Suggestions for substitution of DVT Prophylaxis ...



SUGGESTIONS FOR SUBSTITUTION OF DVT PROPHYLAXIS RECOMMENDATIONS ON ORDER SETS (as of June 7th, 2010)ACUTE PAIN SERVICE (APS) ORDER FORM CONTINUOUS EPIDURAL INFUSION: PR 37006Notify APS before administering any of the following medications: ASA, clopidogrel, ticlopidine, enoxaparin (dose > 40 mg/day), IV heparin or warfarin.ACUTE PAIN SERVICE (APS) ORDER FORM PERIPHERAL NERVE BLOCK: PR 37012Notify APS before administering any of the following medications: ASA, clopidogrel, ticlopidine, enoxaparin (dose > 40 mg/day), IV heparin or warfarin.ROSS TILLEY BURN CENTRE (RTBC) ADMISSION ORDERS: PR 09021Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:enoxaparin (Lovenox?) 40 mg sc QHSenoxaparin (Lovenox?) 30 mg? sc QHS for patients weighing less than 40 kg or? with CrCl less than 30mL/min enoxaparin (Lovenox?) 40 mg sc BID for patients weighing greater than 100 kgFor high risk bleeding ONLY, properly measured, bilateral, below-the-knee TED stockings.? Reassess daily for conversion to enoxaparinNO prophylaxis – REASON: _____________________________________________. Reassess daily for conversion to enoxaparin.STANDARD CARDIOLOGY WARD ADMISSION ORDERS: PR 69026Venous Thromboembolism (VTE) Prophylaxis (see guidelines on back)Patient must NOT be receiving any CONCURRENT therapeutic anticoagulantChoose ONE of the following:enoxaparin 40 mg sc QHS enoxaparin 30 mg? sc QHS for patients weighing less than 40 kg or? with CrCl less than 30 mL/min if enoxaparin not ordered, give REASON:___________________________________. Reassess daily for conversion to enoxaparin. Note: back of order sheet has addition info on prevention of VTE. Proposed change:STEP 3: PROVIDE THROMBOPROPHYLAXISFor almost all patients, the recommended thromboprophylaxis is enoxaparin 40 mg sc QHSReduce the dose to 30 mg sc QHS for patients with CrCl less than 30mL / min or weight less than 40 kg POST-OPERATIVE ORDERS FOR CARDIOVASCULAR SURGERY PATIENTS: PR 36000ANTIPLATELET/ANTICOAGULANT THERAPY: Do not start warfarin until patient extubated and chest tubes, central lines, IABP removed.?Hold treatment dose of enoxaparin at least 12h before removal of chest tubes, central lines, IABP, epicardial pacemaker wires or surgical procedures.?Delay next dose of enoxaparin until at least 2h after line/tube removal and at least 12h after surgical procedures.?Do NOT hold prophylactic enoxaparin (30 mg or 40 mg) for procedures.Refer to Abbreviation Legend on back of page 2Physician ordering instructions: Check one of the following regimens (Orders 54-57). If patient has undergone more than 1 surgical procedure, select the surgical procedure requiring more intensive anticoagulation.* Chest tube drainage criteria: less than 300 mL in previous 6h54. ? Isolated, on-pump CABG ? tissue AVR without an indication for therapeutic anticoagulationenoxaparin 30 mg sc QHS#. Start if chest tube drainage criteria met*EC ASA 81 mg po daily. Start when chest tube drainage criteria met*55. Isolated CABG and coronary patch arterioplasty, coronary endarterectomy, or off-pump bypassenoxaparin 30 mg sc QHS#. Start if chest tube drainage criteria met*EC ASA 81 mg po daily. Start when chest tube drainage criteria met*. clopidogrel 75 mg po daily, starting the day after chest tubes removed56. ? Isolated CABG and Maze procedure or chronic atrial fibrillation ? tissue MVR ? mitral annuloplasty ?mechanical AVR or?tissue AVR with indication for therapeutic anticoagulation: Check indication(s) for therapeutic anticoagulation for tissue AVRSustained or intermittent atrial fibrillation for longer than 48 hMaze procedureGrade IV left ventricleOther (Specify): _________________enoxaparin 30 mg sc QHS#. Start if chest tube drainage criteria met*warfarin po daily. Start when chest tube drainage criteria met*. Target INR range = 2.0-3.0 If INR less than 2.0 at 96h post-operative, obtain order to increase enoxaparin to treatment** dose57. Mechanical MVRenoxaparin 40 mg sc QHS#. Start if chest tube drainage criteria met*warfarin po daily. Start when chest tube drainage criteria met*. Target INR range = 2.5-3.5If INR less than 2.0 at 96h post-operative, obtain order to increase enoxaparin to treatment** doseTable 1. Daily Treatment Doses of Enoxaparin According to Weight and Renal Function. Refer to Abbreviation Legend on back of page 2.