Venous thromboembolism prevention resident survival guide: Difference between revisions

Venous Thromboembolism Prevention Resident Survival Guide Microchapters
Non Surgical Patients
Non Orthopedic Patients
Orthopedic Patients

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Latest revision as of 18:10, 9 November 2014

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

❑ Graduated compression stocking
❑ Intermittent pneumatic compression

Pharmacological VTE prophylaxis

❑ LMWH
❑ LDUH

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?

❑ Previous VTE

❑ Hormonal therapy

❑ Immobilization

❑ Angiogenesis inhibitors

❑ Thalidomide

❑ Lenalidomide

Yes

No

Pharmacological VTE prophylaxis

❑ LMWH
❑ LDUH

❑ 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]

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

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?

No

Yes

No

Yes

❑ LMWH
OR
❑ LDUH
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 have cancer?

❑ Low dose aspirin
OR
❑ Fondaparinux
OR
❑ Mechanical VTE prophylaxis
(Intermittent pneumatic compression is preferred)

No

Yes

Pharmacological VTE prophylaxis

❑ LMWH
OR
❑ LDUH

PLUS
Mechanical VTE prophylaxis

❑ Elastic stockings

❑ Intermittent pneumatic compression

Pharmacological VTE prophylaxis
❑ Extended treatment with LMWH for 4 weeks
PLUS
Mechanical VTE prophylaxis

❑ Elastic stockings

❑ Intermittent pneumatic compression

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

❑ LDUH
OR
❑ LMWH

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?

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)

Pharmacological VTE prophylaxis
When the risk of bleeding subsides

❑ LDUH
OR
❑ LMWH

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

Does the patient who has a major trauma have any contraindications for LDUH or LMWH?

No

Yes

Pharmacological VTE prophylaxis
❑ LDUH
OR
❑ LMWH

PLUS

Mechanical VTE prophylaxis
(Intermittent pneumatic compression is preferred)

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

Begin at least 12 hours before and 12 hours after the surgery

Administer for at least 14 days

Extend the therapy to 35 days as outpatient

Choose ONE of the following:
❑ LMWH (first line)
❑ Fondaparinux
❑ Apixaban
❑ Dabigatran
❑ Rivaroxaban
❑ LDUH
❑ VKA
❑ Aspirin

AND/OR

Intermittent pneumatic compression device

Pharmacological VTE prophylaxis

Begin at least 12 hours before and 12 hours after the surgery

Administer for at least 14 days

Extend the therapy to 35 days as outpatient

Choose ONE of the following:
❑ 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.

[pmid22315261-1] 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.

[pmid20738765-2] 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.

[pmid21436241-3] 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.

[pmid24990708-4] 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.

[pmid20453069-5] 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.

[pmid22315263-6] 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.

[pmid22315265-7] 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.

