Only anticoagulate hospitalized patients who are at risk for VTE (moderate to high risk).
Many hospitalists recommend pharmacologic thromboprophylaxis for patients who have at least one risk factor for VTE and do not have an increased risk of bleeding.
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Patients with Normal Renal Function
Enoxaparin 40 mg SC QD, for patients with BMI < 40
Enoxaparin 40 mg SC BID, for BMI > 40
Patients with Renal Failure
For patients with renal failure (creatinine clearance <30 mL/min) use unfractionated heparin (UFH).
Heparin 5000 units SC q8-12h
Patients with high risk of bleeding or for whom anticoagulation is contraindicated
For patients who have risk factors for VTE and who are at high risk of bleeding or in whom anticoagulation is contraindicated (eg, GI or intracranial hemorrhage) use mechanical methods of VTE prevention such as:
- Intermittent pneumatic compression / Pneumatic compression devices
- Compression boots
- Graduated compression stockings,
- venous foot pump
- Early ambulation.
Early ambulation with or without mechanical methods of thromboprophylaxis.
Special cases: Patients with HIT, Stroke, Cancer, etc
Special cases are patients with:
- Heparin-induced thrombocytopenia – For patients with the HIT, use fondaparinux in place of a heparin.
- Stroke patients –
- Cancer patients – Only Enoxaparin (Lovenox) should be used.
- Patients who are traveling for extended periods,
- Patients who are pregnant.
Long distance travelers at increased risk of VTE
“For long-distance travelers at increased risk of VTE (including previous VTE, recent surgery or trauma, active malignancy, pregnancy, estrogen use, advanced age, limited mobility, severe obesity, or known thrombophilic disorder), we suggest frequent ambulation, calf muscle exercise, or sitting in an aisle seat if feasible (Grade 2C).
For long-distance travelers at increased risk of VTE (including previous VTE, recent surgery or trauma, active malignancy, pregnancy, estrogen use, advanced age, limited mobility, severe obesity, or known thrombophilic disorder), we suggest use of properly fitted, below-knee GCS providing 15 to 30 mm Hg of pressure at the ankle during travel (Grade 2C). For all other long-distance travelers, we suggest against the use of GCS (Grade 2C).
For long-distance travelers, we suggest against the use of aspirin or anticoagulants to prevent VTE(Grade 2C).” Chest 2012
References
Chest. 2012 Feb;141(2 Suppl). https://www.ncbi.nlm.nih.gov/pubmed/22315261
http://journal.chestnet.org/article/S0012-3692(12)60124-X/fulltext