Vascular: Venous Thromboembolism (VTE) Prophylaxis

VTE Prophylaxis

Intermittent Pneumatic Compression (IPC) Device

  • Aka Sequential Compression Devices (SCD)
  • Effects: Decreased Plasminogen Activator Inhibitor (PAI-1) – tPA Inhibitor
    • Also Has Some Decreased Venous Stasis to a Lesser Extent

Caprini Score

  • Determines Risk for VTE
  • Factors:
    • 1 Point: Age 41-60, Minor Surgery, BMI ≥ 30, Recent Major Surgery, Swollen Legs, Varicose Veins, Recent Sepsis, Abnormal Pulmonary Function (COPD), Recent MI, CHF, IBD, On Bed Rest, Pregnant/Post-Partum, Past Unexplained Spontaneous Abortion, Oral Contraceptives or Hormone Replacement
    • 2 Points: Age 61-74 Arthroscopic Surgery, Major Open Surgery (> 45 Minutes), Laparoscopic Surgery (> 45 Minutes), History of Cancer (Except Non-Melanoma Skin Cancer), Current Cancer (Except Breast or Thyroid), Confined to Bed (> 72 Hours), Immobilizing Plaster Cast, Central Venous Access
    • 3 Points: Age ≥ 75, History of VTE, Family History of VTE, Chemotherapy, Factor V Leiden, Prothrombin 20210A, Lupus Anticoagulant, Anticardiolipin Ab, Elevated Serum Homocysteine, HIT, Other Congenital or Acquired Thrombophilia
    • 5 Points: Major Surgery (> 6 Hours, Recent Stroke, Elective Major Lower Extremity Arthroplasty, Recent Hip/Pelvis/Leg Fracture, Recent Acute Spinal Cord Fracture or Paralysis, Recent Multiple Traumas
    • *Recent = < 1 Month
  • Category:
    • Score 0-4: Low Risk
    • Score 5-8: Moderate Risk
    • Score ≥ 9: High Risk

Management Based on Risk

  • Low Risk: IPC
  • Moderate-High Risk: IPC & Chemical
    • CA or IBD – Extended Treatment for 4 Weeks Postop

Sequential Compression Devices 1

Chemical Prophylaxis

Heparin (Unfractionated Heparin)

  • Dosing: 5,000 U Every 8 Hours

Lovenox (Low Molecular Weight Heparin)

  • Dosing: *See Below
  • Comparison to Heparin:
    • Generally Considered More Effective, Especially in Trauma Patients
    • Similar Mortality
  • Larger Dosing Required for Obese Patients
  • Contraindicated for Severe Renal Insufficiency (CrCl < 30 mL/min)
    • *Some Prefer Lower Dosing But Still Use

Lovenox Dosing

  • General: 40 mg Every 24 Hours
  • Obese: Debated
    • BMI ≥ 40: 40 mg Every 12 Hours
    • BMI ≥ 50: 60 mg Every 12 Hours
  • Trauma: 40 mg Every 12 Hours
    • Indications for 30 mg Every 12 Hours Dosing:
      • > 65 Years Old
      • Low Weight
      • TBI or Spinal Cord Injury
      • Pregnancy
    • Consider Adjusting by Anti-Xa Laboratory Monitoring
      • Goal Peak Levels: 0.2-0.5 IU/mL (Debated)
      • Goal Trough Levels: 0.1-0.2 IU/mL (Debated)
    • *Historically 30 mg BID was the Dose for All Trauma Patients – Newer Data Show Inadequate Prophylaxis
  • Cancer Patients: Consider Increased Dosing (Debated)

Other Options

  • Dalteparin
  • Tinzaparin
  • Nadroparin

References

  1. Koo KH, Choi JS, Ahn JH, Kwon JH, Cho KT. Comparison of clinical and physiological efficacies of different intermittent sequential pneumatic compression devices in preventing deep vein thrombosis: a prospective randomized study. Clin Orthop Surg. 2014 Dec;6(4):468-75. (License: CC BY-NC-3.0)