DVT Prophylaxis - PBworks



GENERAL GUIDELINE OF VTE PROPHYLAXISClinical judgment should always be used in utilizing the guideline.References:AAOS Clinical Guideline (Prevention of Symptomatic Pulmonary Embolism Guideline 2007)MedQIC-Surgical Care Improvement Project. Specifications Manual for National Hospital Inpatient Quality Measures. Discharges 10-01-08 (4Q08) through 03-31-09 (1Q09)Prevention of venous thromboembolism: ACCP Evidence-Based Clinical Practice Guidelines (8th edition) Chest 2008;133(6):381S-453SRegional Anesthesia in the Anticoagulated patient: Defining the Risks (The Second American Society of Regional Anesthesia Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Aesth Pain Med 2003;28:172-197.Abbreviations:Sequential Compression devices (SCD)Arterial Venous Impulse Boots (AVI)- Low-dose unfractionated heparin (LDUH)- Low molecular weight heparin (LMWH)- Central Venous Catheter (CVC)Risk factor stratification is based on individual predisposing factors and the risk associated with current illness or procedureMechanical Methods of ProphylaxisSCD or AVI alone or in combination with aspirin in orthopedic surgery patients with documented high risk of bleeding is recommendedSCD or AVI as an adjunct to anticoagulant-based prophylaxisEnsure correct size and application of the mechanical device, and optimal complianceNeuraxial anesthesia/analgesia (NAA) [spinal or epidural anesthesia and continuous epidural anesthesia] -Avoid neuraxial anesthesia/analgesia (NAA) in patients with a known bleeding disorderAvoid NAA in patients whose preoperative hemostasis is impaired by antithrombotic drugsNSAID (generally safe)Clopidogrel should be discontinued 5-14 days prior to NAANeedle insertion: at least 8-12 hours after a subcutaneous (SubQ) dose of unfractionated heparin (UFH) or a twice daily prophylactic dose of low molecular weight heparin (LMWH), or at least 18 hours after a once-daily dose of LMWHNeedle removal: Remove an epidural catheter when the anticoagulant effect is at a minimum just before the next scheduled SubQ injectionDelay anticoagulant prophylaxis for at least 2 hours after spinal needle or epidural catheter removalDelay anticoagulation if a hemorrhagic aspirate is encountered during the initial spinal needle placementIf on prophylaxis with warfarin, remove a catheter when INR <1.5Fondaparinux prophylaxis appears to be safe in patients who have received a spinal anesthetic only if needle placement was atraumatic and accomplished on the first attempt, but should be avoided with continuous epidural analgesiaVENOUS THROMBOEMOLISM RISK ASSESSMENTAcute medical illnessAge >65Cancer (active or occult)Cancer therapy (hormonal, chemo- or radio-therapy, angiogenesis inhibitors)Estrogen-based OC or HRTErythropoiesis-stimulating agentsImmobility, lower-extremity paresisIndwelling central venous catheterInflammatory bowel disease Inherited or acquired thrombophiliaMyeloproliferative disordersNephrotic syndromeObesityParoxysmal nocturnal hemoglobinuriaPregnancy and post-partum periodPrevious VTESelective estrogen receptor modulatorsSurgeryTrauma (major or lower extremity)Venous compression (tumor, hematoma, arterial abnormalityThis is not a permanent part of the medical record. Please discard after completing form.VTE Prophylaxis Selection by Surgery1 Patients who receive neuraxial anesthesia or have a documented contraindication to pharmacological prophylaxis may pass the performance measure if either appropriate pharmacologic prophylaxis or mechanical prophylaxis is ordered.2Recommendations are from the Specifications Manual for National Hospital Quality Measures 10-01-08 (4Q08) through 03-31-09 (1Q09) SCIP-VTE 2-5. AAOS refers to the SCIP Guidelines for patients with high risk of bleeding. SurgeryRecommended Prophylaxis1SurgeryRecommended Prophylaxis1Intracranial Neurosurgery General SurgeryGeneral Surgery with high risk for bleedingGynecologic SurgeryUrologic SurgeryAny of the following:SCD with LDUHLMWHLDUH or LMWH* combined with SCD*Current guidelines recommend