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@@ Line 1: / Line 1: @@
+<div style="width: 80%;">
 __NOTOC__
-{{CMG}}; {{AE}} {{Rim}}
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+! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Venous Thromboembolism Prevention Resident Survival Guide Microchapters}}
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Venous thromboembolism prevention resident survival guide#VTE Prevention in Non Surgical Patients|Non Surgical Patients]]
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Venous thromboembolism prevention resident survival guide#VTE Prevention in Non Orthopedic Patients|Non Orthopedic Patients]]
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Venous thromboembolism prevention resident survival guide#VTE Prevention in Orthopedic Patients|Orthopedic Patients]]
+|}
+'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; {{AE}} {{Rim}}
 ==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 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.<ref name="pmid22315261">{{cite journal| author=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al.| title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e195S-226S | pmid=22315261 | doi=10.1378/chest.11-2296 | pmc=PMC3278052 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315261  }} </ref>
+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.<ref name="pmid22315261">{{cite journal| author=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al.| title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e195S-226S | pmid=22315261 | doi=10.1378/chest.11-2296 | pmc=PMC3278052 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315261  }} </ref>
+<span style="font-size:85%"> '''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 </span>
 {{Family tree/start}}
-{{familytree  | | | | | | A01 | | | A01= What is the risk of thrombosis in the acutely ill patient?}}
+{{familytree  | | | | | | A01 | | | A01= '''[[Venous thromboembolism prevention resident survival guide#Assessment of the Risk of VTE|What is the risk of thrombosis in the acutely ill patient?]]'''}}
 {{familytree  | | | | |,|-|^|-|.| | | }}
 {{familytree  | | | | B01 | | B02 | B01= High| B02= Low}}
 {{familytree  | | | | |!| | | |!| | }}
-{{familytree  | | | | C01 | | C02 | C01= Is the patient bleeding or at high risk of bleeding?| C02= No VTE prophylaxis }}
+{{familytree  | | | | C01 | | C02 | C01= '''[[Venous thromboembolism prevention resident survival guide#IMPROVE Bleeding Risk Score|Is the patient bleeding or at high risk of bleeding?]]'''| C02= No VTE prophylaxis }}
 {{familytree  | | |,|-|^|-|.| | }}
 {{familytree  | | D01 | | D02 | D01= Yes| D02= No}}
 {{familytree  | | |!| | | |!| | }}
-{{familytree  | | E01 | | E02 | E01= '''Mechanical VTE prophylaxis''' <br> '''''For the period of immobilization or hospital stay only'''''<br> Graduated compression stocking <br> Intermittent pneumatic compression| E02= '''Pharmacological VTE prophylaxis'''<br> '''''For the period of immobilization or hospital stay only'''''<br> LMWH <br> Low dose UFH, BID <br> Low dose UFH, TID <br> Fondaparinux}}
+{{familytree  | | E01 | | E02 | E01= '''Mechanical VTE prophylaxis''' <br><div style="float: left; text-align: left; padding:1em;"> '''''For the period of immobilization or hospital stay only'''''<br> ❑ [[Graduated compression stocking]] <br> ❑ [[Intermittent pneumatic compression]]</div>| E02= '''Pharmacological VTE prophylaxis'''<br> <div style="float: left; text-align: left; padding:1em;">'''''For the period of immobilization or hospital stay only'''''<br> ❑ [[LMWH]] <br> ❑ [[LDUH]], BID <br> ❑ [[LDUH]], TID <br> ❑ [[Fondaparinux]] </div>}}
 {{familytree  | | |!| | | | | | }}
-{{familytree  | | F01 | | | | | F01= Did the bleeding or bleeding risk subside<br> AND <br>the patient is still at increased risk of thrombosis?}}
+{{familytree  | | F01 | | | | | F01= '''Did the bleeding or [[bleeding]] risk subside'''<br> AND <br>'''the patient is still at increased risk of [[thrombosis]]?'''}}
 {{familytree  | |,|^|-|-|-|.| | }}
 {{familytree  | G01 | | G02 | G01= Yes| G02= No}}
 {{familytree  | |!| | | |!| | }}
-{{familytree  | H01 | | H02 | H01= Substitute mechanical prophylaxis by pharmacological prophylaxis| H02= Continue mechanical prophylaxis}}
+{{familytree  | H01 | | H02 | H01= ❑ Substitute mechanical prophylaxis by pharmacological prophylaxis| H02=❑ Continue mechanical prophylaxis}}
 {{Family tree/end}}
-====Assessment of the Risk of VTE====
+===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====
-Shown below is a table depicting Padua predictive score for VTE among hospitalized medical patients.  The interpretation of the score is as follows:
+=====Calculation of the Padua Prediction Score=====
+Shown below is a table depicting Padua predictive score for VTE among hospitalized medical patients.
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
+|-
+| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Variable'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Score'''
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Active [[cancer]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 3
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Previous [[VTE]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |3
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Decreased mobility||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |3
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Thrombophilia]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |3
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Previous trauma or surgery within that last month||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |2
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Age≥ 70||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Heart failure|Heart]] and/or [[respiratory failure]]||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Ischemic stroke]] or [[acute myocardial infarction]]||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Acute rheumatologic disorder and/or acute infection||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Obesity]]||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Hormonal therapy]]||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |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'''<ref name="pmid20738765">{{cite journal| author=Barbar S, Noventa F, Rossetto V, Ferrari A, Brandolin B, Perlati M et al.| title=A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. | journal=J Thromb Haemost | year= 2010 | volume= 8 | issue= 11 | pages= 2450-7 | pmid=20738765 | doi=10.1111/j.1538-7836.2010.04044.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20738765  }} </ref>
-{|
-| Variable || Score
+====IMPROVE Predictive Score for VTE====
+=====Calculation of the IMPROVE Predictive Score=====
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
 |-
-| Active cancer || 3
+| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Variable'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Score'''<ref name="pmid21436241">{{cite journal| author=Spyropoulos AC, Anderson FA, Fitzgerald G, Decousus H, Pini M, Chong BH et al.| title=Predictive and associative models to identify hospitalized medical patients at risk for VTE. | journal=Chest | year= 2011 | volume= 140 | issue= 3 | pages= 706-14 | pmid=21436241 | doi=10.1378/chest.10-1944 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21436241  }} </ref>
