patients undergoing surgery for visceral cancer may warrant extended-duration prophylaxis (4 weeks).

Contraindications to Pharmacologic Prophylaxis

  • Scoring systems to predict bleeding risk have poor predictive value and have not been well validated in the context of hospital acquired VTE. 
  • The alternative to pharmacologic prophylaxis is mechanical prophylaxis with intermittent pneumatic compression.

 

Relative Contraindications

Absolute Contraindications

Mild/Moderate bleeding diathesis

Thrombocytopenia (50,000 - 100,000)

Coagulopathy

Active intracranial lesion (especially vascular lesions)

Proliferative retinopathy

Vascular access/biopsy sites inaccessible to hemostasis

Hypertensive emergency

ICH in last 12 months

Craniotomy in last 2 weeks

GI bleeding in last month

Active hemorrhage

Major bleeding diathesis

Active intracranial hemorrhage

Thrombocytopenia (< 50,000)

Thrombolytics within last 24 hours

Spinal or intracranial surgery in last 72 hours

Spinal cord injury or TBI with hematoma

 

Prophylaxis Regimens:

  • LMWH (enoxaparin) 40 mg SQ daily or 30 mg SQ BID
  • Unfractionated heparin (UFH) 5000 units SQ BID or  TID
    • Consider use of UFH instead of LMWH if renal insufficiency (eGFR < 30 mL/min) and/or obesity (BMI ≥40 kg/m2) due to dosing uncertainty. In obesity, consider BID dosing.
  • Special considerations
    • Orthopedic patients: THA, TKA, HFS require a minimum of 10-14 days post-op course of prophylaxis and often up to 35 days.
    • If UFH and LMWH contraindicated (i.e. HIT), discuss with anticoagulation pharmacy to select an alternate agent and see ACCP Guidelines for recommendations.

 

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Guyatt, GH et al. Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis 9th Ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141(2)(Suppl):7S–47S

Kallainen, JS et al. Venous thromboembolism prophylaxis. Institute for Clinical Systems Improvement (ICSI). 2012 Nov. 51 p. http://www.guideline.gov/content.aspx?id=39350

Lim, Wendy. Using low molecular weight heparin in special patient populations. J Thromb Thrombolysis 2010; 29:233–240.

Qaseem, A et al. Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2011;155:625-632.

Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in Nonorthopedic Surgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012;141(2):e227S-e277S.

Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in Orthopedic Surgery Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012;141(2):e278S-e325S.