VTE Prophylaxis in the Trauma Patient
VBMC TRAUMA CARE SERVICES GUIDELINE
CHEMICAL PROPHYLAXIS
VTE Prophylaxis Guideline for Orthopedic Trauma Patients
VTE Prophylaxis Protocol (Inpatient and Discharge) for Trauma Surgery and Orthopedics
**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 forInpatientUtilization |
LE Ortho/Pelvis |
Enoxaparin30mg BID |
Inpatient transfers or injury >48 hours prior topresentation: LE venousduplex on arrival |
Y |
|
Isolated UE Ortho |
No ChemicalProphylaxis |
|
Y |
|
|
Non-Ortho Trauma |
Enoxaparin30mg BID |
|
Y |
|
|
Spine |
Defer to servicespecific recommendations |
|
Y |
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:
· Patients 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 to7500mg 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
Using Chemical DVT Prophylaxis in Patients with TBI and ABNORMAL Head CT
Prophylactic anticoagulation with UF
or LMWH is appropriate 24h after initial evaluation if follow-up computed
tomography scans and clinical neurological examinations do not show
progression. Refer to Neurosurgery Service note, call if needed. In patients
with hemorrhagic stroke, a meta-analysis indicated that chemical prophylaxis
reduces PE significantly but is associated with an insignificant reduction in
mortality and insignificant increase in hematoma size.
Consider dosing modification in small
adults.
References:
1. Shaikh S, Boneva D, et al. Venous thromboembolismchemoprophylaxis 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 andanti-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 Hematology2019 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 theElderly. J
Am Acad Orthop Surg. 2015;23:131-137.
7. Sagi HC, Ahn J, Ciesla D, et al. Venous ThromboembolismProphylaxis in Orthopaedic Trauma Patients: A Survey of OTA
MemberPractice Patterns and OTA Expert Panel Recommendations. J OrthopTrauma 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. VenousThromboembolism 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
12. Schaible EV et al. Anticoagulation in patients with
traumatic brain injury. Curr Opin
Anaesthesiol.2013 Aug 19.
13. Paciaroni M et al. Efficacy and safety
of anticoagulants in the prevention of venous
thromboembolism in patients with acute
cerebral hemorrhage: a meta-analysis of