VTE Guideline

Guideline · Aug 2019 · 3 min read

In brief

Clinical practice guideline for venous thromboembolism (VTE) management, covering risk assessment, prophylaxis strategies, and anticoagulation protocols for prevention and treatment of deep vein thrombosis and pulmonary embolism.

Written by the GCMD Library team from the guideline.

Definitions and Risk Categories

Establishes key terminology including altered mobility (inability to ambulate freely, Braden Q mobility 1-3 or activity 1-2), deep vein thrombosis, and mechanical prophylaxis devices. Defines three VTE risk categories: low risk (no risk factors), moderate risk (multiple risk factors without altered mobility OR altered mobility with ≤1 additional factor), and high risk (altered mobility plus ≥2 additional risk factors).

VTE Risk Assessment Protocol

Requires VTE risk assessment for all patients age 12-17 years at inpatient admission (including Same Day surgery) using the VTE Risk Assessment & Prevention flowsheet in EPIC. Nursing completes initial assessment with automatic SCD placement if indicated, then reassesses at 24 hours of hospitalization. Documentation must occur in the EPIC flowsheet.

Prophylaxis Implementation Guidelines

VTE prophylaxis should be administered based on risk category within 24 hours of assessment unless contraindications exist. For surgical patients considering Lovenox prophylaxis, surgical consultation regarding bleeding risk is required prior to initiation. Hematology consultation is recommended when considering alternative pharmacologic agents.

VTE Risk Factors

Lists 13 specific risk factors including critical illness, central venous catheters, obesity (BMI >95th percentile), major trauma, active malignancy, sepsis, chronic inflammatory disorders, cyanotic heart disease, estrogen therapy, thrombophilic disorders, personal or family history of thrombosis, and recent surgery within 30 days. These factors are used in combination with mobility status to determine risk category and prophylaxis strategy.

Risk-Stratified Prophylaxis Algorithm

Low-risk patients (baseline mobility, zero risk factors) require only mobility encouragement. Moderate-risk patients (baseline mobility with ≥1 risk factor OR altered mobility with 0-1 factors) receive mobility encouragement plus SCDs. High-risk patients (altered mobility with ≥2 risk factors) receive mobility encouragement, SCDs, and consideration of prophylactic anticoagulation with low molecular weight heparin or subcutaneous unfractionated heparin if no contraindications exist.

Statements in this guideline

Altered mobility is defined as a permanent or temporary state in which the patient is unable to ambulate freely, corresponding to a Braden Q scale for mobility 1-3 or activity 1-2.
Established1.0 DEFINITIONS
Low risk is defined as no VTE risk factors.
Established1.0 DEFINITIONS
Moderate risk is defined as multiple risk factors for VTE in the absence of altered mobility or altered mobility with one or fewer additional risk factors.
Established1.0 DEFINITIONS
High risk is defined as altered mobility plus two or more additional risk factors.
Established1.0 DEFINITIONS
Patients age 12-17 years should be assessed for VTE risk factors and assigned to a risk category (low, moderate, high) using the VTE Risk Assessment & Prevention flowsheet in EPIC.
Recommendation2.0 GUIDELINE
Nursing will complete the VTE Risk Assessment & Prevention flowsheet in EPIC at the time of inpatient admission, including in Same Day prior to surgery, and automatically place SCDs if indicated.
Recommendation2.0 GUIDELINE
VTE risk should be reassessed at 24 hours of hospitalization by nursing staff.
Recommendation2.0 GUIDELINE
VTE prophylaxis should be administered based on risk category as soon as feasible, but within 24 hours of assessment, unless there are contraindications.
Recommendation2.0 GUIDELINE
In surgical patients planning to initiate Lovenox prophylaxis, seek surgical input regarding bleeding risk prior to initiation.
Recommendation2.0 GUIDELINE
Obtain Hematology consultation when considering alternative pharmacologic agents for VTE prophylaxis.
Recommendation2.0 GUIDELINE
For low risk patients (baseline mobility, 0 VTE risk factors), encourage the highest degree of mobility.
RecommendationVTE Prevention Intervention Based on VTE Risk Assessment
For moderate risk patients (baseline mobility with 1 or more VTE risk factors), encourage the highest degree of mobility and apply sequential compression devices.
RecommendationVTE Prevention Intervention Based on VTE Risk Assessment
For high risk patients (altered mobility with 0-1 VTE risk factors), encourage the highest degree of mobility and apply sequential compression devices.
RecommendationVTE Prevention Intervention Based on VTE Risk Assessment
For high risk patients (altered mobility with 2 or more VTE risk factors), encourage the highest degree of mobility, apply sequential compression devices, and consider prophylactic anticoagulation.
RecommendationVTE Prevention Intervention Based on VTE Risk Assessment
Prophylactic anticoagulation should utilize a form of low molecular weight heparin or subcutaneous unfractionated heparin.
RecommendationVTE Prevention Intervention Based on VTE Risk Assessment
If a patient is already on other forms of anticoagulants, no additional prophylactic anticoagulation is needed.
RecommendationVTE Prevention Intervention Based on VTE Risk Assessment
Aspirin or other antiplatelet therapy is not considered VTE prophylaxis.
EstablishedVTE Prevention Intervention Based on VTE Risk Assessment
VTE risk factors include critically ill status (in the intensive care unit), presence of a central venous catheter (PICC, non-tunneled or tunneled), obesity (BMI >95th percentile for age), major trauma (>1 extremity, pelvis or spine injury), active cancer/malignancy, acute systemic infection/sepsis, chronic inflammatory disorder (IBD, Lupus), cyanotic heart disease, estrogen therapy, thrombophilic/clotting disorder, personal history of blood clots, recent invasive surgery within past 30 days, and family history of clots in 1st degree relative.
EstablishedVTE Prevention Intervention Based on VTE Risk Assessment

