Hematology and Coagulation | Venous Thromboembolism Prophylaxis - Adult - Inpatient/Ambulatory
Venous Thromboembolism Prophylaxis – Adults - Inpatient/Ambulatory
Consensus Care Guideline Summary
Target Population: inpatients with the intent to remain hospitalized for greater than 24 hours or who are discharged on extended VTE prophylaxis.
Full Guideline: https://uconnect.wisc.edu/clinical/cckm-tools/content/cpg/hematology-and-coagulation/related/name-141119-en.cckm
Guideline Overview
• Risk for thromboembolism and bleeding is evaluated in all inpatients
• Modified Padua risk model is used to assess VTE risk in medical patients; prophylactic recommendations including mechanical and pharmacologic, are provided
• Caprini risk model is used to assess VTE risk in surgical patients; prophylactic recommendations, including mechanical and pharmacologic, are provided
• Prophylactic recommendations, including mechanical and pharmacologic, are provided for orthopedic patients
Definitions
Obesity Class 3 ▪ patients with a BMI ≥ 40 kg/M2
Renal dysfunction ▪ patients with a CrCl < 30 mL/min or evidence
of stage 4 [eGFR 15-29 mL/min/1.73M2] or 5
[eGFR < 15 mL/min/M2] renal dysfunction
Mechanical prophylaxis ▪ methods may include graduated compression
stockings (GCS), intermittent pneumatic
compression devices (IPC), and venous foot
pumps (VFP)
Evaluation of Bleeding Risk
Table 1. IMPROVE bleeding RAM for medical patients
Renal dysfunction (GFR 30-59 mL/min) 1
Male 1
Age 40-84 years old 1.5
Current cancer 2
Rheumatic disease 2
Central venous catheter 2
ICU/Critical care unit during admission 2.5
Renal failure (GFR < 30 mL/min) 2.5
Hepatic failure (INR > 1.5) 2.5
Age >84 years old 3.5
Platelet count < 50 x109/L 4
Bleeding in the 3 months prior to admission 4
Active gastroduodenal ulcer 4
• A score of < 7: 0.4%-1.5% risk for bleeding
• A score of > 7: 4.1%-7.9% risk for bleeding
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Contact: CCKM@uwhealth.org Last Revised: 03/2023
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Table 2. Bleeding risk factor consideration for medical and surgical patients
Medical Patients* Surgical Patients
Platelet count < 50 x109/L Active bleeding or previous major bleeding
Bleeding in the 3 months prior to admission Renal failure (CrCl < 30 mL/min)
Active gastroduodenal ulcer Hepatic failure (INR > 1.5 without anticoagulants)
Thrombocytopenia
Acute stroke
Uncontrolled systemic hypertension
Concomitant use of anticoagulants, antiplatelets or
thrombolytics
• *Risk factors listed under medical patients are considered absolute contraindications to anticoagulation while risk factors listed under surgical patients are relative
contraindications
VTE Risk Assessment Medical Patient
Table 3: Modified Padua Risk Assessment Model
Risk Factor Points
Critically Ill 4
Inflammatory Bowel Disease 4
Admission for trauma (injured patient with fracture) 4
Active COVID-19 infection 4
Active Cancer 3
Previous VTE 3
Reduced Mobility 3
Thrombophilic Condition 3
Recent (< 1month) Trauma/Surgery 2
Age ≥ 70 years 1
Heart or Respiratory Failure 1
Acute Myocardial Infarction or Ischemic Stroke 1
Acute Infection or Rheumatologic Disorder 1
BMI ≥ 30 1
