VTE Prophylaxis Potential Contraindication to VTE Prophylaxis (INCLUDING BUT NOT LIMITED TO) Contraindications to pharmacologic Order mechanical prophylaxis prophylaxis? (See reverse) Y & document “opt out” reason on protocol Absolute Relative Other • Active hemorrhage • ICH in last 12 mos. • Immune-mediated • Recent acute major • Craniotomy in last 2 weeks HIT Re-evaluate risk daily N trauma • Intra-ocular surgery in last 2 • Recent arteriotomy • Spine or intracranial weeks • Anticipated What is patient’s risk for VTE: Low, Moderate/High or Very High? surgery in last 72 hrs • GI/GU bleed in last 30 days admission <48 hrs (See reverse) • Thrombolytics w/in • PLT <50K or coagulopathy last 24 hrs • End-stage liver disease • Active intracranial neoplasm Low Moderate/High or Very High • Hypertensive emergency • Post-op bleeding concerns
Spinal/Epidural UFH 5000 units SQ q8h Y or The risk vs benefit of VTE prophylaxis must be considered in each patient. Are you sure Anesthesia? Enox 40mg SQ daily Contraindications must be interpreted with caution and analyzed on a case-by- there are no case basis. For example, if a patient has minor bleeding, but their risk of VTE is VTE risk exponentially greater, it may be advisable to implement pharmacologic VTE factors? N prophylaxis with UFH which has a short half-life and is reversible. Conversely, if (See reverse) a patient’s bleeding risk is deemed to be greater than clotting risk, mechanical BMI ≥ 40? Y CrCl ≤ 30ml/min? methods may be a better option. Call anticoagulation pharmacist to discuss if you have questions or are unsure (264-6970)
N N N Potential risk factors for VTE Y Y (INCLUDING BUT NOT LIMITED TO)
Underweight? Fonda 2.5mg SQ daily Acute medical illness MI Re-evaluate (<50 kg) Y or risk Enox 0.5 mg/kg SQ Age > 50 yrs Myeloproliferative disorder BID (very high risk) Anesthesia Nephrotic syndrome or Central venous catheter Obesity Mechanical N Call Enox 0.5 mg/kg SQ Dehydration Pregnancy or no clinical DAILY Diabetes Post-partum prophylaxis pharmacy (moderate/high risk) Erythropoesis-stimulating agents Rheumatic disease CrCl ≤ 30ml/min? to Estrogen-based contraceptives Sepsis discuss (Consider checking Heart failure Sickle cell disease dosing HEPXA or Fonda UFH 5000 units SQ q8h Y N options History of VTE (family or patient) Spinal cord injury or Hormone replacement Stroke Call clinical pharmacy to Hypertension Surgery (moderate to major) discuss dosing options Fonda 2.5mg SQ daily (moderate/high/very high risk) Immobility Thrombophilia (eg- FVL, Prot C def) or Inflammatory bowel disease Trauma UFH 5000 units SQ q8h (moderate/high risk) Lung disease (acute or chronic) Vasculitis or Enox 40mg SQ daily (moderate/high risk) Malignancy Varicose veins or Venous access Enox 30mg SQ BID (very high risk) Risk Level (No HEPXA or Fonda levels needed) Low: (<10% of our patients) ambulating as much as they would at home and have none of the VTE risk factors listed above
*UFH= unfractionated heparin Moderate/high: (most of our patients) all patients not at low or very high risk (Call Allison Burnett, PharmD with questions 306-8987) Other resources: Very high risk: hip/knee arthroplasty, hip fracture, trauma, spinal cord injury 1) Call your area PCAP 2) anticoagulant dosing guideline on pharmacy webpage https://hospitals.health.unm.edu/intranet/pharmacy/documents/anticoagulantdosingguideline