postoperative LMWH for Intracranial NeurosurgeryAny of the following:LDUHLMWHFondaparinuxLDUH or LMWH or Fondaparinux combined with SCDAny of the following:SCDAny of the following:LDUHLMWHFondaparinuxSCDLDUH or LMWH or Fondaparinux combined with SCDAny of the following:LDUHLMWHFondaparinuxSCDLDUH or LMWH or Fondaparinux combined with SCDElective Total Hip ReplacementElective Total Hip Replacement with contraindications to pharmacological prophylaxisElective Total Knee ReplacementHip Fracture SurgeryHip Fracture Surgery with contraindications to pharmacological prophylaxisAny of the following:LMWHFondaparinuxWarfarinAny of the following:SCDAVIAny one of the above plus aspirin2Any of the following:LMWHFondaparinuxWarfarinSCDVFPAny of the following:LDUHLMWHFondaparinuxWarfarinAny of the following:SCDAVIAny one of the above plus aspirin2Abbreviations:Sequential Compression devices (SCD)Arterial Venous Impulse Boots (AVI)- Low-dose unfractionated heparin (LDUH)- Low molecular weight heparin (LMWH)- Central Venous Catheter (CVC)This is not a permanent part of the medical record. Please discard after completing form.Adult VTE Risk Assessment and Physician OrderPhysician: Please check risk factor(s) below and order prophylaxis.Acute medical illnessAge >65Cancer (active or occult)Cancer therapy (hormonal, chemo- or radio-therapy, angiogenesis inhibitors)Estrogen-based OC or HRTErythropoiesis-stimulating agentsInherited or acquired thrombophiliaImmobility, lower-extremity paresisIndwelling central venous catheterInflammatory bowel diseaseMyeloproliferative disorderNephrotic syndromeObesityParoxysmal nocturnal hemoglobinuriaPregnancy or post-partum periodPrevious VTESelective estrogen receptor modulatorsSurgeryTrauma (major or lower extremity)Venous compression (Tumor, hematoma, arterial abnormalityPharmacological and Mechanical Prophylaxis Safety Assessment (Physician to check those that apply)Pharmacological Prophylaxis Contraindication(s):Is patient experiencing any active bleeding?Does patient have (or has had history of) heparin-induced thrombocytopenia?Is patient’s platelet count <100,0003/mm?Is patient already on anticoagulant therapy (warfarin, heparin, LMWH, or fondaparinux)?Is patient’s creatinine clearance abnormal (<30 ml/min)? Fondaparinux is contraindicated.Other:If any of the above boxes are checked, the patient may not be a candidate for anticoagulant therapy. Consider alternative prophylactic measures (mechanical prophylaxis) in Section B below.B. Mechanical Prophylaxis Contraindications(s):Does patient have severe peripheral arterial disease?Does patient have congestive heart failure (peripheral edema)?Does patient have an acute superficial/deep vein thrombosis?Does patient have skin conditions (dermatitis, open skin lesions, gangrenous condition, or lymphedema)?Other:If any of the above boxes are checked, then patient may not be a candidate for a sequential compression device.Post-Op Physician’s Order (please check one):Prophylaxis is not indicated as checked above or other reason ___________________________________________________________________________________________________________________Prophylaxis has already been orderedPlace SCD (Sequential Compression Device) or AVI (Arterial Venous Impulse Boots) AND Aspirin 325 mg ______ daily For all post op surgical patients, start the first dose on the morning of POD one or as indicated below.Enoxaparin 40 mg SubQ daily, first dose at ___________. Pharmacy to adjust the dose, if CrCl < 30 ml/min.Enoxaparin 30 mg SubQ twice daily, first dose at ___________. Pharmacy to adjust the dose, if CrCl < 30 ml/min.Fondaparinux 2.5 mg SubQ daily, first dose at ___________. (contraindicated, if CrCl < 30 ml/min)Unfractionated heparin 5000 units every 8 hours, first dose at ___________. Warfarin ________ mg PO, first dose at ___________ and daily (until INR ______) and daily INRPhysician SignatureIDDateTimeAdult VTE Risk Assessment & Physician OrdersTrial Form*0940770* ................
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