GUIDELINES FOR PREVENTION OF VENOUS THROMBOEMBOLISM (VTE)

IN HOSPITALIZED PATIENTS
UW Medicine Recommended Practices based on Antithrombotic Therapy and Prevention of Thrombosis, 9th Edition,
American College of Chest Physicians Evidence Based Clinical Practice Guidelines; Chest 2012 (suppl 2).

HIGH RISK FOR VTE AT RISK FOR VTE NOT AT RISK FOR VTE
Active malignancy Acute medical illness, including critical illness Fully ambulatory with no risk
Prior VTE Recent (< 1 month) surgery factors for VTE
Thrombophilia Immobility/bedrest/bathroom privileges only for >3 days
Acute spinal cord injury Age > 40
Trauma Obesity (BMI > 30)
Hip replacement Central venous access
Knee replacement Pregnancy/post-partum
Hip fracture repair Estrogen/hormonal therapy
Burns Erythropoesis-stimulating agents
Multiple transfusions

CONTRAINDICATIONS TO PHARMACOLOGIC
Use Sequential Compression Devices
PROPHYLAXIS?
(SCDs)
Active bleeding within 48-72 hours
Document contraindications to pharmacologic
Hypertensive crisis
YES prophylaxis
Coagulopathy
Reassess daily
Platelet count < 25,000
Must be worn continuously to be effective
Use of rTPA for stroke within 24 hrs
Caution with fall risk, discomfort, and
Recent head trauma or CNS hemorrhage
lower extremity injury/surgery/infection
Multiple trauma with high bleeding risk
Proven or suspected peri-spinal hematoma
At high risk for bleeding according to clinical judgment

NO
BMI > 40
YES 1st line: enoxaparin 40mg SQ Q12h
BMI > 40?
2nd line: LDUH 7500 units SQ Q8H
NO (preferred if Crcl < 30)
YES
Crcl < 30 ml/min Crcl < 30 ml/min
1st line: LDUH 5000 units SQ Q8H
NO 2nd line: enoxaparin 30mg SQ Q24H

HIGH RISK FOR VTE
See Recommendations by Clinical Group
(attached) and service-specific guidelines
For recent lumbar puncture, spinal
injection or epidural catheter, see
Anticoagulation Guidelines for
Neuraxial/Peripheral Nerve Procedures
[https://.depts.washington.edu/anticoag]
Reassess daily for change in risk
AT RISK FOR VTE NOT AT RISK FOR VTE
1st line: LDUH 5000 units SQ Q8H Document lack of risk
2nd line: enoxaparin 40mg SQ Q24H Reassess daily for new risk
See Recommendations by Clinical Group factors or prolonged length of stay
(attached) Implement appropriate VTE
For recent lumbar puncture, spinal injection prophylaxis if risk changes
or epidural catheter, see Anticoagulation
Guidelines for Neuraxial/Peripheral Nerve
Procedures [https://.depts.washington.edu/anticoag]
Reassess daily for change in risk

Cost considerations: Low dose unfractionated heparin (LDUH) 5000 units SQ: $1.11/dose;
enoxaparin 40mg SQ: $5.90/dose;
Renal failure (CrCl<30): Dose adjustments not necessary for LDUH; enoxaparin 30mg SQ Q24H;
fondaparinux contraindicated; LDUH preferred in dialysis
History of HIT: Consider fondaparinux 2.5 mg SQ daily (contraindicated if CrCl < 60)
THESE GUIDELINES ARE NOT INTENDED TO SUPERCEDE CLINICAL JUDGEMENT
UWMedicine VTE Prophylaxis Taskforce
J Cuschieri MD, R Dumitru PharmD, P Kritek MD , A Schleyer MD, A Wittkowsky PharmD
November 2013