Venous thromboembolism prevention resident survival guide

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

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

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?
 
 
 
 
 
Is the patient at high risk for major bleeding?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pharmacological VTE prophylaxis
LDUH
OR
LMWH


PLUS

Mechanical VTE prophylaxis
 
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]

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. 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.
  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.
  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.
  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.
  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.
  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.
  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.