Venous thromboembolism prevention resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Overview
VTE Prevention in Non Surgical Patients
Hospitalized Acutely Ill Medical Patients
Shown below is the indications and choices of VTE prophylaxis among acutely ill patients. If VTE prophylaxis is recommended, it should be administered for the period of immobilization or hospital stay. Do not extend the duration of the prophylaxis after the period of immobilization or hospital stay. If pharmacological anticoagulation is needed, the choice of the drug should be guided by the patient preference, readiness for compliance and the practicality of administering frequent doses.[1]
| What is the risk of thrombosis in the acutely ill patient? | |||||||||||||||||||||||
| High | Low | ||||||||||||||||||||||
| Is the patient bleeding or at high risk of bleeding? | No VTE prophylaxis | ||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||
| Mechanical VTE prophylaxis For the period of immobilization or hospital stay only Graduated compression stocking Intermittent pneumatic compression | Pharmacological VTE prophylaxis For the period of immobilization or hospital stay only LMWH Low dose UFH, BID Low dose UFH, TID Fondaparinux | ||||||||||||||||||||||
| Did the bleeding or bleeding risk subside AND the patient is still at increased risk of thrombosis? | |||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||
| Substitute mechanical prophylaxis by pharmacological prophylaxis | Continue mechanical prophylaxis | ||||||||||||||||||||||
Assessment of the Risk of VTE
Padua Prediction Score for VTE
Shown below is a table depicting Padua predictive score for VTE among hospitalized medical patients. The interpretation of the score is as follows:
- Score≥ 4: High risk for VTE
- Score< 4: Low risk for VTE[2]
| Variable | Score |
| Active cancer | 3 |
| Previous VTE | 3 |
| Decreased mobility | 3 |
| Thrombophilia | 3 |
| Previous trauma or surgery within that last month | 2 |
| Age≥ 70 | 1 |
| Heart and/or respiratory failure | 1 |
| Ischemic stroke or acute myocardial infarction | 1 |
| Acute rheumatologic disorder and/or acute infection | 1 |
| Obesity | 1 |
| Hormonal therapy | 1 |
IMPROVE Predictive Score
Shown below is a table depicting IMPROVE predictive score for VTE among hospitalized medical patients.[3]
IMPROVE Associative Score
Shown below is a table depicting IMPROVE associative score for VTE among hospitalized medical patients.[3]
IMPROVE Bleeding Risk Score
Shown below is a table depicting the IMPROVE risk score for bleeding among hospitalized medical patients . The scores can be interpreted as such:[4]
- Score ≥7: Elevated risk of bleeding
- Score <7: Not elevated risk of bleeding
| Variable | Score |
| Active gastric or duodenal ulcer | 4.5 |
| Prior bleeding within the last 3 months | 4 |
| Decreased platelet count (<50x109/L) | 4 |
| Age ≥ 85 years | 3.5 |
| Liver failure (INR>1.5) | 2.5 |
| Severe kidney failure (GFR< 30 mL/min/m2) | 2.5 |
| Admission to ICU or CCU | 2.5 |
| Central venous catheter | 2 |
| Rheumatic disease | 2 |
| Active malignancy | 2 |
| Age: 40-84 years | 1.5 |
| Male | 1 |
| Moderate kidney failure (GFR: 30-59 mL/min/m2) | 1 |
Critically Ill Hospitalized Patients
There is not a risk score for the subsequent occurrence of VTE amonf critically ill patients. Shown below is an algorithm depicting the choices for VTE prophylaxis among critically ill patients. Note that routine ultrasound screening for DVT is not recommended among critically ill patients. Do not extend the duration of the prophylaxis after the period of immobilization or hospital stay.[1]
| Is the critically ill patient bleeding or at risk for major bleeding? | |||||||||||||||||
| Yes | No | ||||||||||||||||
| Mechanical VTE prophylaxis Graduated compression stocking Intermittent pneumatic compression | Pharmacological VTE prophylaxis LMWH Low dose UFH | ||||||||||||||||
| Did the bleeding or bleeding risk subside? | |||||||||||||||||
| Yes | No | ||||||||||||||||
| Substitute mechanical prophylaxis by pharmacological prophylaxis | Continue mechanical prophylaxis | ||||||||||||||||
Cancer in Outpatient
Shown below is an algorithm depicting VTE prophylaxis among cancer patients. Note that, cancer patients with indwelling central venous catheters do not require VTE prophylaxis with neither LMWH, low dose unfractionated heparin or vitamin K antagonists.[1]
| ❑ Does the patient have a solid tumor AND ❑ Additional risk factors for VTE?