**Patient weight (kg)Treatment dose enoxaparin for CrCl* greater than 30 mL/min (dose: 1mg/kg sc BID)Treatment dose enoxaparin for CrCl* less than or equal to 30 mL/min (dose: 1mg/kg sc once daily)Less than 36 kgConsult ThromboembolismConsult Thromboembolism36 – 4040 mg sc BID40 mg sc once daily41 - 4540 mg sc BID40 mg sc once daily46 – 5040 mg sc BID40 mg sc once daily51 – 5560 mg sc BID60 mg sc once daily56 – 6060 mg sc BID60 mg sc once daily61 – 6560 mg sc BID60 mg sc once daily66 – 7060 mg sc BID60 mg sc once daily71 – 7580 mg sc BID80 mg sc once daily76 – 8080 mg sc BID80 mg sc once daily81 – 8580 mg sc BID80 mg sc once daily86 – 9080 mg sc BID80 mg sc once daily91 – 95100 mg sc BID100 mg sc once daily96 – 100100 mg sc BID100 mg sc once daily101 – 105100 mg sc BID100 mg sc once daily106 – 110100 mg sc BID100 mg sc once daily111 – 115120 mg sc BID120 mg sc once daily116 – 120120 mg sc BID120 mg sc once daily121 – 125120 mg sc BID120 mg sc once daily126 – 130120 mg sc BID120 mg sc once dailyGreater than 130 Consult ThromboembolismConsult Thromboembolism * Creatinine Clearance can be estimated using the following formula:CrCl (mL/min) = (140-age)(actual body weight in kg) x 1.2 [x 0.85 if female]Serum creatinine (mmol/L)An on-line calculator for creatinine clearance is available on the Sunnybrook intranet under:Quick Links – Pharmacy – Alphabetical Index – letter C – Creatinine clearance calculatoror at: Dosing Considerations for prophylactic enoxaparin:For weight greater than 100 kg, double enoxaparin prophylaxis dose If CrCl less than 30mL/min AND weight less than 40 kg, give enoxaparin 20 mg sc QHSIf CrCl less than 30mL/min AND weight greater than 100 kg, give enoxaparin 40 mg sc QHSWard Transfer Orders for Cardiovascular Surgery Patients: PR 36001Table 1. Daily Treatment Doses of Enoxaparin According to Weight and Renal Function.Patient weight (kg)Treatment dose enoxaparin for CrCl* greater than 30 mL/min(dose: 1 mg/kg sc BID)Treatment dose enoxaparin for CrCl* less than or equal to 30 mL/min(dose: 1 mg/kg sc once daily)Less than 36 kgConsult ThromboembolismConsult Thromboembolism36 – 4040 mg sc BID40 mg sc once daily41 – 4540 mg sc BID40 mg sc once daily46 – 5040 mg sc BID40 mg sc once daily51 – 5560 mg sc BID60 mg sc once daily56 – 6060 mg sc BID60 mg sc once daily61 – 6560 mg sc BID60 mg sc once daily66 – 7060 mg sc BID60 mg sc once daily71 – 7580 mg sc BID80 mg sc once daily76 – 8080 mg sc BID80 mg sc once daily81 – 8580 mg sc BID80 mg sc once daily86 – 9080 mg sc BID80 mg sc once daily91 – 95100 mg sc BID100 mg sc once daily96 – 100100 mg sc BID100 mg sc once daily101 – 105100 mg sc BID100 mg sc once daily106 – 110100 mg sc BID100 mg sc once daily111 – 115120 mg sc BID120 mg sc once daily116 – 120120 mg sc BID120 mg sc once daily121 – 125120 mg sc BID120 mg sc once daily126 – 130120 mg sc BID120 mg sc once dailyGreater than 130 Consult ThromboembolismConsult Thromboembolism* Creatinine Clearance can be estimated using the following formula:CrCl (mL/min) = (140-age)(actual body weight in kg) x 1.2 [x 0.85 if female]Serum creatinine (mmol/L)An on-line calculator for creatinine clearance is available on the Sunnybrook intranet under:Quick Links – Pharmacy – Alphabetical Index – letter C – Creatinine clearance calculatoror