Vte Prophylaxis Order Set

VTE PROPHYLAXIS ORDER SET

STEP 1Risk Stratify Patient (See back for Criteria) VTE Prophylaxis Steps 1-6ordered in CPOE

Low Risk - Fully ambulatory patient WITHOUT additional VTE risk factors (see VTE Risk factors on reverse) OR Minor surgery in patient without additional VTE risk factors (same day surgery or operating room time <30 minutes / Moderate Risk - All patients who are not in either the low or high risk group. These patients have one or more risk factors (see back of sheet) / High Risk - Hip or Knee arthroplasty or replacement
-Multiple major trauma
-Abdominal/ pelvic surgery for cancer
-Stroke
-All Critical Care patients
STEP 2 Select Appropriate Pharmacologic and Mechanical Therapy (Read options carefully prior to selecting
Low Risk: If low risk is chosen then:
No VTE prophylaxis needed
Early Ambulation / Moderate Risk–Select one pharmacologic therapy or document a contraindication in step 3.
Enoxaparin 40mgSubq daily
Enoxaparin 30mgSubq daily(with CrCl20-30mL/min); [If CrCl <20mL/min, order heparin]
Enoxaparin 40mgSubq Q12hours
(BMI 40-50kg/m2)
 Enoxaparin 60mg Q 12hrs (BMI > 50kg/m2)
Heparin 5000 units SubqQ8 hours
Heparin 5000 units SubqQ12 hours (Patients >75 years or weight <50 kg)
Moderate risk: If pharmacologic contraindication is documented then Apply Intermittent Pneum. Compression Device 18 hrs/day / High Risk – Select one pharmaco. therapy AND mechanical therapy OR document contraindications in step 3
Enoxaparin 40mgSubq daily
Enoxaparin 30mgSubq daily(with CrCl<30mL/min)
Enoxaparin 40mgSubq Q12hours
(BMI 40-50kg/m2)
 Enoxaparin 60mgSubqQ 12hrs (BMI > 50kg/m2)
Enoxaparin 30mg Subq Q12 hours (knee arthroplasty) First dose 12-18 hours post-op
Enoxaparin 30mg Subq daily (knee arthroplasty and CrCl <30mL/min)
Heparin 5000 units SubqQ8 hours
Heparin 5000 units SubqQ12 hours (Patients >75 years or weight <50 kg
High risk patient:Apply Intermittent Pneum. Compression device 18 hrs/dayunless contraindicated below.
STEP 3Document any Contraindications OR reason not to order mechanical AND/OR pharmacologic treatment)
Contraindication to mechanical VTE prophylaxis:
 Patient is Comfort Measures Only Patient has skin lesions on both legs Other (specify)______
 Patient intolerant  Severe peripheral vascular disease
Contraindications to Pharmaco-Prophylaxis (*= ABSOLUTE: All others cautionary)
Severe trauma to head or spinal cord with hemorrhage in last 4 wks*
Known hypersensitivity to heparin or pork products*
Neuroaxial blocks with or without catheters(current or planned)*; may begin
prophylaxis 12 hours post catheter removal
Immune-mediated heparin-induced thrombocytopenia*
Intracranial hemorrhage-acute stroke; do not use prophylaxis for 48 hours, then consult neurology
High Risk for Post-operative bleeding concerns (e.g. vascular access/biopsy sites inaccessible to hemostatic control)
Thrombocytopenia (<50K) or coagulopathy (prothrombin time > 18s
Other (MUST SPECIFY)______/ Active hemorrhage *
Subarachnoid hemorrhage *
Warfarin use in pregnancy
Active intracranial lesions/neoplasms
Craniotomy within 2 weeks
Gastrointestinal, genitourinary hemorrhage within the last 6 months
Intraocular surgery within 2 weeks
Diabetic retinopathy
Hypertensive urgency/emergency
STEP 4 Reasons to Not order additional Pharmacologic Prophylaxis:
 INR ≥2 and on Coumadin
 Patient on heparin drip
 Patient on therapeutic Enoxaparin
 Patient is on Arixtra/Fondaparinux
Other______/  Patient is on Comfort Measures Only
 Patient refuses all VTE prophylaxis
 Patient is <18 years old
Patient on Oral Factor Xa Inhibitor due to______(see all-inclusive list of acceptable reasons on back)

STEP 5 Patients undergoing surgery:Pre-op

Hold Pharmacologic prophylaxis 12 hours prior to surgery

STEP 6 Patients undergoing surgery:Post-op

First dose Pharmacologic prophylaxis 12-18 hours post-surgery.

For Reference Only

Venous Thromboembolism Risk Factors

Age >60 years
Myeloproliferative disorder
Congestive heart failure
Active malignancy
Moderate to major surgery
Smoker
Central Venous catheter / Prior history VTE
Impaired mobility
Inflammatory bowel disease
Active rheumatic disease
Sickle cell disease
Estrogen-based contraceptives/
Hormone replacement therapy / Acute or chronic lung disease
Obesity
Known hypercoaguable state
Nephrotic syndrome
Myocardial Infarction
Sepsis
Trauma

All-Inclusive List for using Oral Factor Xa Inhibitor

Atrial fibrillation
Atrial flutter
Hx of remote episode of documented afib/flutter except within 8 weeks following CABG
Treatment of venous thromboembolism / Total/partial hip arthroplasty
Total/partial hip replacement
Total knee arthroplasty
Total knee replacement