| |||||||||||||||
| Yes | No | ||||||||||||||
| Pharmacological VTE prophylaxis LMWH Low dose UFH | No VTE prophylaxis | ||||||||||||||
Chronically Immobilized Patients
No VTE prophylaxis is recommended in subjects who are chronically immobilized either at home or at a nursing home.[1]
Long Travel
Shown below is an algorithm for the indications od preventive measure for VTE among subjects undergoing a long travel.[1]
| Does the patient has any of the following that increase the risk of VTE? Prior VTE episode Recent trauma Recent surgery Active cancer Advanced age Immobility Severe obesity Estrogen intake Thrombophilia | |||||||||||||||||
| Yes | No | ||||||||||||||||
| Frequent ambulation Calf muscle exercise To sit in an aisle seat Graduated compression stockings below the knee (pressure: 15-30 mmHg) No pharmacological VTE prophylaxis | No preventive measures are required | ||||||||||||||||
Asymptomatic Thrombophilia
VTE prophylaxis is not recommended for subjects with asymptomatic thrombophilia. [1]
VTE Prevention in Non Orthopedic Patients
General and Abdominal-Pelvic Surgeries
Shown below is an algorithm depicting the indications and choices of VTE prophylaxis in patients undergoing general and abdominal-pelvic surgeries. Note that inferior vena cava filter is not recommended. In addition, surveillance compression ultrasound should not be done to screen for VTE.[5]
| Assess the risk of VTE | |||||||||||||||||||||||||||||||||||||||||||||||
| Very low <0.5% OR Rogers score <7 OR Caprini score=0 | Low ~ 1.5% OR Rogers score 7-10 OR Caprini score 1-2 | Moderate ~ 3% OR Rogers score >10 OR Caprini score 3-4 | High ~ 6% OR Caprini score ≥5 | ||||||||||||||||||||||||||||||||||||||||||||
| Early ambulation No mechanical VTE prophylaxis No pharmacological VTE prophylaxis | Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) | Is the patient at high risk of bleeding OR Will bleeding cause severe consequences? | Is the patient at high risk of bleeding Will bleeding cause severe consequences? | ||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | No | Yes | ||||||||||||||||||||||||||||||||||||||||||||
| LMWH OR Low dose UH OR Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) | Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) | Are LMWH or UH contraindicated? | Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) | ||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||
| Does the patient has cancer? | Low dose aspirin OR Fondaparinux OR Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) | ||||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||
| Pharmacological VTE prophylaxis LMWH OR Low dose UH PLUS Mechanical VTE prophylaxis
| Pharmacological VTE prophylaxis Extended treatment with LMWH for 4 weeks PLUS Mechanical VTE prophylaxis | ||||||||||||||||||||||||||||||||||||||||||||||
Cardiac Surgery
Thoracic Surgery
| Is the patient undergoing ANY of the following surgeries that are associated with a high risk of VTE? Pulmonary resection Pneumonectomy Extrapleural pneumonectomy Esophagectomy | |||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||
| Patient is at HIGH risk of VTE | Patient is at MODERATE risk for VTE | ||||||||||||||||||||||||||||||
| Is the patient at high risk for major bleeding? | Is the patient at moderate risk for major bleeding? | ||||||||||||||||||||||||||||||
| No | Yes | No | Yes | ||||||||||||||||||||||||||||
| Pharmacological VTE prophylaxis LDUH OR LMWH PLUS Mechanical VTE prophylaxis Elastic stocking Intermittent pneumatic compression | Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) Pharmacological VTE prophylaxis when the risk of bleeding subsides LDUH OR LMWH | LDUH OR LMWH OR Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) | Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) | ||||||||||||||||||||||||||||
VTE Prevention in Orthopedic Patients
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA; et al. (2012). "Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e195S–226S. doi:10.1378/chest.11-2296. PMC 3278052. PMID 22315261.
- ↑ Barbar S, Noventa F, Rossetto V, Ferrari A, Brandolin B, Perlati M; et al. (2010). "A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score". J Thromb Haemost. 8 (11): 2450–7. doi:10.1111/j.1538-7836.2010.04044.x. PMID 20738765.
- ↑ 3.0 3.1 Spyropoulos AC, Anderson FA, Fitzgerald G, Decousus H, Pini M, Chong BH; et al. (2011). "Predictive and associative models to identify hospitalized medical patients at risk for VTE". Chest. 140 (3): 706–14. doi:10.1378/chest.10-1944. PMID 21436241.
- ↑ Decousus H, Tapson VF, Bergmann JF, Chong BH, Froehlich JB, Kakkar AK; et al. (2011). "Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators". Chest. 139 (1): 69–79. doi:10.1378/chest.09-3081. PMID 20453069.
- ↑ Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA; et al. (2012). "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. 141 (2 Suppl): e227S–77S. doi:10.1378/chest.11-2297. PMC 3278061. PMID 22315263.