at: ordering instructions: Select only one of the following regimens (a-d). If patient has undergone more than 1 surgical procedure, select the regimen (a-d) for the surgical procedure requiring more intensive anticoagulation. * Chest tube drainage criteria: less than 300 mL in previous 6h**Treatment dose enoxaparin dosing chart on Table 1 above. a) ? Isolated, on-pump CABG ? tissue AVR without an indication for therapeutic anticoagulationenoxaparin 30 mg sc QHS#. Start if chest tube drainage criteria met*EC ASA 81 mg po daily. Start when chest tube drainage criteria met*b) Isolated CABG and coronary patch arterioplasty, coronary endarterectomy, or off-pump bypassenoxaparin 30 mg sc QHS#. Start if chest tube drainage criteria met*EC ASA 81 mg po daily. Start when chest tube drainage criteria met*. clopidogrel 75 mg po daily, starting the day after chest tubes removedc) ? Isolated CABG and Maze procedure or chronic atrial fibrillation ? tissue MVR ? mitral annuloplasty?mechanical AVR or ?tissue AVR with indication for therapeutic anticoagulation: Check indication(s) for therapeutic anticoagulation for tissue AVRSustained or intermittent atrial fibrillation for longer than 48 hMaze procedureGrade IV left ventricleOther (Specify): _______________enoxaparin 30 mg sc QHS#. Start if chest tube drainage criteria met*warfarin po daily. Start when chest tube drainage criteria met*. Target INR range = 2.0-3.0 If INR less than 2.0 at 96h post-operative, obtain order to increase enoxaparin to treatment** dosed) Mechanical MVRenoxaparin 40 mg sc QHS#. Start if chest tube drainage criteria met*warfarin po daily. Start when chest tube drainage criteria met*. Target INR range = 2.5-3.5# Dosing Considerations for prophylactic enoxaparin:For weight greater than 100 kg, double enoxaparin prophylaxis dose If CrCl less than 30mL/min AND weight less than 40 kg, give enoxaparin 20 mg sc QHSIf CrCl less than 30mL/min AND weight greater than 100 kg, give enoxaparin 40 mg sc QHSIf INR less than 2.0 at 96h post-operative, obtain order to increase enoxaparin to treatment** doseANTIPLATELETS/ANTICOAGULANTS:(Physician to reference regimens on the back of page 3 AND confirm with CVICU orders and kardex for most recent therapy)EC ASA 81 mg po dailyclopidogrel 75 mg po daily, start day after chest tubes removed enoxaparin _____________ mg sc ___________ (frequency) warfarin po dailyDaily CBC and INRDo not start warfarin until all chest tubes and epicardial pacemaker wires are removed If patient is receiving warfarin and INR less than 2.0 at 96h postoperative, obtain physician order to increase enoxaparin to treatment dose. Physician to use enoxaparin dosing table on back of page 3. When treatment dose enoxaparin is ordered:Hold AM dose for removal of chest tubes or epicardial wires or surgical proceduresGive same dose 2h post line removals or 12h post surgical procedureBloodwork: CBC, INR daily and urea/creatinine every other day GENERAL INTERNAL MEDICINE STANDARD ADMISSION ORDERS: PR 99979Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:enoxaparin (Lovenox?) 40 mg sc QHSenoxaparin (Lovenox?) 30 mg? sc QHS for patients weighing less than 40 kg or? with CrCl less than 30mL/min properly measured, bilateral, below-the-knee TED stockings because of:active bleedinghemorrhagic stroke in past 7 days Reassess daily for conversion to enoxaparinNO prophylaxis – REASON: _____________________________________________. Reassess daily for conversion to enoxaparin.On back of page of GIM order sheet, table:Excerpt from:Guidelines for Prevention and Treatment of Venous ThromboembolismIndicationRecommendations for ProphylaxisMedical patients (e.g. congestive heart failure, severe respiratory disease, confined to bed with active cancer, previous venous thromboembolism, sepsis, acute neurologic disease, inflammatory