PLACE LABEL HERE

VENOUS THROMBOEMBOLISM (VTE)

PROPHYLAXIS ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. No Pharmacologic or Mechanical VTE Prophylaxis needed:

Low Risk / No pharmacologic or mechanical prophylaxis
Ambulate 3 times daily
  1. Pharmacologic VTE Prophylaxis:

Medical
Moderate to
High Risk /  VTE pharmacologic prophylaxis has already been ordered
 Patient is therapeutic on anticoagulant therapy, no additional orders
 Lovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 ml/min)
 Start Lovenox 24 hrs post thrombolytic therapy (tissue plasminogen activator, tPA, Activase, alteplase) for stroke
 Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg OR age > 75)
 Start Heparin 24 hrs post thrombolytic therapy (tissue plasminogen activator, tPA, Activase, alteplase) for stroke
 Contraindication: must use mechanical prophylaxis, indicate order below
 Active hemorrhage or high risk for bleeding (including post-procedural risk)
 Recent GI or GU hemorrhage < 1 month
 Thrombocytopenia, coagulopathy, history of Heparin Induced Thrombocytopenia (HIT)
 Recent head trauma, spinal cord injury, intracranial hemorrhage, or neoplasm
 Epidural or spinal catheter within past 6 hours or next 12 hours
 Uncontrolled systemic hypertension
 Patient/family refuses
 Other: ______
Surgical
Non-orthopedic
Moderate to
High Risk
  • Hold enoxaparin until epidural has been out for 12 hrs
  • Hold Heparin until epidural has been out for 2 hrs
/  VTE pharmacologic prophylaxis has already been ordered
 Patient is therapeutic on anticoagulant therapy, no additional orders
 Lovenox (enoxaparin) 40 mg SQ q24hrs, begin in AMon POD #1 (30 mg if CrCl < 30ml/min)
 Heparin 5,000 units SQ q8hrs  q12hrs begin in AM on POD #1
 Contraindication: must use mechanical prophylaxis,indicate order below
 Active bleeding/high risk for bleeding (including post-surgical or post-procedural risk)
 Thrombocytopenia, coagulopathy, history of Heparin Induced Thrombocytopenia (HIT)
 Head trauma, neurosurgery/spinal procedures
 Epidural or spinal catheter within past 6 hrs or next 12 hrs
 Patient/family refuses
 Other: ______
Surgical Orthopedic /  See Orthopedic Post-op Orders for DVT prophylaxis.
  1. Mechanical VTE Prophylaxis:

Moderate to
High Risk
Optional unless contraindication to pharmacologic prophylaxis /  VTE mechanical prophylaxis has already been ordered
 Sequential Compression Device (SCD)
 Contraindication, no additional orders
 Known or Suspected DVT
 Severe Ischemic vascular disease
 Local condition (gangrene, leg wounds, skin graft, cellulitis, amputee)
 Other: ______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

*2-33058* FORM 2-33058 REV. 06/2015 Page 1 of 2

PLACE LABEL HERE

VENOUS THROMBOEMBOLISM (VTE)

PROPHYLAXIS ORDERS

Reference Page

Venous Thromboembolism (VTE) Risk Factors

Age > 50 years / Prior History of VTE / Active or chronic lung disease
Myeloproliferative Disorder / Impaired Mobility / Obesity
Dehydration / Inflammatory bowel disease / Known thrombophilic state
CHF / Active rheumatic disease / Varicose veins/chronic stasis
Active malignancy / Sickle cell disease / Recent post-partum w/immobility
Hormonal replacement / Estrogen based contraceptives / Nephrotic syndrome
Moderate to Major Surgery / Central venous catheter / Myocardial Infarction

Risk Factor Guide for VTE in Hospitalized Medical Patients

(Padua Prediction Score Risk Assessment Model – CHEST, 2012)

Risk Factor / Points
Active Cancer
Patients with local or distant metastases and or in whom chemotherapy or radiotherapy has been performed in the past 6 months / 3
Previous VTE
With exclusion of superficial vein thrombosis / 3
Reduced Mobility
Anticipated bed rest w/ bathroom privileges because of patient limitations or Physician orders for at least 3 days / 3
Already known thrombophilic condition
Defects of antithrombin, protein C or S, factor V Leiden, antiphospholipid syndrome / 3
Recent (< 1 month) trauma or surgery / 2
Elderly age (> 70 y) / 1
Heart or Respiratory failure / 1
Acute myocardial Infarction or ischemic stroke / 1
Acute Infection or rheumatologic disorder / 1
Obesity (BMI > 30) / 1
Ongoing hormonal treatment / 1
High risk for VTE is defined by a cumulative score equal or greater than 4. In those cases, pharmacologic prophylaxis is strongly recommended, unless contraindicated.

Disclaimer:

This chart is a guide only to help physicians assess VTE risk. It should not be used as a substitute for medical judgement.

Risk Factor Guide for VTE in Hospitalized Surgical Patients

LOW RISK / MODERATE RISK / HIGH RISK
Ambulatory patient without additional VTE risk factors / All other patients not in LOW or HIGH Risk Category / Elective major lower extremity arthroplasty
Hip, pelvic or severe lower extremity fractures
Ambulatory patient with expected LOS < 2 days/minor surgery / Acute spinal cord injury with paresis
Multiple major trauma
Abdominal or pelvic surgery for cancer
Ambulation & Education / LMWH or UFH/ SCD if neither / LMWH (or therapeutic anticoagulation) AND SCD
LMWH = Low Molecular Weight Heparin UFH = Unfractionated Heparin SCD = Sequential Compression Device HIT= Heparin Induced Thrombocytopenia

FORM 2-33058 REV. 06/2015 REFERENCE PAGE Page 2 of 2