VTE Risk Assessment

Deep Vein Thrombosis (DVT) Prophylaxis Orders
(For use in Elective General Surgery Patients)
BIRTHDATE NAME CPI No. SEX M F VISIT No. _____________________
Thrombosis Risk Factor Assessment (Choose all that apply)

Each Risk Factor Represents 1 Point
Acute myocardial infarction Age 41-60 years Swollen legs (current) Congestive heart failure (<1 month) Varicose veins Medical patient currently at bed rest Obesity (BMI >25) History of inflammatory bowel disease Minor surgery planned History of prior major surgery (<1 month) Sepsis (<1 month) Abnormal pulmonary function (COPD) Serious Lung disease including pneumonia (<1 month) Oral contraceptives or hormone replacement therapy Pregnancy or postpartum (<1 month) History of unexplained stillborn infant, recurrent spontaneous abortion (> 3), premature birth with toxemia or growth-restricted infant Other risk factors___________________ Subtotal:
Each Risk Factor Represents 2 Points

Central venous access Age 61-74 years Arthroscopic surgery Major surgery (>45 minutes) Malignancy (present or previous) Subtotal: Laparoscopic surgery (>45 minutes) Patient confined to bed (>72 hours) Immobilizing plaster cast (<1 month)

Family History of thrombosis* Age 75 years or older History of DVT/PE Positive Prothrombin 20210A Positive Factor V Leiden Positive Lupus anticoagulant Elevated serum homocysteine Heparin-induced thrombocytopenia (HIT) (Do not use heparin or any low molecular weight heparin) Elevated anticardiolipin antibodies Subtotal: Other congenital or acquired thrombophilia If yes: Type_____________________________ * most frequently missed risk factor

Multiple trauma (<1 month) Stroke (<1 month) Elective major lower extremity arthroplasty Subtotal: Hip, pelvis or leg fracture (<1 month) Acute spinal cord injury (paralysis) (<1 month)
TOTAL RISK FACTOR SCORE:
FACTORS ASSOCIATED WITH INCREASED BLEEDING Patient may not be a candidate for anticoagulant therapy & SCDs should be considered. Active Bleed, Ingestion of Oral Anticoagulants, Administration of glycoprotein IIb/IIIa inhibitors, History of heparin induced thrombocytopenia CLINICAL CONSIDERATIONS FOR THE USE OF SEQUENTIAL COMPRESSION DEVICES (SCD) Patient may not be a candidate for SCDs & alternative prophylactic measures should be considered. Patients with Severe Peripheral Arterial Disease, CHF, Acute Superficial DVT
Total Risk Factor Score 0-1 2
Risk Level Low Risk Moderate Risk
Incidence of DVT
Prophylaxis Regimen Early ambulation Choose the following medication OR compression devices: Sequential Compression Device (SCD) Heparin 5000 units SQ BID Choose ONE of the following medications + / - compression devices: Sequential Compression Device (SCD) Heparin 5000 units SQ TID Enoxaparin/Lovenox: 40mg SQ daily (WT < 150kg, CrCl > 30mL/min) 30mg SQ daily (WT < 150kg, CrCl = 10-29mL/min) 30mg SQ BID (WT > 150kg, CrCl > 30mL/min) (Please refer to Dosing Guidelines on the back of this form) Choose ONE of the following medications PLUS compression devices: Sequential Compression Device (SCD) Heparin 5000 units SQ TID (Preferred with Epidurals) Enoxaparin/Lovenox (Preferred): 40mg SQ daily (WT < 150kg, CrCl > 30mL/min) 30mg SQ daily (WT < 150kg, CrCl = 10-29mL/min) 30mg SQ BID (WT > 150kg, CrCl > 30mL/min) (Please refer to Dosing Guidelines on the back of this form)
Joseph A. Caprini, MD, MS, FACS, RVT VTE Risk Factor Assessment Tool
2% 10-20%
3-4
Higher Risk
20-40%
5 or more
Highest Risk
40-80%
Ambulatory Surgery - No orders for venous thromboembolic prophylaxis required
VTE Prophylaxis Contraindicated, Reason: _________________________________________________________
Physician Signature Processed By:
Dr. # Date/Time: White-Medical Record Yellow-MIS Pink-Pharmacy
Date
Time
DVT Prophylaxis Regimen
UMHS ENOXAPARIN DOSING GUIDELINES

o o o MUST wait 24 hours before starting Enoxaparin if patient has epidural catheter D/C Enoxaparin 10-12 hours prior to removing epidural catheter May restart Enoxaparin 24 hours after epidural catheter has been removed.
NON-PREGNANT PATIENTS Body weight < 150kg, CrCl > 30mL/min: Enoxaparin 40mg SQ daily Body weight < 150kg, CrCl = 10-29mL/min: Enoxaparin 30mg SQ daily Body weight > 150kg, CrCl > 30mL/min: Enoxaparin 30mg SQ BID PREGNANT PATIENTS Prevention of DVT:# Maternal body weight (start of therapy) < 75 kg: Recommend 30 mg SQ once daily until 20 weeks Recommend 30 mg SQ BID after 20 weeks Maternal body weight (start of therapy) > 75 kg: Recommend 40 mg SQ once daily until 20 weeks Recommend 40 mg SQ BID after 20 weeks # Wait 12 hours before regional anesthesia MONITORING RECOMMENDATIONS Patients who are obese (actual body weight > 150 kg) Patients who are pregnant Patients with renal insufficiency (creatinine clearance < 30 ml/min) Desired Level Indication (Draw 4 hours after the 4th dose)
Recommendations for Dose Alteration

Dose Adjustment Increase by 25 % No change Decrease by 20 % Hold for 3 hours, then decrease next dose by 30% Repeat Anti-factor Xa To Be Obtainted 4 hours after 4th dose Repeat in 1 week, then monthly thereafter 4 hours after 4th dose 4 hours after 4th dose
Anti-factor Xa Level (units/ml) < 0.2 0.2 to 0.5 0.6 to 1 Prevention of DVT/PE 0.2 to 0.5 units/ml >1
Ideal Body Weight IBW, men = 50 kg + 2.3 (inches > 5 feet) IBW, women = 45.5 kg + 2.3 (inches > 5 feet)

VTE Risk Assessment

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Deep Vein Thrombosis (DVT) Prophylaxis Orders

(For use in Elective General Surgery Patients)

BIRTHDATE NAME CPI No. SEX M F VISIT No. _____________________

Thrombosis Risk Factor Assessment (Choose all that apply)

Each Risk Factor Represents 2 Points

Each Risk Factor Represents 3 Points

Each Risk Factor Represents 5 Points

TOTAL RISK FACTOR SCORE:

Total Risk Factor Score 0-1 2

Risk Level Low Risk Moderate Risk

Ambulatory Surgery - No orders for venous thromboembolic prophylaxis required

VTE Prophylaxis Contraindicated, Reason: _________________________________________________________

Physician Signature Processed By:

Dr. # Date/Time: White-Medical Record Yellow-MIS Pink-Pharmacy

DVT Prophylaxis Regimen

UMHS ENOXAPARIN DOSING GUIDELINES

Recommendations for Dose Alteration

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