Full text

Risk Assessment for Non-Bariatric Surgical Patients 12-17 years old 1.0 DEFINITIONS 1.1. Altered mobility: A permanent or temporary state in which the patient is unable to ambulate freely, corresponds to a Braden Q scale for mobility 1-3 or activity 1-2. 1.2. Deep Vein Thrombosis (DVT): A thrombus in a deep vein. 1.3. Graduated Compression Stocking (GCS): Elastic stockings, either knee- or thigh-high, also known as TED hose. 1.4. Risk category: Refer to VTE Risk Factors algorithm below 1.4.1. Low risk: No VTE risk factors 1.4.2. Moderate risk: Multiple risk factors for VTE in the absence of altered mobility or has altered mobility with one or fewer additional risk factors. 1.4.3. High risk: Altered mobility plus two or more additional risk factors 1.5. Sequential Compression Device (SCD): A device designed to intermittently squeeze blood from underlying deep veins in the leg upon compression of an inflatable sleeve, and to allow the blood to flow again when it decompresses. 1.6. Venous Thromboembolism (VTE): A thrombus in a vein or one that has broken free and is carried in the bloodstream (embolus). 2.0 GUIDELINE 2.1. It is recommended that patient’s age 12-17 years be assessed for VTE risk factors, and based on that assessment, assigned to a risk category (low, moderate, high) using the VTE Risk Assessment & Prevention flowsheet in EPIC. 2.1.1. Nursing will complete the VTE Risk Assessment & Prevention flowsheet in EPIC at the time of inpatient admission, including in Same Day prior to surgery, and automatically place SCDs if indicated. 2.1.2. Reassessed at 24 hours of hospitalization by nursing staff. 2.1.3. This should be documented in the patient’s medical record in the VTE Risk Assessment & Prevention flowsheet in EPIC. 2.2. It is recommended that VTE prophylaxis be administered based on risk category as soon as feasible, but within 24 hours of assessment, unless there are contraindications (See below). 2.3. If planning to initiate Lovenox prophylaxis, it is recommended: 2.3.1. In surgical patients to seek surgical input regarding bleeding risk prior to initiation 2.3.2. Obtain Hematology consultation when considering alternative pharmacologic agents.

Venous Thromboembolism (VTE) Prophylaxis Page 2 of 3 VTE Prevention Intervention Based on VTE Risk Assessment 1 Baseline Mobility: usual state of mobility Altered Mobility: inability to ambulate freely, corresponds to a Braden Q scale for mobility 1-3 or activity 1-2 2 VTE Risk Factors: • Critically ill (in the intensive care unit) • Presence of a Central Venous Catheter (PICC, non-tunneled or tunneled) • Obesity (BMI >95th percentile for age) • Major Trauma (>1 extremity, pelvis or spine injury) • Active cancer/malignancy • Acute systemic infection/sepsis • Chronic Inflammatory disorder (IBD, Lupus) • Cyanotic heart disease • Estrogen therapy • Thrombophilic/Clotting disorder • Personal history of blood clots • Recent invasive surgery within past 30 days • Family history of clots in 1st degree relative 3Prophylactic Anticoagulation: utilize a form of low molecular weight heparin or subcutaneous unfractionated heparin. If a patient is already on other forms of anticoagulants no additional prophylactic anticoagulation is needed. Aspirin or other antiplatelet therapy is not considered VTE prophylaxis. LOW RISK MODERATE RISK HIGH RISK Mobility Status1 Baseline Baseline Altered Altered Number of VTE Risk Factors2 0 1 or more 0-1 2 or more Interventions: with no contraindications present o Encourage highest degree of mobility Yes Yes Yes Yes o Sequential Compression Device (SCD) - Yes Yes Yes o Prophylactic Anticoagulation3 - - - Consider

Venous Thromboembolism (VTE) Prophylaxis Page 3 of 3 3.0 REFERENCES 4.1 Petty, J. K. (2017). Venous thromboembolism prophylaxis in the pediatric trauma patient. Seminars in Pediatric Surgery, 26, 14-20. 4.2 Mahajerin, A., Petty, J., Hanson, S. J., Thompson, A. J., O’Brien, S. H., Streck, C. J., . . . Faustino, V. S. (2016). Prophylaxis against venous thromboembolism in pediatric trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society. Journal of Trauma and Acute Care Surgery, 82(3), 627-636. 4.3 Landisch, R. M., Hanson, S. J., Cassidy, L. D., Braun, K., Punzalan, R. C., & Gourlay, D. M. (2016). Evaluation of guidelines for injured children at high risk for venous thromboembolism: A prospective observational study. Journal of Trauma and Acute Care Surgery, 82(5), 836-844.

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