 |-
-| Previous VTE|| 3
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Prior episode of [[VTE]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 3
 |-
-| Decreased mobility||3
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Thrombophilia]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |3
 |-
-| Thrombophilia|| 3
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Malignancy]]||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1
 |-
-| Previous trauma or surgery within that last month||2
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Age more than 60 years|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1
+|}
+=====Interpretation of the IMPROVE Predictive Score=====
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
+|-
+| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Score'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Predicted VTE risk through 3 months'''<ref name="pmid21436241">{{cite journal| author=Spyropoulos AC, Anderson FA, Fitzgerald G, Decousus H, Pini M, Chong BH et al.| title=Predictive and associative models to identify hospitalized medical patients at risk for VTE. | journal=Chest | year= 2011 | volume= 140 | issue= 3 | pages= 706-14 | pmid=21436241 | doi=10.1378/chest.10-1944 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21436241  }} </ref>
 |-
-| Age≥ 70||1
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 0|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |0.5%
 |-
-| Heart and/or respiratory failure||1
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1.0%
 |-
-| Ischemic stroke or acute myocardial infarction||1
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |2||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1.7%
 |-
-| Acute rheumatologic disorder and/or acute infection||1
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |3|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |3.1%
 |-
-| Obesity||1
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |4|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |5.4%
 |-
-| Hormonal therapy||1
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |5-8|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |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.<ref name="pmid21436241">{{cite journal| author=Spyropoulos AC, Anderson FA, Fitzgerald G, Decousus H, Pini M, Chong BH et al.| title=Predictive and associative models to identify hospitalized medical patients at risk for VTE. | journal=Chest | year= 2011 | volume= 140 | issue= 3 | pages= 706-14 | pmid=21436241 | doi=10.1378/chest.10-1944 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21436241  }} </ref>
-====IMPROVE Predictive Score====
+=====Calculation of the IMPROVE Associative Score=====
-Shown below is a table depicting IMPROVE predictive score for VTE among hospitalized medical patients.<ref name="pmid21436241">{{cite journal| author=Spyropoulos AC, Anderson FA, Fitzgerald G, Decousus H, Pini M, Chong BH et al.| title=Predictive and associative models to identify hospitalized medical patients at risk for VTE. | journal=Chest | year= 2011 | volume= 140 | issue= 3 | pages= 706-14 | pmid=21436241 | doi=10.1378/chest.10-1944 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21436241  }} </ref>
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
+|-
+| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Variable'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Score'''<ref name="pmid21436241">{{cite journal| author=Spyropoulos AC, Anderson FA, Fitzgerald G, Decousus H, Pini M, Chong BH et al.| title=Predictive and associative models to identify hospitalized medical patients at risk for VTE. | journal=Chest | year= 2011 | volume= 140 | issue= 3 | pages= 706-14 | pmid=21436241 | doi=10.1378/chest.10-1944 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21436241  }} </ref>
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Prior episode of [[VTE]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 3
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Thrombophilia]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |2
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Paralysis of the lower extremity during the hospitalization||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |2
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Current [[malignancy]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |2
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Immobilization for at least 7 days|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[ICU]] or [[CCU]] admission|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Age more than 60 years|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1
+|}
-====IMPROVE Associative Score====
+=====Interpretation of the IMPROVE Associative Score=====
-Shown below is a table depicting IMPROVE associative score for VTE among hospitalized medical patients.<ref name="pmid21436241">{{cite journal| author=Spyropoulos AC, Anderson FA, Fitzgerald G, Decousus H, Pini M, Chong BH et al.| title=Predictive and associative models to identify hospitalized medical patients at risk for VTE. | journal=Chest | year= 2011 | volume= 140 | issue= 3 | pages= 706-14 | pmid=21436241 | doi=10.1378/chest.10-1944 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21436241  }} </ref>
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
+|-
+| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Score'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Risk''' ||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center  colspan="2" | '''Predicted VTE risk through 3 months<br/>(derivation study)'''<ref name="pmid21436241">{{cite journal| author=Spyropoulos AC, Anderson FA, Fitzgerald G, Decousus H, Pini M, Chong BH et al.| title=Predictive and associative models to identify hospitalized medical patients at risk for VTE. | journal=Chest | year= 2011 | volume= 140 | issue= 3 | pages= 706-14 | pmid=21436241 | doi=10.1378/chest.10-1944 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21436241  }} </ref> ||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center colspan="2"| '''Predicted VTE risk through 3 months<br/>(validation study - VTE-VALOURR)'''<ref name="pmid24990708">{{cite journal| author=Mahan CE, Liu Y, Turpie AG, Vu JT, Heddle N, Cook RJ et al.| title=External validation of a risk assessment model for venous thromboembolism in the hospitalised acutely-ill medical patient (VTE-VALOURR). | journal=Thromb Haemost | year= 2014 | volume= 112 | issue= 4 | pages= 692-9 | pmid=24990708 | doi=10.1160/TH14-03-0239 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24990708  }} </ref>
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 0|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center rowspan="2"|Low ||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center |0.4%||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center rowspan="2"|0.5%|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center |0.7%||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center rowspan="2"|0.20%
