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Information

Population: Hospitalized patients not undergoing surgery.

Organizations

ImagesASH 2018, ACCP 2016, ACP 2011

Prevention Recommendations

–In acutely ill patients (hospitalized, not in ICU/CCU), determine risk for VTE using Padua Prediction Score or IMPROVE score (Table 2–6). (ASH)

–Consider determining risk of bleeding using IMPROVE bleeding score or risk factors (Tables 2–7 and 2–8). (ASH)

–Do not use pharmacologic prophylaxis or mechanical prophylaxis in low-risk patients.

–Use thromboprophylaxis with LMWH in acutely ill hospitalized patients at elevated risk: equivalent of enoxaparin 40 mg SQ daily; fondaparinux 2.5 mg SQ daily. Only use low-dose unfractionated heparin (UFH) 5000 units BID or TID in patients with significant renal disease. UFH has a 10-fold increased risk of heparin-induced thrombocytopenia (HIT). Women are 2.5 times likely to develop HIT compared to men. Continue for duration of hospital stay.

–If not using pharmacological prophylaxis because of bleeding risk, use mechanical (use intermittent pneumatic compression [IPC] or graduated compression stockings [GCS]).

–If unable to use pharmacologic or mechanical prophylaxis, consider aspirin.

–Do not use both pharmacological and mechanical prophylaxis together.

–Do not use DOACs for prophylaxis unless on DOAC for some other reason.

–Do not use VTE prophylaxis in chronically ill (including nursing home), outpatients with minor risk factors, or low-risk long-distance travelers (≥4 h).

–For high-risk long-distance travelers (Table 2–9): use graduated compression stockings or LMWH.

TABLE 2–6 RISK FACTORS FOR VTE IN HOSPITALIZED MEDICAL PATIENTS

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TABLE 2–7 RISK FACTORS FOR BLEEDING (CHEST. 2011;139:69–79)

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TABLE 2–8 IMPROVE BLEEDING RISK SCALE

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TABLE 2–9 HEREDITARY THROMBOPHILIC DISORDERS

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Sources

–Blood Adv. 2018;2:3198-3225.

–American Society of Hematology 2018. Guidelines for Management of Venous Thromboembolism: Prophylaxis for Hospitalized and Nonhospitalized Medical Patients.

–JAMA. 2012;307:306.

–Ann Intern Med. 2011;155:625-632.

–Chest. 2016;149:315-352.

–http://www.uwhealth.org/files/uwheath/docs/anticoagulation/VTE

Population: Patients undergoing surgery.

Organization

ImagesACCP 2016

Prevention Recommendations

–Stratify surgical risk:

• Low risk: <40 y, minor surgery,1no risk factors,2Caprini score < 2 (Table 2–10).

• Intermediate risk: minor surgery plus risk factors, age 40–60 y, major surgery with no risk factors, Caprini score 3–4.

• High risk: major surgery plus risk factors, high-risk medical patient, major trauma, spinal cord injury, craniotomy, total hip or knee arthroplasty (THA, TKA), thoracic, abdominal, pelvic cancer surgery.

TABLE 2–10 CAPRINI RISK STRATIFICATION MODEL

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–Employ preventive measures:

• Early ambulation: consider mechanical prophylaxis and IPC or GCS.

• UFH 5000 U SQ q 8–12 h should ONLY be used in patients with renal disease with a Ccr < 20–30 mL/min.

• LMWH equivalent to enoxaparin 40 mg SQ 2 h before surgery then daily or 30 mg q 12 h SQ starting 8–12 h postop.

• Fondaparinux 2.5 mg SQ daily starting 8–12 h postop.

• LMWH: equivalent to enoxaparin 40 mg SQ 2 h preoperative then daily or 30 mg SQ q 12 h starting 8–12 h postop and also use mechanical prophylaxis with IPC or GCS.

• Extend prophylaxis for as long as 28–35 d in high-risk patients. In THA, TKA ortho patients, acceptable VTE prophylaxis also includes rivaroxaban 10 mg/d, dabigatran 225 mg/d, adjusted dose warfarin, and aspirin, although LMWH is preferred. DOACs are likely to play a larger role in the future as trials continue to show superiority over warfarin. (Ann Int Med. 2013;159:275) (Thromb Haemot. 2011;105:444)

• If high risk of bleeding, use IPC alone. (Ann Intern Med. 2012;156:710, 720) (JAMA. 2012;307:294)

• Do not use UFH for prophylaxis if Ccr is ≥20 mL/min. There is a 10-fold increased risk of HIT compared to LMWH.

Sources

–Chest. 2016;149:315.

–http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm390574.htm