VTE Prophylaxis Guideline for Trauma Patients

VTE Prophylaxis Protocol (Inpatient and Discharge) for Trauma Surgery and Orthopaedics

**Note: All Inpatients Should Have SCDs Placed on Uninjured Legs while in bed

 

This document is intended to serve only as a guideline based on current review of

medical literature, and not intended to replace clinical judgement, physician/surgeon

discretion, or special circumstances

 

INPATIENT PROTOCOL:

 

				SCDs
VTE ppx for Inpatient Utilization	LE Ortho/Pelvis	Enoxaparin 30mg BID	Inpatient transfers or injury >48 hours prior to presentation: LE venous duplex on arrival	Y
	Isolated UE Ortho	No Chemical Prophylaxis		Y
	Non-Ortho Trauma	Enoxaparin 30mg BID		Y
	Spine	Defer to service specific recommendations		Y

*See page 2 for dosage adjustments based on body weight and renal function*

 

DISCHARGE PROTOCOL:

 

Contraindications to VTE prophylaxis:

1.     Active bleeding within 72 hours

2.     Head trauma, intracranial hemorrhage, or high risk for peri-spinal hematoma (lumbar puncture, spinal injection, epidural catheter placement, incomplete spinal cord injury with hematoma)

3.     Multiple trauma with high bleeding risk

4.     Coagulopathy secondary to medical condition or anticoagulation

5.     Therapeutic anticoagulation presented on admission and to be continued

6.     Severe thrombocytopenia with platelet count < 25,000

Orthopedic Indications for Suspension of VTE PPX

*VTE PPX should be held pre-operatively on day of surgery (after midnight) until 12 hours post-operatively for the following procedures:

·         All Pelvis Surgeries

·         All Acetabulum Surgeries

·         All Proximal Femur Surgeries (Femoral Head, Neck & Trochanteric Femur (subtroch, pertroch, intertroch))

·         All Arthroplasty Surgeries

*The orthopedic service is responsible for placing the order to suspend VTE PPX. For all other orthopedic surgeries, do not hold VTE PPX (i.e. SQ Lovenox or SQ Heparin).

*Unless explicitly stated in consult documents, there is no indication to hold other antiplatelet agents (aspirin, clopidogrel, ticagrelor, prasugrel) peri-operatively for any orthopedic surgery

 

Dosage Adjustments based on Co-morbid conditions:

Renal Dysfunction:

·         CrCl <30ml/min: decrease Enoxaparin to 30mg Q24 for all indications.

·         RRT (renal replacement therapy) or AKI (acute kidney injury): Do not use enoxaparin, use heparin subq 5000units Q8 instead

 

Liver Dysfunction:

·         Patient’s with significant liver dysfunction with concomitant thrombocytopenia are at an elevated risk of bleeding with the use of VTE prophylaxis

o    Make clinical judgment regarding appropriate prophylaxis agent

o    If patient’s protocol recommends aspirin, discuss appropriate prophylaxis regimen with clinical pharmacist on service

 

Patients Requiring Dual Antiplatelet Therapy (DAPT):

·         Dual antiplatelet therapy is not considered sufficient VTE prophylaxis for traumatic injuries

o    Make clinical judgment regarding appropriate prophylaxis agent based on DAPT indication

o    If patient’s protocol recommends aspirin, discuss appropriate prophylaxis regimen with clinical pharmacist on service

**Routine anti-Xa monitoring for dosage adjustments is not recommended for VTE prophylaxis; however recommend monitoring Hgb/Hct, and PLT trends**

 

Dosage Adjustments based on Body weight (will change BOTH inpatient and outpatient regimen):

·         High body weight

o    BMI > 30: enoxaparin 0.5mg/kg BID (unless renal adjustment is necessary)

§   Dose will be capped at 60mg BID

o    If heparin subq is required due to comorbidities, increase dose to 7500mg q8h

·         ROUND enoxaparin dose to nearest 10mg and/or consider commercially available prefilled syringes and graduated prefilled syringes in determining dose

·         Low body weight

o    Actual body weight < 50kg: enoxaparin 30mg daily

 

VTE Prophylaxis in Critically Ill Patient Populations

The eCAT ICU physician may screen patients at the points of transitions of care (new ICU admission, perioperative transitions, etc) and patients with an ICU length of stay of 24 hours or more for appropriateness or contraindications to VTE prophylaxis as described above.  Primary teams will be notified if patients are identified as being candidates for VTE prophylaxis that do not have either mechanical or chemical prophylaxis ordered.  The eCAT ICU physician may enter orders only in conjunction with the primary team approval and will document the placement of any orders or document contraindications to VTE prophylaxis in the electronic medical record.

References:

1.      Shaikh S, Boneva D, et al. Venous thromboembolism chemoprophylaxis regimens in trauma and surgery patients with obesity: A systematic review. J Trauma Acute Care Surg. 2020;88:522-535.
2.      Yam L, Khaled B, et al. Enoxaparin thromboprophylaxis dosing and anti-factor Xa levels in low-weight patients.
Pharmacotherapy. 2019;39(7):749-755.
3.      Sebaaly J, Covert K. Enoxaparin Dosing at Extremes of Weight: Literature Review and Dosing Recommendations.
Annals of Pharmacotherapy. 2018;52(9):898-909.
4.      Anderson, DR, Morgano, GP, et al. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv. 2019;3(23):3893-3944.
5.      Karcutskie CA, Dharmaraja A, et al. Association of Anti-Factor Xa-Guided Dosing of Enoxaparin With Venous Thromboembolism After Trauma. JAMA Surg. 2018;153(2):144-149
6.      Roberts KC, Brox WT, et al. Management of Hip Fractures in the Elderly. J Am Acad Orthop Surg. 2015;23:131-137.
7.      Sagi HC, Ahn J, Ciesla D, et al. Venous Thromboembolism Prophylaxis in Orthopaedic Trauma Patients: A Survey of OTA Member Practice Patterns and OTA Expert Panel Recommendations. J Orthop Trauma 2015;29:e355-e363.
8.      Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest. 2012;141:e278S-325S
9.      MacDonald DRW, Neilly D, Schneider PS, et al. Venous Thromboembolism in Hip Fracture Patients: A Subanalysis of the FAITH and HEALTH Trials. J Orthop Trauma 2020;34(suppl 3):S70-S75
10.     Major Extremity Trauma Research Consotium (METRC), O’Toole RV, Stein DM, et al. Aspirin or Low-Molecular Weight Heparin for Thromboprophylaxis after a Fracture. N Engl J Med. 2023; 388(3): 203-213
11.     Teichman AL, Cotton BA, Byrne J, et al. Approaches for optimizing venous thromboembolism prevention in injured patients: Findings from the consensus conference to implement optimal venous thromboembolism prophylaxis in trauma. J Trauma Acute Care Surg. 2023; 94(3): 469-478

Established 2013; Revised 2-20-24 Bernard/C Reynolds/C Bradley