bowel disease, etc.) Enoxaparin 40 mg SC daily at bedtime* OR Enoxaparin 30 mg SC daily at bedtime for patients with CrCl < 30mL/min** or weighing less than 40 kgFor patients at high risk of bleeding only, properly measured, bilateral, below-the-knee TED stockings. Reassess daily for conversion to enoxaparin.Stroke, hemorrhagic Properly measured, bilateral, below-the-knee TED stockings initially; reassess daily for conversion to enoxaparin. When “safe”: Enoxaparin 40 mg SC daily at bedtime* OR Enoxaparin 30 mg SC daily at bedtime for patients with CrCl < 30mL/min** or weighing less than 40 kgStroke, non-hemorrhagic Enoxaparin 40 mg SC daily* at bedtime Enoxaparin 30 mg SC daily at bedtime for patients with CrCl < 30mL/min** or weighing < 40 kgFor patients at high risk of bleeding only, properly measured, bilateral, below-the-knee TED stockings. Reassess daily for conversion to enoxaparin.* Consider increasing the dose of enoxaparin to 40 mg SC BID for patients weighing more than 100 kg** Consider giving enoxaparin 40 mg SC daily for patients with CrCl < 30mL/min and weighing > 100 kgStandard Admission Orders for Acute Stroke: PR 74021 Venous Thromobembolism (VTE) Prophylaxis. Choose ONE of the following:enoxaparin 40 mg sc QHSenoxaparin 30 mg? sc QHS for patients weighing less than 40 kg or? with CrCl less than 30mL/min For high risk bleeding ONLY, properly measured, bilateral, below-the-knee TED stockings.? Reassess daily for conversion to enoxaparinNO prophylaxis – REASON: _____________________________________________. Reassess daily for conversion to enoxaparin.PRE-OPERATIVE ORDERS FOR HEPATOBILIARY, PANCREATIC & GASTRIC SURGERY – DAY OF SURGERY: PR 14086 Venous Thromboembolism (VTE) Prophylaxis – choose ONE of the following:enoxaparin 40 mg sc to be sent with the patient to the operating room for administrationenoxaparin 30 mg sc (if weight less than 40 kg or CrCl less than 30mL/min) to be sent with the patient to the operating room for administrationno pre-op anticoagulant prophylaxis (e.g. for liver resection)PREOPERATIVE ORDERS FOR GYNAECOLOGIC ONCOLOGY PROCEDURES: PR 80021 (no anticoagulant order)POSTOPERATIVE ORDERS FOR GYNAECOLOGIC ONCOLOGY PROCEDURES: PR 46002Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:enoxaparin (Lovenox?):40mg sc QHS starting tonight (2200 hours) 40mg sc daily starting tomorrow morning (1000 hours)enoxaparin (Lovenox?) (for patients weighing less than 40 kg or with CrCl less than 30 mL/min): 30 mg sc QHS starting tonight (2200 hours) 30 mg sc daily starting tomorrow morning (1000 hours)If enoxparin not odered, give REASON:____________________________________. Reassess daily for conversion to enoxaparinADMISSION ORDERS FOR PATIENTS WITH HIP FRACTURE: PR 68053Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:enoxaparin (Lovenox?) 30 mg sc QHS. Do not hold enoxaparin if patient is scheduled for surgery tomorrow morning. If enoxaparin not ordered, give REASON:__________________________POST OPERATIVE ORDERS FOR PATIENTS WITH HIP FRACTURE: PR 68054Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:enoxaparin (Lovenox?):40mg sc QHS starting tonight (2200 hours) 40mg sc daily starting tomorrow morning (1000 hours)enoxaparin (Lovenox?) (for patients weighing less than 40 kg or with CrCl less than 30 mL/min): 30 mg sc QHS starting tonight (2200 hours) 30 mg sc daily starting tomorrow morning (1000 hours)If enoxparin not odered, give REASON:____________________________________. Reassess daily for conversion to enoxaparinADMISSION ORDERS FOR PATIENTS WITH LOWER EXTREMITY FRACTURE: PR 68055Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:enoxaparin 40 mg sc QHS. Do not hold enoxaparin if surgery is scheduled for tomorrow morning.enoxaparin 30 mg sc QHS (for patients weighing less than 40kg or with CrCl less than 