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center |0.6%|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center |0.8%
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |2||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center rowspan="2"|Moderate||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center |1.0%|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center rowspan="2"|1.3%|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center|1.4%||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center rowspan="2"|1.0%
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |3|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center |1.7%|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center |1.9%
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |4|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center rowspan="2"|High|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center |2.9%||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center rowspan="2"|4.7%||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center |4.2%||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center rowspan="2"|4.2%
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |5-10|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center |7.2%|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=center |7% to 100%<br/>(exact rate not calculable)
+|}
-====IMPROVE Bleeding Risk Score====
+===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:<ref name="pmid20453069">{{cite journal| author=Decousus H, Tapson VF, Bergmann JF, Chong BH, Froehlich JB, Kakkar AK et al.| title=Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. | journal=Chest | year= 2011 | volume= 139 | issue= 1 | pages= 69-79 | pmid=20453069 | doi=10.1378/chest.09-3081 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20453069  }} </ref>
+Shown below is a table depicting the IMPROVE risk score for bleeding among hospitalized medical patients.  The scores can be interpreted as such:<ref name="pmid20453069">{{cite journal| author=Decousus H, Tapson VF, Bergmann JF, Chong BH, Froehlich JB, Kakkar AK et al.| title=Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. | journal=Chest | year= 2011 | volume= 139 | issue= 1 | pages= 69-79 | pmid=20453069 | doi=10.1378/chest.09-3081 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20453069  }} </ref>
 * '''Score ≥7: Elevated risk of bleeding'''
 * '''Score <7: Not elevated risk of bleeding'''
-{|
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
-| Variable || Score
 |-
-| Active gastric or duodenal ulcer || 4.5
+| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Variable'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Score'''
 |-
-| Prior bleeding within the last 3 months|| 4
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Active [[gastric ulcer|gastric]] or [[duodenal ulcer]] || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |4.5
 |-
-| Decreased platelet count (<50x10<sup>9</sup>/L)||4
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Prior [[bleeding]] within the last 3 months|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |4
 |-
-| Age ≥ 85 years||3.5
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Thrombocytopenia]] (<50x10<sup>9</sup>/L)||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |4
 |-
-| Liver failure (INR>1.5)||2.5
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Age ≥ 85 years||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |3.5
 |-
-| Severe kidney failure (GFR< 30 mL/min/m<sup>2</sup>)||2.5
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Liver failure]] ([[INR]]>1.5)||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |2.5
 |-
-| Admission to [[ICU]] or [[CCU]]||2.5
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Kidney failure|Severe kidney failure]] ([[GFR]]< 30 mL/min/m<sup>2</sup>)||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |2.5
 |-
-| Central venous catheter||2
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Admission to [[ICU]] or [[CCU]]||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |2.5
 |-
-| Rheumatic disease||2
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Central venous catheter]]||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |2
 |-
-| Active malignancy||2
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Rheumatic disease||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |2
 |-
-| Age: 40-84 years|| 1.5
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Active [[malignancy]]||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |2
 |-
-| Male||1
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Age: 40-84 years|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1.5
 |-
-| Moderate kidney failure (GFR: 30-59 mL/min/m<sup>2</sup>)||1
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Male||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Kidney failure|Moderate kidney failure]] ([[GFR]]: 30-59 mL/min/m<sup>2</sup>)||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |1
 |}
-===Critically Ill Hospitalized Patients===
+===Hospitalized Critically Ill 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.<ref name="pmid22315261">{{cite journal| author=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al.| title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e195S-226S | pmid=22315261 | doi=10.1378/chest.11-2296 | pmc=PMC3278052 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315261  }} </ref>
+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.<ref name="pmid22315261">{{cite journal| author=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al.| title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e195S-226S | pmid=22315261 | doi=10.1378/chest.11-2296 | pmc=PMC3278052 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315261  }} </ref>
+<span style="font-size:85%"> '''Abbreviations:''' '''LDUH:''' low dose [[unfractionated heparin]]; '''LMWH:''' low molecular weight heparin; '''VTE:''' Venous thromboembolism </span>
 {{Family tree/start}}
-{{familytree  | | | | A01 | | | A01= Is the critically ill patient bleeding or at risk for major bleeding?}}
+{{familytree  | | | | A01 | | | A01= '''Is the critically ill patient bleeding or at risk for major bleeding?'''}}
 {{familytree  | | |,|-|^|-|.| | }}
 {{familytree  | | B01 | | B02 | B01= Yes| B02= No}}
 {{familytree  | | |!| | | |!| | }}
-{{familytree  | | C01 | | C02 | C01= '''Mechanical VTE prophylaxis''' <br>Graduated compression stocking <br> Intermittent pneumatic compression| C02= '''Pharmacological VTE prophylaxis'''<br> LMWH <br> Low dose UFH}}
+{{familytree  | | C01 | | C02 | C01= '''Mechanical VTE prophylaxis''' <br><div style="float: left; text-align: left; padding:1em;">❑ [[Graduated compression stocking]] <br> ❑ [[Intermittent pneumatic compression]]</div>| C02= '''Pharmacological VTE prophylaxis'''<br><div style="float: left; text-align: left; padding:1em;"> ❑ [[LMWH]] <br> ❑  [[LDUH]]</div>}}
 {{familytree  | | |!| | | | | | }}
-{{familytree  | | F01 | | | | | F01= Did the bleeding or bleeding risk subside?}}