Ongoing Hormonal Treatment 1
Total Points
Low VTE Risk – no prophylaxis needed < 4
High VTE Risk – prophylaxis recommended > 4
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Contact: CCKM@uwhealth.org Last Revised: 03/2023
Effective 3/16/2023. Contact CCKM@uwhealth.org for previous versions
Table 4: VTE Prophylaxis Regimens for High VTE Risk Medical Patients
Patient Population VTE Prophylaxis Regimens
Preferred Option Alternative Option
High VTE Risk Enoxaparin 40 mg SQ every 24 hrsa Heparin 5000 units SQ every 8-12 hrsa
Trauma/Injury with fracture Enoxaparin 30 mg SQ every 12 hrsa Enoxaparin 0.5 mg/kg every 12 hrs
Heparin 5000 units SQ every 8-12 hrsc
Renal failure
(CrCl < 30 mL/min)*
*Not on renal replacement therapy
Heparin 5000 units SQ every 8-12 hrsa
Enoxaparin 30 mg SQ every 24 hrsb
Obesity Class 3
(BMI > 40 kg/M2)
Enoxaparin 40 mg SQ every 12 hrsb Heparin 5000 units SQ every 8 hrsb
Low body weight
(weight < 50 kg)
Heparin 5000 units SQ every 8-12 hrsa Enoxaparin 30 mg SQ every 24 hrsc
High Bleeding Risk Intermittent pneumatic compression
devices (IPC)a
Graduated compression stockings (GCS) or Venous
foot pumps (VFP)c
a: UW Health GRADE Moderate quality evidence, strong recommendation
b: UW Health GRADE Low quality evidence, strong recommendation
c: UW Health GRADE Low quality evidence, weak/conditional recommendation
VTE Risk Assessment Surgical Patient
Table 5: Caprini Risk Assessment Model
1 Point 2 Points 3 Points 5 Points
Age 41-60 Age 61-74 Age ≥ 75 Acute spinal cord injury
(< 1 mo)
Acute MI (<1 mo) Central venous access Established
thrombophilia
Elective lower extremity
arthroplasty
BMI > 25 Immobile > 72 hrs HIT Hip, pelvis, or leg fracture
(< 1 mo)
CHF exacerbation
(<1 mo)
Leg plaster cast or
brace
Hx of VTE Stroke (< 1 mo)
Hx of Inflammatory Bowel
Disease
Malignancy Family hx VTE
(1 degree relative)
Procedure with local
anesthesia
Surgery- arthroscopic
Swollen legs or
Varicose veins
Surgery > 45 mins
Sepsis (< 1 mo)
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Serious lung dx
ex. Pneumonia (<1 mo)
1 point
(For Women Only)
Oral contraceptives or HRT
Pregnancy or postpartum (< 1 month)
Hx of unexplained stillborn infant, spontaneous
abortion (≥3), premature birth with toxemia or
growth restricted infant
Points Risk Recommendation
0 Very Low VTE Risk Early and frequent ambulation
1-2 Low VTE Risk Mechanical Prophylaxis
3-4 Moderate VTE Risk and Low Bleed Risk Pharmacologic Prophylaxis
> 5 High VTE Risk and Low Bleed Risk Mechanical AND Pharmacologic Prophylaxis
> 2 High Bleed Risk Mechanical Prophylaxis
Table 6: VTE Prophylaxis Regimens for High VTE Risk General Surgery Patients
Patient Population VTE Prophylaxis Regimens
Preferred Option Alternative Option
High VTE Risk Heparin 5000 units SQ every 8-12 hrsa Enoxaparin 40 mg SQ every 24 hrsa
Renal impairment
(CrCl < 30 mL/min)*
*Not on hemodialysis
Heparin 5000 units SQ every 8-12 hrsa Enoxaparin 30 mg SQ every 24 hrsb
Bariatric Surgery Enoxaparin 40 mg SQ every 12 hrsa Heparin 5000 units SQ every 8-12 hrsc
Major Trauma Enoxaparin 30 mg SQ every 12 hrsa Enoxaparin 0.5 mg/kg every 12 hrs
Heparin 5000 units SQ every 8-12 hrsc
Abdominal/Pelvic Surgery for Cancer Enoxaparin 40 mg SQ every 24 hrsb Heparin 5000 units SQ every 8-12 hrsc
