Appendix B: Sample Venous Thromboembolism Protocol/Order Set
University of California, San Diego Medical Center VTE Risk Assessment and Prophylaxis Orders
(paper version of computerized order set)
| Low Risk |
Moderate Risk |
High Risk |
Ambulatory patient without additional VTE risk factors or expected length of stay <2
days.
Minor surgery in patient without additional VTE risk factors (same day surgery or operating room time <30 minutes).
* Early ambulation. |
Patients who aren't in either the low- or high-risk group (go to VTE risk factor table)
Select one pharmacologic* option:
- Enoxaparin# 40 mg SQ q 24 hours
- UFH 5,000 units SQ q 8 hours
- UFH 5,000 units SQ q 12 hours (use only if wt <50kg or >75 yrs)
or
Sequential compression device aka SCDs (Optional for these patients if they are on pharmacologic prophylaxis, mandatory if not).
SCDs to
- Both lower extremities.
- Right leg only.
- Left leg only.
- Patient intolerant or has skin lesions on both legs, do not use SCDs.
|
Elective hip or knee arthroplasty.
Acute spinal cord injury with paresis.
Multiple major trauma .
Abdominal or pelvic surgery for cancer.
Select one pharmacologic # option:
- Enoxaparin* 40 mg SQ q 24 hours.
- Enoxaparin* 30 mg SQ q 12 hours (knee replacement).
- Warfarin _______mg PO daily, target INR 2-3; hold INR >3.
or
- UFH 5,000 units SQ q 8 hours (only if creatinine clearance is < 30, SCr >2, and warfarin is not an option).
- No pharmacologic prophylaxis because of contraindication.
________________________
(go to Contraindications table below)
and
SCDs to
- Both lower extremities.
- Right leg only.
- Left leg only.
- Patient intolerant or has skin lesions on both legs, do not use SCDs.
|
* Go to Contraindications table.
# Enoxaparin should only be used in patients with CrCl>30 and SCr<2; do not use if epidural/spinal catheter is in place.
SCDs should be used in all patients for whom pharmacologic prophylaxis is contraindicated and in all high-risk patients unless patient is intolerant or with contraindications to SCDs.
Note: Enoxaparin is the USCD Medical Center formulary low molecular weight heparin (LMWH); other LMWHs are considered equivalent.
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Venous Thromboembolism Risk Factors
Age >50 years
Myeloproliferative disorder
Dehydration
Congestive heart failure
Active malignancy
Hormonal replacement
Moderate to major surgery
|
Prior history of VTE
Impaired mobility
Inflammatory bowel disease
Active rheumatic disease
Sickle cell disease
Estrogen-based contraceptives
Central venous catheter |
Acute or chronic lung disease
Obesity
Known thrombophilic state
Varicose veins/chronic stasis
Recent post-partum with
immobility
Nephrotic syndrome
Myocardial infarction
|
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Contraindications or Other Conditions to Consider With Pharmacologic VTE Prophylaxis
| Absolute |
Relative |
Other Conditions |
- Active hemorrhage.
- Severe trauma to head or spinal cord with hemorrhage in the last 4 weeks.
- Other___________________
|
- Intracranial hemorrhage within last year.
- Craniotomy within 2 weeks
- Intraocular surgery within 2 weeks.
- Gastrointestinal, genitourinary hemorrhage within the last month.
- Thrombocytopenia (<50K) or coagulopathy (prothrombin time >18 seconds).
- End stage liver disease.
- Active intracranial lesions/neoplasms.
- Hypertensive urgency/emergency.
- Post-operative bleeding concerns**
|
- Immune mediated heparin-induced thrombocytopenia.
- Epidural analgesia with spinal catheter (current or planned).
|
** Scheduled return to OR within the next 24 hours: major ortho: 24 hours leeway; spinal cord or ortho spine: 7 days leeway; general surgery, status post transplant, status post trauma admission: 48 hours leeway.
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