+{{familytree  | | F01 | | | | | F01= '''Did the [[bleeding]] or [[bleeding risk]] subside?'''}}
 {{familytree  | |,|^|-|-|-|.| | }}
 {{familytree  | G01 | | G02 | G01= Yes| G02= No}}
 {{familytree  | |!| | | |!| | }}
-{{familytree  | H01 | | H02 | H01= Substitute mechanical prophylaxis by pharmacological prophylaxis| H02= Continue mechanical prophylaxis}}
+{{familytree  | H01 | | H02 | H01= ❑ Substitute mechanical prophylaxis by pharmacological prophylaxis| H02= ❑ Continue mechanical prophylaxis}}
 {{Family tree/end}}
 ===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.<ref name="pmid22315261">{{cite journal| author=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al.| title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e195S-226S | pmid=22315261 | doi=10.1378/chest.11-2296 | pmc=PMC3278052 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315261  }} </ref>
+Shown below is an algorithm depicting VTE prophylaxis among [[cancer]] patients.  Note that, cancer patients with indwelling [[central venous catheter]]s do not require VTE prophylaxis with neither [[low molecular weight heparin]], low dose [[unfractionated heparin]] or [[vitamin K antagonist]]s.<ref name="pmid22315261">{{cite journal| author=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al.| title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e195S-226S | pmid=22315261 | doi=10.1378/chest.11-2296 | pmc=PMC3278052 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315261  }} </ref>
+<span style="font-size:85%"> '''Abbreviations:''' '''LDUH:''' low dose [[unfractionated heparin]]; '''LMWH:''' low molecular weight heparin; '''VTE:''' Venous thromboembolism </span>
 {{Family tree/start}}
-{{familytree  | | | A01 | | | A01= ❑ Does the patient have a solid tumor <br> AND <br> ❑ Additional risk factors for VTE?
+{{familytree  | | | A01 | | | A01= <div style="float: left; text-align: left; padding:1em;">❑ '''Does the patient have a [[solid tumor]]''' <br> '''AND''' <br> ❑ '''Additional risk factors for [[VTE]]?'''
 :❑ Previous [[VTE]]
-:❑ Hormonal therapy
+:❑ [[Hormonal therapy]]
 :❑ Immobilization
-:❑ Angiogenesis inhibitors
+:❑ [[Angiogenesis inhibitor]]s
-:❑ Thalidomide
+:❑ [[Thalidomide]]
-:❑ Lenalidomide}}
+:❑ [[Lenalidomide]] </div>}}
 {{familytree  | |,|-|^|-|.| | }}
 {{familytree  | B01 | | B02 | | B01= Yes| B02= No}}
 {{familytree  | |!| | | |!| | }}
-{{familytree  | C01 | | C02 | | C01= '''Pharmacological VTE prophylaxis''' <br> LMWH <br>Low dose UFH| C02= No VTE prophylaxis}}
+{{familytree  | C01 | | C02 | | C01= '''Pharmacological VTE prophylaxis''' <br> <div style="float: left; text-align: left; padding:1em;">❑ [[LMWH]]<br>❑ [[LDUH]] </div>| C02= ❑ No VTE prophylaxis}}
 {{Family tree/end}}
 ===Chronically Immobilized Patients===
-No VTE prophylaxis is recommended in subjects who are chronically immobilized either at home or at a nursing home.<ref name="pmid22315261">{{cite journal| author=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al.| title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e195S-226S | pmid=22315261 | doi=10.1378/chest.11-2296 | pmc=PMC3278052 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315261  }} </ref>
+No VTE prophylaxis is recommended among subjects who are chronically immobilized either at home or at a nursing home.<ref name="pmid22315261">{{cite journal| author=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al.| title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e195S-226S | pmid=22315261 | doi=10.1378/chest.11-2296 | pmc=PMC3278052 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315261  }} </ref>
 ===Long Travel===
-Shown below is an algorithm for the indications od preventive measure for VTE among subjects undergoing a long travel.<ref name="pmid22315261">{{cite journal| author=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al.| title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e195S-226S | pmid=22315261 | doi=10.1378/chest.11-2296 | pmc=PMC3278052 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315261  }} </ref>
+Shown below is an algorithm for the indications of preventive measure for VTE among subjects undergoing a long travel.<ref name="pmid22315261">{{cite journal| author=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al.| title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e195S-226S | pmid=22315261 | doi=10.1378/chest.11-2296 | pmc=PMC3278052 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315261  }} </ref>
 {{Family tree/start}}
-{{familytree  | | | A01 | | | | A01= '''Does the patient has any of the following that increase the risk of VTE?''' <br> Prior [[VTE]] episode <br> Recent [[trauma]] <br> Recent [[surgery]] <br> Active [[cancer]] <br> Advanced age <br> Immobility<br> Severe [[obesity]] <br> [[Estrogen]] intake<br> [[Thrombophilia]]}}
+{{familytree  | | | A01 | | | | A01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Does the patient has any of the following that increase the risk of VTE?''' <br> ❑ Prior [[VTE]] episode <br>❑ Recent [[trauma]] <br> ❑ Recent [[surgery]] <br> ❑ Active [[cancer]] <br> ❑ Advanced age <br> ❑ Immobility<br> ❑ Severe [[obesity]] <br> ❑ [[Estrogen]] intake<br> ❑ [[Thrombophilia]] </div>}}
 {{familytree  | |,|-|^|-|.| | | }}
 {{familytree  | B01 | | B02 | | B01= Yes| B02= No}}
 {{familytree  | |!| | | |!| | | }}
-{{familytree  | C01 | | C02 | | C01= Frequent ambulation <br> Calf muscle exercise <br> To sit in an aisle seat <br> Graduated compression stockings below the knee (pressure: 15-30 mmHg)<br> No pharmacological VTE prophylaxis| C02= No preventive measures are required}}
+{{familytree  | C01 | | C02 | | C01= <div style="float: left; text-align: left; width: 15em; padding:1em;">Recommend VTE preventive measures:<br>❑ Calf muscle exercise <br> ❑ Frequent ambulation <br> ❑ To sit in an aisle seat <br> ❑ [[Graduated compression stockings]] below the knee (pressure: 15-30 mmHg)<br> ❑ No pharmacological VTE prophylaxis</div>| C02= ❑ No preventive measures are required}}
 {{Family tree/end}}
 ===Asymptomatic Thrombophilia===
-VTE prophylaxis is not recommended for subjects with asymptomatic thrombophilia.
+VTE prophylaxis is not recommended among subjects with asymptomatic [[thrombophilia]].<ref name="pmid22315261">{{cite journal| author=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al.| title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e195S-226S | pmid=22315261 | doi=10.1378/chest.11-2296 | pmc=PMC3278052 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315261  }} </ref>
-<ref name="pmid22315261">{{cite journal| author=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al.| title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e195S-226S | pmid=22315261 | doi=10.1378/chest.11-2296 | pmc=PMC3278052 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315261  }} </ref>
 ==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.<ref name="pmid22315263">{{cite journal| author=Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA et al.| title=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. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e227S-77S | pmid=22315263 | doi=10.1378/chest.11-2297 | pmc=PMC3278061 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315263  }} </ref>
