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VENOUS THROMBOEMBOLISM - PREVENTION
Venous thromboembolism is comprised of pulmonary embolism and deep venous thrombosis and is associated with significant morbidity and mortality.
Decision on which type of prophylaxis to be given must be individualized for each patient.
All patients admitted for major trauma, surgery or acute medical illness should be assessed for risk of venous thromboembolism and bleeding before starting prophylaxis for venous thromboembolism.
Early mobilization and leg exercises for any patient recently immobilized are recommended. Immobilized patients should also be adequately hydrated.
Intermittent pneumatic compression devices periodically compress calf and/or thighs and stimulate fibrinolysis. It has been shown to be effective in prophylaxis of asymptomatic deep venous thrombosis in surgical patients.
Graduated compression stockings may be used for deep venous thrombosis prophylaxis in surgical patients with no contraindication for use.

Evaluation

Venous Thromboembolism (VTE) Risk Assessment Tools

Padua Risk Assessment Prediction Score

  • Used to assess hospitalized patients’ risk for VTE
  • Scores ≥4 indicated high VTE risk
Points Medical History
3 Cancer, past VTE, immobile, thrombophilic
2 History of trauma or surgery 1 month prior to assessment
1 Age ≥70 years, congestive heart failure (CHF), acute myocardial infarction (MI), ischemic cerebrovascular accident, BMI ≥30, hormonal therapy, infections, rheumatologic diseases

Adapted from Institute for Clinical Systems Improvement. Venous thromboembolism prophylaxis guideline. 2012.

  • Pharmacoprophylaxis is suggested in patients at high risk for VTE but at low risk for bleeding
  • Patients at high risk for both VTE and bleeding should also be given intermittent pneumatic compression
  • No prophylactic measures are needed for patients at low risk for VTE and/or bleeding

Caprini VTE Risk Assessment

  • Used to assess the risk for VTE of patients scheduled for surgery
  • Points are given depending on different risk factors

Risk factors equivalent to 1 point each:

  • Age 41-60 years
  • Elective minor surgical procedure
  • Minor surgery <1 month prior
  • Varicose veins
  • History of inflammatory bowel disease
  • Edematous lower extremities
  • Obesity (BMI >25)
  • Acute MI
  • CHF <1 month prior
  • Sepsis <1 month prior
  • Serious pulmonary disease including pneumonia <1 month prior
  • Abnormal lung function [chronic obstructive pulmonary disease (COPD)]
  • Patient advised bed rest
  • Other risk factors

Risk factors equivalent to 2 points each

  • Age 61-74 years
  • Arthroscopic surgery
  • Present or history of malignancy
  • Major surgery of >45 minutes duration
  • Laparoscopic surgery of >45 minutes duration
  • Patient confined to bed for >72 hours
  • Plaster cast applied, immobilized for <1 month
  • Central venous access

Risk factors equivalent to 1 point each for female patients:

  • Oral contraceptive or hormonal therapy
  • Pregnant or <1 month postpartum
  • (+) stillborn birth, recurrent (>3) spontaneous abortion, premature birth with toxemia, growth restricted infant

Risk factors equivalent to 3 points each:

  • Age >75 years
  • History of DVT/PE
  • Family history of thrombosis
  • Positive factor V Leiden
  • Positive prothrombin A
  • Increased serum homocysteine
  • Positive lupus anticoagulant
  • Increased anticardiolipin antibodies
  • Heparin-induced thrombocytopenia
  • Congenital or acquired thrombophilia

Risk factors equivalent to 5 points each:

  • Elective major lower extremity arthroplasty
  • Hip/pelvis/lower extremity fracture of <1 month
  • Cerebrovascular accident <1 month
  • Multiple trauma <1 month
  • Acute spinal cord injury/paralysis <1 month

Adapted from Institute for Clinical Systems Improvement. Venous thromboembolism prophylaxis guideline. 2012.

VTE Risk Category Caprini Score
Very Low 0
Low 1-2
Moderate 3-4
High ≥5

Other Medical Conditions

  • Acute MI (please see Myocardial Infarction Disease Management Chart for details)
  • Acute stroke (please see Ischemic Stroke and Intracerebral Hemorrhage Disease Management Charts for details)
  • Routine thromboprophylaxis is recommended in the following:
    • Burn patients who have ≥1 additional VTE risk factors
    • Intensive care unit (ICU) and septic patients
    • Patients with severe respiratory disease
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