1. General considerations
Venous thromboembolism (VTE) prophylaxis consists of pharmacologic and nonpharmacologic measures to diminish the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE).
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Assess the major risk factors for Venous Thromboembolism which are as follows: ● Age > 60. ● Cancer. ● Previous VTE. ● Acute Stroke with paresis (<3 months). ● Thrombophilia and acquired coagulopathy. ● Decompensated NYHA Class III/IV heart failure. ● Acute infection/sepsis. ● Respiratory failure (ventilator-dependent). ● Pregnancy/post-partum. ● Post trauma. ● Prolonged immobility (more than 48 hours) ● Obesity. ● Post surgery (within last three months). |
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A full history and examination should be obtained to assess the risk of bleeding in all acutely ill hospitalized medical patients. Patients at high risk of bleeding in whom pharmacologic thromboprophylaxis is typically contraindicated includes the following: ● Active bleeding or intracranial haemorrhage. ● Recent acute major trauma. ● Thrombolytics within last 24 hours. ● Spine or Intracranial surgery in last 48 hours. ● Planned surgical procedure in immediate 6 to 12 hours. ● Patients who have a moderate or severe coagulopathy (INR ≥ 1.5 or aPTT ratio ≥ 1.3). ● Patients with a severe bleeding diathesis or thrombocytopenia (e.g., platelet count <50,000/microL). |
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Consult with surgery team before starting pharmacological prophylaxis in postoperative patients. (if they are reluctant to start, always discuss pro and cons of prophylaxis) |
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Consider withholding the heparin product when there is a significant decrease of platelet count (50% of initial count) or decrease to less than 50,000/µl of blood or when INR > 1.5. |
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Prophylaxis should be reviewed daily and changed, if necessary. Prophylaxis should be reviewed daily and changed, if necessary. |
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VTE prophylaxis should continue until the patient is fully ambulatory or discharged from the hospital. |
2. Pharmacological prophylaxis
2.1. Unfractionated heparin (UFH)
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Dose: UFH 5000 units subcutaneously twice daily. |
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For Morbidly obese (BMI-40kg/m 2 or more) patient: dose and timing have to increase 5000-7500 units 8 hourly. |
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Safe in CKD patients as it's not cleared by the kidneys. |
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Platelet count should be monitored regularly (e.g., days 3 and 6) in all patients receiving low-dose UFH to detect the development of Heparin Induced Thrombocytopenia. |
2.2. Low molecular weight Heparin (LMWH)
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Dose: Enoxaparin 40 mg subcutaneously once daily when Creatinine Clearance> 30mL/min. |
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For patients with BMI>40kg/m2use 40mg 12hourly |
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For patients with BMI>50kg/m 2 use 60mg 12hourly |
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For patient with weight <50 kg: decrease the dose of enoxaparin to 30 mg s/c daily. |
2.3. Dalteparin: 5000 units subcutaneously once daily when Creatinine Clearance> 30mL/min.
2.4. Fondaparinux:
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Dose >50 kg: Fondaparinaux 2.5 mg SC once daily |
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Fondaparinux should be avoided in those with a creatinine clearance <30 mL/min. |
3. Non-Pharmacological
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Pneumatic Sequential Compression Devices (SCDs) must be used for patients in whom pharmacological prophylaxis is contraindicated. |
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Pneumatic Sequential Compression Devices (SCDs) can be discontinued once the patient is started on pharmacological prophylaxis. |
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Prior to use of SCD, Doppler of leg veins should be performed. |
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Choose the right size of SCD sleeves. |
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TED Stockings has NO ROLEin DVT/VTE Prophylaxis and should not be used in ICU for VTE Prophylaxis. |
4. General Measures
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Early mobilization |
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Adequate hydration |
Further Readings:
1. Alhazzani, W., Lim, W., Jaeschke, R. Z., Murad, M. H., Cade, J., & Cook, D. J. (2013). Heparin thromboprophylaxis in medical-surgical critically ill patients: a systematic review and meta-analysis of randomized trials. Critical care medicine, 41(9), 2088-2098.
2. Rondina, M. T., Wheeler, M., Rodgers, G. M., Draper, L., & Pendleton, R. C. (2010). Weight-based dosing of enoxaparin for VTE prophylaxis in morbidly obese, medically-Ill patients. Thrombosis research, 125(3), 220-223.
3. Guideline, N. I. C. E. (2018). Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. NICE guideline Published, 21.
4. Tang, X., Lyu, W. R., Jin, Y., Wang, R., Li, X. Y., Li, Y., ... & Sun, B. (2022). Modern thromboprophylaxis protocol based on guidelines applied in a respiratory intensive care unit: a single-center prospective cohort study. Thrombosis Journal, 20(1), 1-11.
5. Streiff, M. B., Carolan, H. T., Hobson, D. B., Kraus, P. S., Holzmueller, C. G., Demski, R., ... & Haut, E. R. (2012). Lessons from the Johns Hopkins multi-disciplinary venous thromboembolism (VTE) prevention collaborative. BMj, 344.