+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.<ref name="pmid22315263">{{cite journal| author=Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA et al.| title=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. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e227S-77S | pmid=22315263 | doi=10.1378/chest.11-2297 | pmc=PMC3278061 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315263  }} </ref>
+<span style="font-size:85%"> '''Abbreviations:''' '''LDUH:''' low dose [[unfractionated heparin]]; '''LMWH:''' [[low molecular weight heparin]]; '''UH:''' [[unfractionated heparin]]; '''VTE:''' [[venous thromboembolism]] </span>
 {{Family tree/start}}
-{{familytree  | | | | | | | | | | A01 | | | | | | | | | A01= '''Assess the risk of VTE'''}}
+{{familytree  | | | | | | | | | A01 | | | | | | | | | A01= '''Assess the risk of VTE'''}}
-{{familytree  | |,|-|-|-|v|-|-|-|-|+|-|-|-|-|-|-|-|.| | }}
+{{familytree  | |,|-|-|-|v|-|-|-|+|-|-|-|-|-|-|-|.| | }}
-{{familytree  | B01 | | B02 | | | B03 | | | | | | B04 | | B01= '''Very low''' <br> <0.5% <br> OR <br> Rogers score <7 <br> OR <br> Caprini score=0| B02= '''Low''' <br> ~ 1.5% <br> OR <br> Rogers score 7-10<br> OR <br> Caprini score 1-2| B03= '''Moderate''' <br> ~ 3% <br> OR <br> Rogers score >10 <br> OR <br> Caprini score 3-4| B04= '''High''' <br> ~ 6% <br> OR <br> Caprini score ≥5}}
+{{familytree  | B01 | | B02 | | B03 | | | | | | B04 | | B01= '''Very low''' <br> <0.5% <br> OR <br> [[Rogers score]] <7 <br> OR <br> [[Caprini score]]=0| B02= '''Low''' <br> ~ 1.5% <br> OR <br> [[Rogers score]] 7-10<br> OR <br> [[Caprini score]] 1-2| B03= '''Moderate''' <br> ~ 3% <br> OR <br> [[Rogers score]] >10 <br> OR <br> [[Caprini score]] 3-4| B04= '''High''' <br> ~ 6% <br> OR <br> [[Caprini score]] ≥5}}
 {{familytree  | |!| | | |!| | | | |!| | | | | | | |!| | | }}
-{{familytree  | C01 | | C02 | | | C03 | | | | | | C04 | | | | C01= Early ambulation <br> No mechanical VTE prophylaxis <br> No pharmacological VTE prophylaxis| C02= Mechanical VTE prophylaxis <br> (Intermittent pneumatic compression is preferred)| C03= Is the patient at high risk of bleeding <br> OR <br>Will bleeding cause severe consequences?| C04=Is the patient at high risk of bleeding <br>Will bleeding cause severe consequences?}}
+{{familytree  | C01 | | C02 | | C03 | | | | | | C04 | | | | C01= <div style="float: left; text-align: left; width: 15em; padding:1em;">❑ Early ambulation <br> ❑ No mechanical VTE prophylaxis <br> ❑ No pharmacological VTE prophylaxis </div>| C02= <div style="float: left; text-align: left; width: 15em; padding:1em;">❑ Mechanical VTE prophylaxis <br> ([[Intermittent pneumatic compression]] is preferred)</div>| C03= Is the patient at high risk of [[bleeding]] <br> OR <br>Will bleeding cause severe consequences?| C04=Is the patient at high risk of bleeding <br>OR <br> Will bleeding cause severe consequences?}}
-{{familytree  | | | | | | | | |,|-|^|-|.| | | |,|-|^|-|.| | | }}
+{{familytree  | | | | | | | |,|-|^|-|.| | | |,|-|^|-|.| | | }}
-{{familytree  | | | | | | | | D01 | | D02 | | D03 | | D04 | | D01= No| D02= Yes| D03= No| D04= Yes}}
+{{familytree  | | | | | | | D01 | | D02 | | D03 | | D04 | | D01= No| D02= Yes| D03= No| D04= Yes}}
-{{familytree  | | | | | | | | |!| | | |!| | | |!| | | |!| | | }}
+{{familytree  | | | | | | | |!| | | |!| | | |!| | | |!| | | }}
-{{familytree  | | | | | | | | E01 | | E02 | | E03 | | E04 | | E01= LMWH <br> OR <br> Low dose UH <br> OR <br> Mechanical VTE prophylaxis <br> (Intermittent pneumatic compression is preferred)| E02= Mechanical VTE prophylaxis <br> (Intermittent pneumatic compression is preferred)| E03= Are LMWH or UH contraindicated?| E04= Mechanical VTE prophylaxis <br> (Intermittent pneumatic compression is preferred)}}
+{{familytree  | | | | | | | E01 | | E02 | | E03 | | E04 | | E01= <div style="float: left; text-align: left; width: 15em; padding:1em;">❑ [[LMWH]] <br> OR <br> ❑ [[LDUH]] <br> OR <br> ❑ Mechanical VTE prophylaxis <br>([[Intermittent pneumatic compression]] is preferred) </div>| E02= ❑ Mechanical VTE prophylaxis <br> ([[Intermittent pneumatic compression]] is preferred)| E03= Are [[LMWH]] or [[UH]] contraindicated?| E04= ❑ Mechanical VTE prophylaxis <br> ([[Intermittent pneumatic compression]] is preferred)}}
-{{familytree  | | | | | | | | | | | | | | |,|-|^|-|.| | | | | }}
+{{familytree  | | | | | | | | | | | | | |,|-|^|-|.| | | | | }}
-{{familytree  | | | | | | | | | | | | | | F01 | | F02 | | | | F01= No| F02= Yes}}
+{{familytree  | | | | | | | | | | | | | F01 | | F02 | | | | F01= No| F02= Yes}}
-{{familytree  | | | | | | | | | | | | | | |!| | | |!| | | | | }}
+{{familytree  | | | | | | | | | | | | | |!| | | |!| | | | | }}
-{{familytree  | | | | | | | | | | | | | | G01 | | G02 | | | | G01= Does the patient has cancer?| G02= Low dose aspirin <br> OR <br> Fondaparinux <br> OR <br> Mechanical VTE prophylaxis <br> (Intermittent pneumatic compression is preferred)}}
+{{familytree  | | | | | | | | | | | | | G01 | | G02 | | | | G01= Does the patient have [[cancer]]?| G02= <div style="float: left; text-align: left; width: 15em; padding:1em;">❑ Low dose [[aspirin]] <br> OR <br> ❑ [[Fondaparinux]] <br> OR <br> ❑ Mechanical VTE prophylaxis <br> ([[Intermittent pneumatic compression]] is preferred)</div>}}
-{{familytree  | | | | | | | | | | | | |,|-|^|-|.| | }}
+{{familytree  | | | | | | | | | | | |,|-|^|-|.| | }}
-{{familytree  | | | | | | | | | | | | H01 | | H02 | H01= No| H02= Yes}}
+{{familytree  | | | | | | | | | | | H01 | | H02 | H01= No| H02= Yes}}
-{{familytree  | | | | | | | | | | | | |!| | | |!| | }}
+{{familytree  | | | | | | | | | | | |!| | | |!| | }}
-{{familytree  | | | | | | | | | | | | I01 | | I02 | I01= '''Pharmacological VTE prophylaxis ''' <br> LMWH <br> OR <br> Low dose UH <br> '''PLUS''' <br> '''Mechanical VTE prophylaxis'''
+{{familytree  | | | | | | | | | | | I01 | | I02 | I01= '''Pharmacological VTE prophylaxis ''' <br> <div style="float: left; text-align: left; width: 15em; padding:1em;">❑ [[LMWH]] <br> OR <br> ❑ [[LDUH]] </div><br> '''PLUS''' <br> '''Mechanical VTE prophylaxis'''
-:Elastic stockings
+<div style="float: left; text-align: left; width: 15em; padding:1em;">
-:Intermittent pneumatic compression| I02= '''Pharmacological VTE prophylaxis''' <br> Extended treatment with LMWH for 4 weeks <br> '''PLUS''' <br> '''Mechanical VTE prophylaxis'''
+❑ [[Elastic stockings]] <br>
-:Elastic stockings
+❑ [[Intermittent pneumatic compression]]</div>| I02= '''Pharmacological VTE prophylaxis''' <br> ❑ Extended treatment with [[LMWH]] for 4 weeks <br> '''PLUS''' <br> '''Mechanical VTE prophylaxis'''
-:Intermittent pneumatic compression}}
+<div style="float: left; text-align: left; width: 15em; padding:1em;">
+❑ [[Elastic stockings]]
+❑ [[Intermittent pneumatic compression]] </div>}}
 {{Family tree/end}}
 ===Cardiac Surgery===
+Shown below is an algorithm depicting the indications and choices of VTE prophylaxis among patients undergoing cardiac surgery.<ref name="pmid22315263">{{cite journal| author=Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA et al.| title=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. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e227S-77S | pmid=22315263 | doi=10.1378/chest.11-2297 | pmc=PMC3278061 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315263  }} </ref>
