1 VTE Protocol Presented by: Selina Baskins, RN Quality Coordinator

2 Each Risk Factor Represents 1 Point Age years Minor surgery planned Hx of prior major surgery (<1 month) Varicose veins Hx of inflammatory bowel disease Swollen legs (current) Obesity (BMI>25kg/m2) AMI CHF Sepsis Serious lung disease including pneumonia

3 Each Risk Factor Represents 1 Point  Abnormal pulmonary function  (COPD)  Medical patient currently at bed rest  Oral contraceptives  Pregnancy or postpartum (<1month)  Hx of unexplained stillborn infant,  recurrent spontaneous abortion (>3),  premature birth with toxemia, or  growth-restricted infant

4 Each Risk Factor Represents 2 Points  Age years  Arthroscopic surgery  Malignancy (present or previous) Major  surgery (over 45 minutes) Laparascopic  surgery (over 45 minutes) Patient  confined to bed (>72 hours)  Immobilizing plaster cast (<1 month)  Central venous access

5 Each Risk Factor Represents 3 Points  Age ≥ 75 years  Hx of VTE/PE  Family Hx of thrombosis  Blood/bone marrow dyscrasias *  Thrombophilic condition **  Heparin induce thrombocytopenia

6 Each Risk Factor represents 5 Points  Elective major lower extremity  arthroplasty  Hip, pelvis, or leg fracture  Stroke  Multiple trauma  Acute spinal cord injury (paralysis

7 Contraindications  Contraindications to pharmacologic prophylaxis i.e. active bleeding, current or history of heparin induced  thrombocytopenia, platelet count < 100,000  Contraindications to sequential compression devices, i.e. severe peripheral arterial disease, CHF, acute/superficial  VTE Other contraindications

8 Standard of Care for assessed Risk Score: IF INTERVENTIONS HAVE NOT BEEN ORDERED, CALL MD FOR ORDERS!  0-1 Low Risk = Early and aggressive ambulation  2 Moderate Risk Lovenox 40 mg subcutaneous daily  (Choose one) Lovenox 30 mg subcutaneous daily if CrCl less than 30  Graduated compression stockings thigh, knee high  Sequential compression device  3-4 High Risk Lovenox 40 mg subcutaneous daily AND Sequential compression device

9 Standard of Care for assessed Risk Score: IF INTERVENTIONS HAVE NOT BEEN ORDERED, CALL MD FOR ORDERS (Cont’d)  (Choose one) Lovenox 30 mg subcutaneous daily AND Sequential compression device if CrCl less than 30  5 or more Very High Lovenox 40 mg subcutaneous daily, Sequential compression device AND graduated  Risk compression stocking  Lovenox 30 mg subcutaneous daily if CrCl less than 30, Sequential compression device  AND graduated compression stocking

10 Other instructions  If the patient received epidural anesthesia, do not start Lovenox until 24 hours after establishment of stable hemostasis  If the patient has an epidural postoperatively, do not start Heparin/LMWH until epidural ha

11 QUESTIONS????