DVT/VTE Prophylaxis

Venous Thromboembolism (VTE) Prophylaxis

David Ray Velez, MD

Table of Contents

Caprini Score
Mechanical Prophylaxis
Chemical Prophylaxis

Caprini Score

A Score to Determine the Risk for VTE and Guide Prophylactic Management

Factors

  • 1 Point:
    • Age 41-60 Years
    • Obese (BMI ≥ 30)
    • Minor Surgery
    • Swollen Legs
    • Varicose Veins
    • Abnormal Pulmonary Function (COPD)
    • Recent Sepsis
    • Recent Pneumonia
    • Recent Major Surgery
    • Recent Myocardial Infarction (MI)
    • Recent Congestive Heart Failure (CHF)
    • History of Inflammatory Bowel Disease (IBD)
    • Currently On Bed Rest
    • Pregnant or Post-Partum
    • Past Unexplained Spontaneous Abortion
    • Oral Contraceptives
    • Hormone Replacement
  • 2 Points:
    • Age 61-74 Years
    • Major Open Surgery (> 45 Minutes)
    • Laparoscopic Surgery (> 45 Minutes)
    • Arthroscopic Surgery
    • History of Cancer (Except Non-Melanoma Skin Cancer)
    • Current Cancer (Except Breast or Thyroid)
    • Confined to Bed (> 72 Hours)
    • Immobilizing Plaster Cast
    • Central Venous Access
  • 3 Points:
    • Age ≥ 75 Years
    • Personal History of VTE
    • Family History of VTE
    • Chemotherapy
    • Factor V Leiden
    • Prothrombin 20210A
    • Lupus Anticoagulant
    • Anticardiolipin Ab
    • Elevated Serum Homocysteine
    • Heparin Induced Thrombocytopenia (HIT)
    • Other Congenital or Acquired Thrombophilia
  • 5 Points:
    • Major Surgery (> 6 Hours)
    • Recent Stroke
    • Elective Major Lower Extremity Arthroplasty
    • Recent Pelvis, Hip, or Leg Fracture
    • Recent Acute Spinal Cord Injury Causing Paralysis
    • Recent Multiple Trauma
  • *Recent Definition: < 1 Month

Category

  • Score 0-4: Low Risk
  • Score 5-8: Moderate Risk
  • Score ≥ 9: High Risk

Management Based on Risk

  • Low Risk: Mechanical Prophylaxis
  • Moderate-High Risk: Mechanical and Chemical Prophylaxis
    • Consider Extended Treatment for 4 Weeks in Cases of Cancer or Inflammatory Bowel Disease (IBD)
    • Nearly Every Major Trauma or Critical Care Patient Will Be Moderate-High Risk

Mechanical Prophylaxis

Intermittent Pneumatic Compression (IPC)/Sequential Compression Devices (SCD)

  • A Garment Applied Around the Calves that Sequentially Inflates and Deflates to Apply Pressure
  • Primary Effect: Decreased Plasminogen Activator Inhibitor (PAI-1) – tPA Inhibitor
    • Also Decreases Venous Stasis (Smaller Effect)
  • Patients at Low Risk (Based on the Caprini Score) Can Be Managed with SCD’s Alone but the Majority of ICU Patients Should Receive Both SCD’s and Chemical Prophylaxis Unless Otherwise Contraindicated

Graduated Compression Stockings (GCS)

  • Knee- or Thigh-High Elastic Stockings to Apply Circumferential Pressure Around the Legs
  • Generally Considered Inferior to IPC When Used Alone
  • A Combination of IPC and GCS May Be More Efficacious than GCS Alone (No Data Comparing Combination Therapy to IPC Alone)

Sequential Compression Devices 1

Chemical Prophylaxis

Prophylactic Anticoagulant Agents

  • Lovenox (Low Molecular Weight Heparin)
    • The Preferred Agent for the Majority of Patients
    • Contraindicated for Severe Renal Insufficiency (CrCl < 30 mL/min) – Some Prefer Lower Dosing but Still Use
  • Heparin (Unfractionated Heparin)
    • Mostly Reserved for Prophylaxis when Severe Renal Insufficiency is Present and Lovenox is Contraindicated
  • Less Commonly Used Agents:
    • Dalteparin
    • Tinzaparin
    • Nadroparin

Comparison: Lovenox vs Heparin

  • Lovenox is Generally Considered More Effective than Heparin, Especially in Trauma Patients
  • Lovenox Has a Lower Risk of Complications Such as HIT, Although Still Possible
  • Similar Mortality

Heparin Prophylactic Dosing

  • 5,000 U Every 8 Hours

Lovenox Prophylactic Dosing

  • Best Dosing is Highly Controversial
  • General Patients: 40 mg Every 24 Hours
  • Cancer Patients: Consider Increased Dosing (Debated)
  • Obese Patients:
    • BMI ≥ 40: 40 mg Every 12 Hours
    • BMI ≥ 50: 50-60 mg Every 12 Hours
  • Trauma: 40 mg Every 12 Hours
    • Indications for Lower Dosing (30 mg Every 12 Hours):
      • > 65 Years Old
      • Low Weight
      • TBI or Spinal Cord Injury
      • Pregnancy
    • Consider Adjusting by Anti-Xa Laboratory Monitoring
      • Drawn at the Peak (3-5 Hours After the Third Dose)
      • Goal Peak Levels: 0.2-0.5 IU/mL

References

  1. Koo KH, Choi JS, Ahn JH, Kwon JH, Cho KT. Comparison of clinical and physiological efficacies of different intermittent sequential pneumatic compression devices in preventing deep vein thrombosis: a prospective randomized study. Clin Orthop Surg. 2014 Dec;6(4):468-75. (License: CC BY-NC-3.0)