+<span style="font-size:85%"> '''Abbreviations:''' '''LDUH:''' low dose [[unfractionated heparin]]; '''LMWH:''' [[low molecular weight heparin]]; '''VTE:''' [[venous thromboembolism]] </span>
 {{Family tree/start}}
 {{familytree  | | | A01 | | | | A01= Is the postoperative period prolonged by<br> one or more non hemorrhagic surgical complications?}}
@@ Line 185: / Line 286: @@
 {{familytree  | B01 | | B02 | | B01= Yes| B02= No <br> (Uncomplicated post-op period)}}
 {{familytree  | |!| | | |!| | | }}
-{{familytree  | C01 | | C02 | | C01= '''Pharmacological VTE prophylaxis''' <br> LDUH <br> OR <br> LMWH <br><br> '''PLUS'''<br><br> '''Mechanical VTE prophylaxis''' | C02= '''Mechanical VTE prophylaxis''' <br>  (Intermittent pneumatic compression is preferred)}}
+{{familytree  | C01 | | C02 | | C01= '''Pharmacological VTE prophylaxis''' <br> <div style="float: left; text-align: left; width: 15em; padding:1em;">❑ [[LDUH]] <br> OR <br> ❑ [[LMWH]] </div> <br><br> '''PLUS'''<br><br> '''Mechanical VTE prophylaxis''' | C02= '''Mechanical VTE prophylaxis''' <br>  (Intermittent pneumatic compression is preferred)}}
 {{Family tree/end}}
 ===Thoracic Surgery===
+Shown below is an algorithm depicting the indications and choices of VTE prophylaxis among patients undergoing thoracic surgery.<ref name="pmid22315263">{{cite journal| author=Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA et al.| title=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. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e227S-77S | pmid=22315263 | doi=10.1378/chest.11-2297 | pmc=PMC3278061 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315263  }} </ref>
+<span style="font-size:85%"> '''Abbreviations:''' '''LDUH:''' low dose [[unfractionated heparin]]; '''LMWH:''' [[low molecular weight heparin]]; '''VTE:''' [[venous thromboembolism]] </span>
 {{Family tree/start}}
-{{familytree  | | | | | | | A01 | | | | | | A01= '''Is the patient undergoing ANY of the following surgeries that are associated with a high risk of VTE?''' <br>
+{{familytree  | | | | | | | A01 | | | | | | A01= <div style="float: left; text-align: left;padding:1em;">'''Is the patient undergoing ANY of the following surgeries that are associated with a high risk of VTE?''' <br>❑ Pulmonary resection<br>❑ Pneumonectomy<br>❑ Extrapleural pneumonectomy<br>❑ Esophagectomy </div>}}
-Pulmonary resection<br> Pneumonectomy<br> Extrapleural pneumonectomy<br> Esophagectomy}}
 {{familytree  | | | |,|-|-|-|^|-|-|-|.| | | }}
 {{familytree  | | | B01 | | | | | | B02 | | B01= Yes| B02= No}}
 {{familytree  | | | |!| | | | | | | |!| | | }}
-{{familytree  | | | B03 | | | | | | B04 | | B03= Patient is at HIGH risk of VTE| B04= Patient is at MODERATE risk for VTE}}
+{{familytree  | | | B03 | | | | | | B04 | | B03= '''Patient is at HIGH risk of VTE'''| B04= '''Patient is at MODERATE risk for VTE'''}}
 {{familytree  | | | |!| | | | | | | |!| | | }}
 {{familytree  | | | C01 | | | | | | C02 | | C01= Is the patient at high risk for major bleeding?| C02= Is the patient at high risk for major bleeding?}}
@@ Line 201: / Line 305: @@
 {{familytree  | D01 | | D02 | | D03 | | D04 | D01= No| D02= Yes| D03= No| D04= Yes}}
 {{familytree  | |!| | | |!| | | |!| | | |!| | }}
-{{familytree  | E01 | | E02 | | E03 | | E04 | E01= '''Pharmacological VTE prophylaxis''' <br> LDUH <br> OR <br> LMWH <br><br> '''PLUS'''<br><br> '''Mechanical VTE prophylaxis''' <br> Elastic stocking <br> Intermittent pneumatic compression| E02= '''Mechanical VTE prophylaxis''' <br> (Intermittent pneumatic compression is preferred) <br><br> '''Pharmacological VTE prophylaxis''' <br> '''''When the risk of bleeding subsides''''' <br> LDUH <br> OR <br> LMWH | E03= LDUH <br> OR <br> LMWH <br> OR <br> Mechanical VTE prophylaxis <br> (Intermittent pneumatic compression is preferred)| E04= '''Mechanical VTE prophylaxis''' <br> (Intermittent pneumatic compression is preferred) <br><br> '''Pharmacological VTE prophylaxis''' <br> '''''When the risk of bleeding subsides''''' <br> LDUH <br> OR <br> LMWH}}
+{{familytree  | E01 | | E02 | | E03 | | E04 | E01= '''Pharmacological VTE prophylaxis''' <br> <div style="float: left; text-align: left;padding:1em;" >❑ [[LDUH]] <br> OR <br> ❑ [[LMWH]] </div> <br> <br>  '''PLUS'''<br><br> '''Mechanical VTE prophylaxis''' <br> <div style="float: left; text-align: left;padding:1em;" >❑ [[Elastic stocking]] <br>❑ [[Intermittent pneumatic compression]] </div>| E02= '''Mechanical VTE prophylaxis''' <br> ([[Intermittent pneumatic compression]] is preferred) <br><br>  '''Pharmacological VTE prophylaxis''' <br> '''''When the risk of bleeding subsides''''' <div style="float: left; text-align: left;padding:1em;"> <br>❑ [[LDUH]] <br> OR <br>❑ [[LMWH]] </div>| E03= <div style="float: left; text-align: left;padding:1em;"> ❑ [[LDUH]] <br> OR <br>❑ [[LMWH]] <br> OR <br >❑ Mechanical VTE prophylaxis <br> ([[Intermittent pneumatic compression]] is preferred)</div>| E04= '''Mechanical VTE prophylaxis''' <br> ([[Intermittent pneumatic compression]] is preferred) <br><br> '''Pharmacological VTE prophylaxis''' <br> '''''When the risk of bleeding subsides''''' <br> <div style="float: left; text-align: left;padding:1em;"> ❑ [[LDUH]] <br> OR <br>❑ [[LMWH]] </div>}}
 {{Family tree/end}}
 ===Craniotomy===
-There is no validated risk score for the occurrence of subsequent VTE or for bleeding, particularly [[intracranial hemorrhage]] among patients undergoing [[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.
 {{Family tree/start}}
-{{familytree | | | A01 | | | A01= Is the patient undergoing craniotomy for a maligncy?}}
+{{familytree | | | A01 | | | A01= '''Is the patient undergoing craniotomy for a malignancy?'''}}
 {{familytree | |,|-|^|-|.| | }}
 {{familytree | B01 | | B02 | B01= Yes| B02= No}}
 {{familytree | |!| | | |!| | }}
-{{familytree | C01 | | C02 | C01= Very high risk of VTE| C02= High risk of VTE}}
+{{familytree | C01 | | C02 | C01= '''Very high risk of VTE (≥ 10%)'''| C02= '''High risk of VTE (~ 5%)'''}}
 {{familytree | |!| | | |!| | }}
-{{familytree | D01 | | D02 | C01= '''Mechanical VTE prophylaxis''' <br> (Intermittent pneumatic compression is preferred)<br><br> '''PLUS''' <br><br>'''Pharmacological VTE prophylaxis'''<br> '''''when the risk of bleeding subsides'''''| C02= '''Mechanical VTE prophylaxis''' <br> (Intermittent pneumatic compression is preferred) }}
+{{familytree | D01 | | D02 | D01= '''Mechanical VTE prophylaxis''' <br> (Intermittent pneumatic compression is preferred)<br><br> '''PLUS''' <br><br>'''Pharmacological VTE prophylaxis'''<br> '''''when the risk of bleeding subsides'''''| D02= '''Mechanical VTE prophylaxis''' <br> (Intermittent pneumatic compression is preferred) }}
 {{Family tree/end}}
 ===Spinal Surgery===
+{{Family tree/start}}
+{{familytree | | | A01 | | | A01= '''Is the patient undergoing spinal surgery for malignancy'''<br> '''OR''' <br> '''undergoing surgery with a combined anterior-posterior approach?'''}}
