Venous thromboembolism prevention resident survival guide
| Venous Thromboembolism Prevention Resident Survival Guide Microchapters |
|---|
| Non Surgical Patients |
| Non Orthopedic Patients |
| Orthopedic Patients |
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Overview
Venous thromboembolism (VTE) is a disease associated with morbidity and mortality; therefore, thromboprophylaxis is indicated among specific categories of patients at elevated risk for VTE. VTE prophylaxis can be either pharmacological through the administration of medications such as low molecular weight heparin (LMWH) or fondaparinux among others, or mechanical through intermittent pneumatic compression or elastic stockings. The decision to administer VTE prophylaxis, the duration, and the choice of prophylaxis depend on the reason for hospitalization such as medical illness, non orthopedic surgery, or orthopedic surgery, as well as on the estimated risks of subsequent VTE and bleeding.
VTE Prevention in Non Surgical Patients
Hospitalized Acutely Ill Medical Patients
Shown below is an algorithm depicting 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 the administration of frequent doses.[1]
Abbreviations: BID: bis in die (twice daily); LDUH: Low dose unfractionated heparin; LMWH: Low molecular weight heparin; TID: ter in die (three times daily); VTE: Venous thromboembolism
| 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 ❑ LDUH, BID ❑ LDUH, 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
The subsequent risk of VTE can be estimated by risk scores, such as PADUA risk score and IMPROVE risk score.
Padua Prediction Score for VTE
Calculation of the Padua Prediction Score
Shown below is a table depicting Padua predictive score for VTE among hospitalized medical patients.
| 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 |
Interpretation of the Padua Prediction Score
The interpretation of the score is as follows:
- Score≥ 4: High risk for VTE
- Score< 4: Low risk for VTE[2]
IMPROVE Predictive Score for VTE
Calculation of the IMPROVE Predictive Score
| Variable | Score[3] |
| Prior episode of VTE | 3 |
| Thrombophilia | 3 |
| Malignancy | 1 |
| Age more than 60 years | 1 |
Interpretation of the IMPROVE Predictive Score
| Score | Predicted VTE risk through 3 months[3] |
| 0 | 0.5% |
| 1 | 1.0% |
| 2 | 1.7% |
| 3 | 3.1% |
| 4 | 5.4% |
| 5-8 | 11% |
IMPROVE Associative Score for VTE
IMPROVE associative risk score assesses the risk of VTE among hospitalized medical patients. While the IMPROVE predictive score includes 4 independent risk factors for VTE which are present at admission, IMPROVE associative score includes 7 variables present either at admission or during hospitalization; however the timing of the presence of some of the factors compared to the onset of VTE is not available.[3]
Calculation of the IMPROVE Associative Score
| Variable | Score[3] |
| Prior episode of VTE | 3 |
| Thrombophilia | 2 |
| Paralysis of the lower extremity during the hospitalization | 2 |
| Current malignancy | 2 |
| Immobilization for at least 7 days | 1 |
| ICU or CCU admission | 1 |
| Age more than 60 years | 1 |
Interpretation of the IMPROVE Associative Score
| Score | Risk | Predicted VTE risk through 3 months (derivation study)[3] |
Predicted VTE risk through 3 months (validation study - VTE-VALOURR)[4] | ||
| 0 | Low | 0.4% | 0.5% | 0.7% | 0.20% |
| 1 | 0.6% | 0.8% | |||
| 2 | Moderate | 1.0% | 1.3% | 1.4% | 1.0% |
| 3 | 1.7% | 1.9% | |||
| 4 | High | 2.9% | 4.7% | 4.2% | 4.2% |
| 5-10 | 7.2% | 7% to 100% (exact rate not calculable) | |||
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:[5]
- 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 |
| Thrombocytopenia (<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 |
Hospitalized Critically Ill Patients
Shown below is an algorithm depicting the choices for VTE prophylaxis among critically ill patients. Note that there is not a risk score to estimate the risk subsequent occurrence of VTE among critically ill patients. In addition, routine compression ultrasound screening for DVT is not recommended among critically ill patients. Do not extend the duration of the VTE prophylaxis after the period of immobilization or hospital stay.[1]
Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VTE: Venous thromboembolism
| Is the critically ill patient bleeding or at risk for major bleeding? | |||||||||||||||||
| Yes | No | ||||||||||||||||
| Mechanical VTE prophylaxis | Pharmacological VTE prophylaxis | ||||||||||||||||
| 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 low molecular weight heparin, low dose unfractionated heparin or vitamin K antagonists.[1]
Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VTE: Venous thromboembolism
❑ Does the patient have a solid tumor AND ❑ Additional risk factors for VTE?
