Venous Thromboprophylaxis in Acutely Ill Adult Medical ...



Yes

No

Yes

Yes

No

No

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NICE Additional Risk Factors for VTE (any one of) - tick box:

• Malignancy or cancer therapy

• Personal/Family history of VTE / thrombophilia

• Certain medical conditions - acute MI (within last 12/52), heart failure, sepsis, respiratory failure, acute medical illness, myeloproliferative disease, para-proteinaemia, previous ischaemic stroke, inflammatory bowel disease, nephrotic syndrome, Behcet’s disease, paroxysmal nocturnal haemoglobinuria, antiphospholipid sy.

• Hormone therapy - combined oral contraceptives, HRT, high dose progestogens, selective oestrogen receptor modulators

• Pregnancy and the postpartum period (up to 6/52)

• Obesity (BMI > 30kg/m2)

• Immobility e.g. bed/chair ridden >50% of day

• Age >60 years

• Dehydration

• Smoking

• Major trauma and trauma to lower extremities

• Central venous line

• Varicose veins with thrombophlebitis

Hospital No

Surname

First name

DOB

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Adult Medical Inpatient VTE Risk Assessment Chart

All relevant section tick boxes to be completed including relevant risk factors and contra-indications. All relevant yes/no bubbles should be circled.

Refer to full guideline which includes monitoring requirements.

Assessors Name: Date:

Assessors Position: Time:

Assessors Signature:

Does the patient have:

• Severe Congestive Cardiac Failure

OR

• Severe Respiratory disease

OR

• Immobility (expected to last > 72 hours) WITH an additional risk factor for VTE

Is the patient bleeding or at high risk of bleeding?

□ No thromboprophylaxis required

□ No prescription, reassess on ward round

Mechanical prophylaxis only

□ below knee GCS (TEDS)

Are heparins contra-indicated?

YES

YES

NO

YES

Does the patient have chronic kidney disease? (eGFR150micromol/L).

NO

YES

NO

NO

Contra-indications to UFH/LMWH – tick box:

• Allergy to heparin or LMWH

• Therapeutic dose LMWH or IV heparin prescribed

• On oral anticoagulant with INR > 2

• Thrombocytopenia (platelets < 100x109/L)

• Known bleeding disorder or haemophilia

• Previous heparin-induced thrombocytopenia (HIT)

• Evidence of active bleeding

• Severe hypertension (BP systolic >200 or diastolic >120mmHg)

• Lumbar puncture/epidural/spinal analgesia expected within next 12 hours

• Lumbar puncture/epidural/spinal analgesia in previous 4 hours (24 hours if traumatic)

• New CVA (ischaemic ( ................
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