+{{familytree | |,|-|^|-|.| | }}
+{{familytree | B01 | | B02 | B01= Yes| B02= No}}
+{{familytree | |!| | | |!| | }}
+{{familytree | C01 | | C02 | C01= '''High risk for VTE'''| C02= '''Low risk for VTE''' }}
+{{familytree | |!| | | |!| | }}
+{{familytree | D01 | | D02 | D01= '''Mechanical VTE prophylaxis''' <br> (Intermittent pneumatic compression is preferred)<br><br> '''PLUS''' <br><br>'''Pharmacological VTE prophylaxis'''  when the risk of bleeding subsides| D02= '''Mechanical VTE prophylaxis''' <br> (Intermittent pneumatic compression is preferred) }}
+{{Family tree/end}}
 ===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.<ref name="pmid22315263">{{cite journal| author=Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA et al.| title=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. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e227S-77S | pmid=22315263 | doi=10.1378/chest.11-2297 | pmc=PMC3278061 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315263  }} </ref>
+<span style="font-size:85%"> '''Abbreviations:''' '''LDUH:''' low dose [[unfractionated heparin]]; '''LMWH:''' [[low molecular weight heparin]]; '''VTE:''' [[venous thromboembolism]] </span>
+{{Family tree/start}}
+{{familytree | | | A01 | | | A01=<div style="float: left; text-align: left;padding:1em;">'''Does the patient who has a major trauma have any contraindications for [[LDUH]] or [[LMWH]]?''' </div>}}
+{{familytree | |,|-|^|-|.| | }}
+{{familytree | C01 | | C02 | C01= No| C02= Yes}}
+{{familytree | |!| | | |!| | }}
+{{familytree | D01 | | D02 | D01= <div style="float: left; text-align: left;padding:1em;">'''Pharmacological VTE prophylaxis'''<br>
+❑ [[LDUH]] <br>OR <br> ❑ [[LMWH]] <br> <br> '''PLUS''' <br> <br>'''Mechanical VTE prophylaxis''' <br> (Intermittent pneumatic compression is preferred)</div>| D02= <div style="float: left; text-align: left;padding:1em;">'''Mechanical VTE prophylaxis''' <br> (Intermittent pneumatic compression is preferred)<br><br> '''PLUS''' <br><br>'''Pharmacological VTE prophylaxis''' <br> when the risk of bleeding subsides </div>}}
+{{familytree/end}}
 ==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.<ref name="pmid22315265">{{cite journal| author=Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S et al.| title=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. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e278S-325S | pmid=22315265 | doi=10.1378/chest.11-2404 | pmc=PMC3278063 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315265  }} </ref>
+<span style="font-size:85%"> '''Abbreviations:''' '''LDUH:''' low dose [[unfractionated heparin]]; '''LMWH:''' [[low molecular weight heparin]]; '''VKA:''' [[Vitamin K antagonist]]; '''VTE:''' [[venous thromboembolism]] </span>
+{{Family tree/start}}
+{{familytree | | | A01 | | | | | | A01= '''What is the risk of bleeding of the patient undergoing the major orthopedic surgery?'''}}
+{{familytree | |,|-|^|-|.| | | | | }}
+{{familytree | B01 | | B02 | | | | B01= High| B02= Low}}
+{{familytree | |!| | | |!| | | | | }}
+{{familytree | C01 | | C02 | | | | C01= ❑ [[Intermittent pneumatic compression]]| C02= '''What is the type of the orthopedic surgery?'''}}
+{{familytree | | | |,|-|^|-|.| | | }}
+{{familytree | | | D01 | | D02 | | D01= '''Total hip [[arthroplasty]]''' <br>OR <br> '''Total knee [[arthroplasty]]'''| D02= '''Hip fracture surgery'''}}
+{{familytree | | | |!| | | |!| | | }}
+{{familytree | | | E01 | | E02 | E01= <div style="float: left; text-align: left;padding:1em;">'''Pharmacological VTE prophylaxis'''<br>
+: '''''Begin at least 12 hours before and 12 hours after the surgery'''''<br>
+: '''''Administer for at least 14 days''''' <br>
+: '''''Extend the therapy to 35 days as outpatient''''' <br>
+Choose ONE of the following: <br> ❑ [[LMWH]] (first line)<br> ❑ [[Fondaparinux]] <br> ❑ [[Apixaban]] <br> ❑ [[Dabigatran]] <br> ❑ [[Rivaroxaban]] <br> ❑ [[LDUH]] <br> ❑ [[VKA]] <br> ❑ [[Aspirin]]<br> <br> '''AND/OR''' <br> <br>'''Intermittent pneumatic compression device'''</div>| E02=  <div style="float: left; text-align: left;padding:1em;">'''Pharmacological VTE prophylaxis'''<br>
+: '''''Begin at least 12 hours before and 12 hours after the surgery'''''<br>
+: '''''Administer for at least 14 days''''' <br>
+: '''''Extend the therapy to 35 days as outpatient''''' <br>
+Choose ONE of the following: <br> ❑ [[LMWH]] (first line)<br> ❑ [[Fondaparinux]] <br> ❑ [[LDUH]] <br>❑ [[VKA]] <br> ❑ [[Aspirin]]<br> <br> '''AND/OR''' <br> <br>'''Intermittent pneumatic compression device'''</div>}}
+{{Family tree/end}}
+====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:<ref name="pmid22315265">{{cite journal| author=Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S et al.| title=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. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e278S-325S | pmid=22315265 | doi=10.1378/chest.11-2404 | pmc=PMC3278063 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315265  }} </ref>
+* 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.<ref name="pmid22315265">{{cite journal| author=Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S et al.| title=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. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e278S-325S | pmid=22315265 | doi=10.1378/chest.11-2404 | pmc=PMC3278063 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315265  }} </ref>
+===Knee Arthroscopy===
+VTE prophylaxis is not recommended among patients who undergo knee arthroscopy and who have no previous VTE episodes.<ref name="pmid22315265">{{cite journal| author=Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S et al.| title=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. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e278S-325S | pmid=22315265 | doi=10.1378/chest.11-2404 | pmc=PMC3278063 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315265  }} </ref>
 ==References==
@@ Line 226: / Line 390: @@
 [[Category:Resident survival guide]]
+<div style="width: 80%;">

Venous thromboembolism prevention resident survival guide: Difference between revisions

Latest revision as of 18:10, 9 November 2014

Overview

VTE Prevention in Non Surgical Patients

Hospitalized Acutely Ill Medical Patients

Assessment of the Risk of VTE

Padua Prediction Score for VTE

Calculation of the Padua Prediction Score

Interpretation of the Padua Prediction Score

IMPROVE Predictive Score for VTE

Calculation of the IMPROVE Predictive Score

Interpretation of the IMPROVE Predictive Score

IMPROVE Associative Score for VTE

Calculation of the IMPROVE Associative Score

Interpretation of the IMPROVE Associative Score

IMPROVE Bleeding Risk Score

Hospitalized Critically Ill Patients

Cancer in Outpatient

Chronically Immobilized Patients

Long Travel

Asymptomatic Thrombophilia

VTE Prevention in Non Orthopedic Patients

General and Abdominal-Pelvic Surgeries

Cardiac Surgery

Thoracic Surgery

Craniotomy

Spinal Surgery

Trauma

VTE Prevention in Orthopedic Patients

Major Orthopedic Surgery

Assessment of Bleeding in Major Orthopedic Surgeries

Isolated Lower-Leg Injuries

Knee Arthroscopy

References

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