30mL/min). Do not hold enoxaparin if surgery is scheduled for tomorrow morning.If enoxaparin not ordered, give REASON:___________________________________ POST OPERATIVE ORDERS for patients with LOWER EXTREMITY FRACTURE: PR 68056Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:enoxaparin (Lovenox?):40mg sc QHS starting tonight (2200 hours) 40mg sc daily starting tomorrow morning (1000 hours)enoxaparin (Lovenox?) (for patients weighing less than 40 kg or with CrCl less than 30 mL/min): 30 mg sc QHS starting tonight (2200 hours) 30 mg sc daily starting tomorrow morning (1000 hours)If enoxparin not odered, give REASON:____________________________________. Reassess daily for conversion to enoxaparinCRITICAL CARE UNIT ADMISSION ORDERS: PR 58045Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:enoxaparin 40 mg sc daily at 22:00henoxaparin 30 mg sc daily at 22:00h (for patients weighing less than 40 kg or with CrCl less than 30mL/minenoxaparin 40 mg sc BID at 10:00h and 22:00h (for patients weighing greater than 100 kg)For high risk bleeding ONLY, properly measured, bilateral, below-the-knee TED stockings.? Reassess daily for conversion to enoxaparinNO prophylaxis – REASON: _____________________________________________. Reassess daily for conversion to enoxaparinLEVEL-II ICU ADMISSION ORDERS: PR 99823Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:Without epidural, enoxaparin 40 mg sc daily at 22:00 h Without epidural, enoxaparin 30 mg sc daily at 22:00 h (for patients weighing less than 40kg or with CrCl less than 30 mL/min)With epidural, enoxaparin 40 mg sc daily at 10:00 hWith epidural, enoxaparin 30 mg sc daily at 10:00 h (for patients weighing less than 40kg or with CrCl less than 30 mL/min)enoxaparin 40 mg sc bid at 10:00h and 22:00h (for patients weighing greater than 100kg) For high risk bleeding ONLY, properly measured, bilateral, below-the-knee TED stockings.? Reassess daily for conversion to enoxaparinNO prophylaxis – REASON: _____________________________________________. Reassess daily for conversion to enoxaparinCRITICAL CARE TO WARD TRANSFER ORDERS: PR 14012Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:enoxaparin 40 mg sc QHSenoxaparin 30 mg sc QHS (for patients weighing less than 40 kg or with CrCl less than 30 mL/min)enoxaparin 40 mg sc bid at 10:00h and 22:00h (for patients weighing greater than 100 kg)For high risk bleeding ONLY, properly measured, bilateral, below-the-knee TED stockings.? Reassess daily for conversion to enoxaparinNO prophylaxis – REASON: _____________________________________________. Reassess daily for conversion to enoxaparinGYNECOLOGY POST-OPERATIVE ORDERS: PR 14003 (Women’s College)ANTI-THROMBOTICS Refer to table on back of page for guidelinesVenous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:enoxaparin (Lovenox?):40mg sc QHS starting tonight (2200 hours) 40mg sc daily starting tomorrow morning (1000 hours)enoxaparin (Lovenox?) (for patients weighing less than 40 kg or with CrCl less than 30 mL/min): 30 mg sc QHS starting tonight (2200 hours) 30 mg sc daily starting tomorrow morning (1000 hours)If enoxparin not odered, give REASON:____________________________________. Reassess daily for conversion to enoxaparinPost-Operative Orders for Open Aortic Vascular Surgery Patients: PR 74025 Under SCHEDULED MEDICATIONS:Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:enoxaparin 40 mg sc daily starting POD #1. Hold dose if chest tube(s) in situ and drainage > 300mL/6h enoxaparin 30 mg sc daily (for patients weighing less than 40kg or with CrCl less than 30mL/min). Hold dose if chest tube(s) in situ and drainage > 300mL/6hIf enoxaparin not ordered, give REASON:___________________________________. Reassess daily for conversion to enoxaparin. ................
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