| |||||||||||||||
| Yes | No | ||||||||||||||
| Pharmacological VTE prophylaxis | ❑ No VTE prophylaxis | ||||||||||||||
Chronically Immobilized Patients
No VTE prophylaxis is recommended among subjects who are chronically immobilized either at home or at a nursing home.[1]
Long Travel
Shown below is an algorithm for the indications of preventive measure for VTE among subjects undergoing a long travel.[1]
| Yes | No | ||||||||||||||||
Recommend VTE preventive measures: ❑ Calf muscle exercise ❑ Frequent ambulation ❑ 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 among 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 among 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.[6]
Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; UH: unfractionated heparin; VTE: venous thromboembolism
| 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 OR Will bleeding cause severe consequences? | ||||||||||||||||||||||||||||||||||||||||||
| No | Yes | No | Yes | ||||||||||||||||||||||||||||||||||||||||||
| ❑ 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 have cancer? | ❑ Low dose aspirin OR ❑ Fondaparinux OR ❑ Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) | ||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||||
| Pharmacological VTE prophylaxis PLUS Mechanical VTE prophylaxis | Pharmacological VTE prophylaxis ❑ Extended treatment with LMWH for 4 weeks PLUS Mechanical VTE prophylaxis | ||||||||||||||||||||||||||||||||||||||||||||
Cardiac Surgery
Shown below is an algorithm depicting the indications and choices of VTE prophylaxis among patients undergoing cardiac surgery.[6]
Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VTE: venous thromboembolism
| Is the postoperative period prolonged by one or more non hemorrhagic surgical complications? | |||||||||||||||||
| Yes | No (Uncomplicated post-op period) | ||||||||||||||||
| Pharmacological VTE prophylaxis PLUS Mechanical VTE prophylaxis | Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) | ||||||||||||||||
Thoracic Surgery
Shown below is an algorithm depicting the indications and choices of VTE prophylaxis among patients undergoing thoracic surgery.[6]
Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VTE: venous thromboembolism
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 high risk for major bleeding? | ||||||||||||||||||||||||||||||
| No | Yes | No | Yes | ||||||||||||||||||||||||||||
| Pharmacological VTE prophylaxis PLUS Mechanical VTE prophylaxis | Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) Pharmacological VTE prophylaxis When the risk of bleeding subsides | Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) Pharmacological VTE prophylaxis When the risk of bleeding subsides | |||||||||||||||||||||||||||||
Craniotomy
There is no validated risk score for the occurrence of subsequent VTE or for bleeding, particularly intracranial hemorrhage among patients undergoing craniotomy. Since the risk for intracranial hemorrhage is the highest within the first 12 to 24 hours following craniotomy, pharmacological therapy should be delayed until the risk of bleeding subsides.
| Is the patient undergoing craniotomy for a malignancy? | |||||||||||||||
| Yes | No | ||||||||||||||
| Very high risk of VTE (≥ 10%) | High risk of VTE (~ 5%) | ||||||||||||||
| Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) PLUS Pharmacological VTE prophylaxis when the risk of bleeding subsides | Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) | ||||||||||||||
Spinal Surgery
| Is the patient undergoing spinal surgery for malignancy OR undergoing surgery with a combined anterior-posterior approach? | |||||||||||||||
| Yes | No | ||||||||||||||
| High risk for VTE | Low risk for VTE | ||||||||||||||
| Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) PLUS Pharmacological VTE prophylaxis when the risk of bleeding subsides | Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) | ||||||||||||||
Trauma
Shown below is an algorithm depicting the indications and choices of VTE prophylaxis among patients with major trauma. Major trauma include traumatic brain or spine injury. Note that inferior vena cava filter is not recommended. In addition, surveillance compression ultrasound should not be done to screen for VTE.[6]
Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VTE: venous thromboembolism
| No | Yes | ||||||||||||||
Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) PLUS Pharmacological VTE prophylaxis when the risk of bleeding subsides | |||||||||||||||
VTE Prevention in Orthopedic Patients
Major Orthopedic Surgery
Shown below is an algorithm depicting VTE prophylaxis in patients undergoing major orthopedic surgeries which include total hip arthroplasty, total knee arthroplasty and hip fracture surgery. Among patients who are not at elevated risk of bleeding, LMWH is the first line choice for VTE therapy. Among patients who refuse LMWH injection or intermittent pneumatic compression device, apixaban or dabigatran can be administered. Do not consider inferior vena cava filter as VTE prophylaxis or screening with a compression ultrasound for VTE.[7]
Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VKA: Vitamin K antagonist; VTE: venous thromboembolism
| What is the risk of bleeding of the patient undergoing the major orthopedic surgery? | |||||||||||||||||||||
| High | Low | ||||||||||||||||||||
| ❑ Intermittent pneumatic compression | What is the type of the orthopedic surgery? | ||||||||||||||||||||
| Total hip arthroplasty OR Total knee arthroplasty | Hip fracture surgery | ||||||||||||||||||||
Pharmacological VTE prophylaxis
❑ LMWH (first line) ❑ Fondaparinux ❑ Apixaban ❑ Dabigatran ❑ Rivaroxaban ❑ LDUH ❑ VKA ❑ Aspirin AND/OR Intermittent pneumatic compression device | Pharmacological VTE prophylaxis
❑ LMWH (first line) ❑ Fondaparinux ❑ LDUH ❑ VKA ❑ Aspirin AND/OR Intermittent pneumatic compression device | ||||||||||||||||||||
Assessment of Bleeding in Major Orthopedic Surgeries
There is no score to estimate the risk of bleeding in major orthopedic surgeries. However, some factors have been identified to increase the risk of bleeding in this category of patients. These factors include:[7]
- Prior major bleeding
- Severe kidney failure
- Concomitant administration of an antiplatelet
- Bleeding during the current surgery which was difficult to control
- Extensive surgical dissection
- Revision surgery
Isolated Lower-Leg Injuries
VTE prophylaxis is not recommended among patients who have isolated lower leg injuries distal to the knee.[7]
Knee Arthroscopy
VTE prophylaxis is not recommended among patients who undergo knee arthroscopy and who have no previous VTE episodes.[7]
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 3.2 3.3 3.4 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.
- ↑ Mahan CE, Liu Y, Turpie AG, Vu JT, Heddle N, Cook RJ; et al. (2014). "External validation of a risk assessment model for venous thromboembolism in the hospitalised acutely-ill medical patient (VTE-VALOURR)". Thromb Haemost. 112 (4): 692–9. doi:10.1160/TH14-03-0239. PMID 24990708.
- ↑ 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.
- ↑ 6.0 6.1 6.2 6.3 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.
- ↑ 7.0 7.1 7.2 7.3 Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S; et al. (2012). "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. 141 (2 Suppl): e278S–325S. doi:10.1378/chest.11-2404. PMC 3278063. PMID 22315265.