High Bleed Risk Intermittent pneumatic compression
devices (IPC)a
Graduated compression stockings (GCS) or
Venous foot pumps (VFP)c
Cardiac Surgery Heparin 5000 units SQ every 8-12 hrs Enoxaparin 40 mg SQ every 24 hrs
Craniotomy Intermittent pneumatic compression
devices (IPC)a
Graduated compression stockings (GCS) or
Venous foot pumps (VFP)c
Spinal Surgery Intermittent pneumatic compression
devices (IPC)a
Graduated compression stockings (GCS) or
Venous foot pumps (VFP)c
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Contact: CCKM@uwhealth.org Last Revised: 03/2023
Effective 3/16/2023. Contact CCKM@uwhealth.org for previous versions
Thoracic Surgery Heparin 5000 units SQ every 8-12 hrs Enoxaparin 40 mg SQ every 24 hrs
Trauma Surgery Enoxaparin 30 mg every 12 hrsa Enoxaparin 0.5 mg/kg every 12 hrs
Heparin 5000 units SQ every 8-12 hrsc
a: UW Health GRADE Moderate quality evidence, strong recommendation
b: UW Health GRADE Low quality evidence, strong recommendation
c: UW Health GRADE Low quality evidence, weak/conditional recommendation
VTE Prophylaxis Orthopedic Patient
Table 7. VTE Risk Categories for Orthopedic Surgery Population
Elevated Risk (if any are present) Elevated Risk (if 2 or more are present)
Hip fracture surgery Age > 70 years
Surgical revision or protective weight bearing New onset ischemic stroke
Personal history of DVT or PE Morbid obesity (BMI > 40 or >120 kg)
History of active malignancy Venous stasis (varicose veins)
History of known thrombophilia Active heart failure (NYHA Class III or IV)
Acute myocardial infarction
Acute respiratory disease (COPD or asthma
exacerbation or pneumonia)
1st degree family history of DVT or PE
Active (treated) inflammatory disease (IBD, rheumatic
disease
Immobility (bedridden > 72 hrs, immobilizing lower
extremity cast, paralysis)
Table 8. VTE prophylaxis regimens for orthopedic surgeries
Standard VTE Risk Elevated VTE Risk High Bleed Risk
Total Hip,
Total Knee, or
Shoulder
Arthroplasty
Apixaban 2.5 mg PO BIDa
ASA 81 mg BID b
ASA 325 mg QD - BID b
Enoxaparin 40 mg SQ dailya
Enoxaparin 30 mg SQ every 12 hrsa
*Fondaparinux 2.5 mg daily b
Rivaroxaban 10 mg PO dailya
Warfarin (target INR 1.8-2.2) b
Apixaban 2.5 mg PO BIDa
Enoxaparin 30 mg SQ every 12 hrsa
Enoxaparin 40 mg SQ dailya
*Fondaparinux 2.5 mg daily b
Rivaroxaban 10 mg PO dailya
Warfarin (target INR 1.8-2.2) b
Mechanical prophylaxis
Hip Fracture
Surgery
All patients considered at elevated VTE risk:
Apixaban 2.5 mg BID
Enoxaparin 30 mg SQ every 12 hrsa
Enoxaparin 40 mg Sq every 24 hrsa
*Fondaparinux 2.5 mg daily b
Mechanical prophylaxis
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Contact: CCKM@uwhealth.org Last Revised: 03/2023
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Rivaroxaban 10 mg PO dailya
Warfarin (target INR 1.8-2.2) b
* May be considered for patients with heparin allergy
a: UW Health GRADE Moderate quality evidence, strong recommendation
b: UW Health GRADE Very Low quality evidence, strong recommendation
Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: CCKM@uwhealth.org Last Revised: 03/2023
Effective 3/16/2023. Contact CCKM@uwhealth.org for previous versions