Venous thromboembolism prevention resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Overview
VTE Prevention in Non Surgical Patients
Hospitalized Acutely Ill Medical Patients
Shown below is the indications and choices of VTE prophylaxis among acutely ill patients. If VTE prophylaxis is recommended, it should be administered for the period of immobilization or hospital stay. Do not extend the duration of the prophylaxis after the period of immobilization or hospital stay.[1]
| What is the risk of thrombosis in the acutely ill patient? | |||||||||||||||||||||||
| High | Low | ||||||||||||||||||||||
| Is the patient bleeding or at high risk of bleeding? | No VTE prophylaxis | ||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||
| Mechanical VTE prophylaxis For the period of immobilization or hospital stay only Graduated compression stocking Intermittent pneumatic compression | Pharmacological VTE prophylaxis For the period of immobilization or hospital stay only LMWH Low dose UFH, BID Low dose UFH, TID Fondaparinux | ||||||||||||||||||||||
| Did the bleeding or bleeding risk subside AND the patient is still at increased risk of thrombosis? | |||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||
| Substitute mechanical prophylaxis by pharmacological prophylaxis | Continue mechanical prophylaxis | ||||||||||||||||||||||
Assessment of the Risk of VTE
Padua Prediction Score for VTE
Shown below is a table depicting Padua predictive score for VTE. The interpretation of the score is as follows:
- Score≥ 4: High risk for VTE
- Score< 4: Low risk for VTE[2]
| Variable | Score |
| Active cancer | 3 |
| Previous VTE | 3 |
| Decreased mobility | 3 |
| Thrombophilia | 3 |
| Previous trauma or surgery within that last month | 2 |
| Age≥ 70 | 1 |
| Heart and/or respiratory failure | 1 |
| Ischemic stroke or acute myocardial infarction | 1 |
| Acute rheumatologic disorder and/or acute infection | 1 |
| Obesity | 1 |
| Hormonal therapy | 1 |
IMPROVE Predictive Score
IMPROVE Associative Score
Assessment of the Risk of Bleeding
The following factors are associated with an increased risk of bleeding:[4]
| Variable | Score |
| Active gastric or duodenal ulcer | 4.5 |
| Prior bleeding within the last 3 months | 4 |
| Decreased platelet count (<50x109/L) | 4 |
| Age ≥ 85 years | 3.5 |
| Liver failure (INR>1.5) | 2.5 |
| Severe kidney failure (GFR< 30 mL/min/m2) | 2.5 |
| Admission to ICU or CCU | 2.5 |
| Central venous catheter | 2 |
| Rheumatic disease | 2 |
| Active malignancy | 2 |
| Age: 40-84 years | 1.5 |
| Male | 1 |
| Moderate kidney failure (GFR: 30-59 mL/min/m2) | 1 |
Critically Ill Hospitalized Patients
Shown below is an algorithm depicting the choices for VTE prophylaxis among critically ill patients. Note that routine ultrasound screening for DVT is not recommended among critically ill patients. Do not extend the duration of the prophylaxis after the period of immobilization or hospital stay.[1]
| Is the critically ill patient bleeding or at risk for major bleeding? | |||||||||||||||||
| Yes | No | ||||||||||||||||
| Mechanical VTE prophylaxis Graduated compression stocking Intermittent pneumatic compression | Pharmacological VTE prophylaxis LMWH Low dose UFH | ||||||||||||||||
| Did the bleeding or bleeding risk subside? | |||||||||||||||||
| Yes | No | ||||||||||||||||
| Substitute mechanical prophylaxis by pharmacological prophylaxis | Continue mechanical prophylaxis | ||||||||||||||||
Cancer in Outpatient
Shown below is an algorithm depicting VTE prophylaxis among cancer patients. Note that, cancer patients with indwelling central venous catheters do not require VTE prophylaxis with neither LMWH, low dose unfractionated heparin or vitamin K antagonists.[1]
| ❑ Does the patient have a solid tumor AND ❑ Additional risk factors for VTE?
| |||||||||||||||
| Yes | No | ||||||||||||||
| Pharmacological VTE prophylaxis LMWH Low dose UFH | No VTE prophylaxis | ||||||||||||||
Chronically Immobilized Patients
No VTE prophylaxis is recommended in subjects who are chronically immobilized either at home or at a nursing home.[1]
Long Travel
| Does the patient has any of the following that increase the risk of VTE? Prior VTE episode Recent trauma Recent surgery Active cancer Advanced age Immobility Severe obesity Estrogen intake Thrombophilia | |||||||||||||||||
| Yes | No | ||||||||||||||||
| Frequent ambulation Calf muscle exercise To sit in an aisle seat Graduated compression stockings below the knee (pressure: 15-30 mmHg) No pharmacological VTE prophylaxis | No preventive measures are required | ||||||||||||||||
Asymptomatic Thrombophilia
VTE prophylaxis is not recommended for subjects with asymptomatic thrombophilia. [1]
VTE Prevention in Non Orthopedic Patients
VTE Prevention in Orthopedic Patients
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA; et al. (2012). "Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e195S–226S. doi:10.1378/chest.11-2296. PMC 3278052. PMID 22315261.
- ↑ Barbar S, Noventa F, Rossetto V, Ferrari A, Brandolin B, Perlati M; et al. (2010). "A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score". J Thromb Haemost. 8 (11): 2450–7. doi:10.1111/j.1538-7836.2010.04044.x. PMID 20738765.
- ↑ 3.0 3.1 Spyropoulos AC, Anderson FA, Fitzgerald G, Decousus H, Pini M, Chong BH; et al. (2011). "Predictive and associative models to identify hospitalized medical patients at risk for VTE". Chest. 140 (3): 706–14. doi:10.1378/chest.10-1944. PMID 21436241.
- ↑ Decousus H, Tapson VF, Bergmann JF, Chong BH, Froehlich JB, Kakkar AK; et al. (2011). "Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators". Chest. 139 (1): 69–79. doi:10.1378/chest.09-3081. PMID 20453069.