Anticoagulant Protocol by Shymaa Shehata June 2022

Ministry of Health ‫وزارة اﻟﺻﺣﺔ‬
Specialized Medical center ‫أﻣﺎﻧﺔ اﻟﻣراﻛز اﻟطﺑﯾﺔ اﻟﻣﺗﺧﺻﺻﺔ‬

Mansoura International Hospital ‫ﻣﺳﺗﺷﻔﻰ اﻟﻣﻧﺻورة اﻟدوﻟﻲ‬
Clinical pharmacy Department ‫ﻗﺳم اﻟﺻﯾدﻟﺔ اﻹﻛﻠﯾﻧﯾﻛﯾﺔ‬
Protocol for adult inpatients
Version 1
June 2022
1
Content
No. Headlines Page

1 Cover photo 1
2 Content 2
3 Aim and scope of this protocol 3
4 1- NON-SURGICAL HOSPITALIZED PATIENTS 4
5 2- SURGICAL HOSPITALIZED PATIENTS 5
6 APPENDIX A: Padua VTE Risk Assessment Model 6
7 APPENDIX B: The IMPROVE Bleeding Risk Assessment Tool 7
8 APPENDIX C: Modified Caprini 8
APPENDIX D: Contraindications to Pharmacological Options for
9 9
VTE Prophylaxis
10 APPENDIX E: Pharmacological Options for VTE Prophylaxis 9
APPENDIX F: Dosing Recommendations for Renal Impairment,
11 13
Obesity, and Underweight Patients
APPENDIX G: Risk Factors for Major Bleeding Complications in
12 13
Surgical Patients
APPENDIX H: Spinal Procedure and/or Epidural Placement
13 15
Management
14 References 16
2
Aim and scope:

To standardize Venous Thromboembolism (VTE) risk assessment that delivers
decision support to the point of care and standardize the clinical practice for VTE
prevention to reduce morbidity and mortality related to thrombosis. The VTE
prevention protocol developed to cover all related clinical specialties.
Targeted end users:

This protocol intended to be used by the physicians and other Health Care
Providers working at MIH hospital.
Targeted population:
All adult patients admitted to MIH hospital.
Level of Evidence:
Review of best practice and expert opinion.
Disclaimer:
This living guidance is subject to updates with new emerging data.
The task force members have no conflict of interest. This protocol is not
attached to anyfunding.
Protocol written by:

Shymaa Shehata, PharmD, BCPS
Coordinating Team Member:
Esraa Moawad
Review board members:
Release Date:
Next Review Date:
3
1-NON-SURGICAL HOSPITALIZED PATIENTS

Patient admitted to hospital
Assess for VTE risk factors by Padua VTE Risk Assessment Model and bleeding risk by IMPROVE
bleeding risk assessment tool at time of admission and reassess as clinically indicated
LOW VTE RISK High VTE RISK

VTE Risk1
Padua Score Less than 4 Padua Score 4 or more

Bleeding Risk2
Are there contraindications?3

Or High BLEEDING RISK
(IMPROVE Bleeding risk score
≥7)
NO YES
Encourage ambulation if not Suggest mechanical

Pharmacoprophylaxis
restricted prophylaxis,
With mechanical prophylaxis Once bleeding risk is low:
Encourage ambulation if +
not restricted
4
With or without
mechanical prophylaxis • Enoxaparin 40mg SC once
daily OR
• Unfractionated Heparin 5000 4,5,6
Units SC TID OR
• Fondaparinux dose 2.5 mg SC
q24h 5,6
*N.B: If Cr.Cl. < 30ml/min, Enoxaparin 30 mg subcutaneously once daily and avoid Fondaparinux
1
See Appendix A for VTE Risk Factors in Non-Surgical Hospitalized Patients
2
See Appendix B for Factors with a Strong Association with Bleeding Risk in Hospitalized Medical Patients
3
See Appendix D for Contraindications to Pharmacologic Options for VTE Prophylaxis
4
See Appendix F for Dosing Recommendations for Renal Impairment, Obesity, and Underweight Patient
5
Contraindicated if total body weight < 50 kg
6
Patients intolerant to heparin products can also use Rivaroxaban 10 mg every 24 hours or Apixaban 2.5 mg PO
every 12 hours
4
2-SURGICAL HOSPITALIZED PATIENTS
Patient admitted to
hospital
Assess for VTE risk factors by Modified Caprini and bleeding risk by The IMPROVE bleeding risk assessment tool at
time of admission and reassess as clinically indicated
Low VTE RISK Moderate VTE RISK High VTE RISK Very High VTE RISK
Modified Caprini scores Modified Caprini scores Modified Caprini scores Modified Caprini scores
equal to 0 or 1 equal to 2 equal to 3 or 4 equal to or more than 5
VTE Risk1
Encourage ambulation if not restricted
With mechanical
With or without mechanical prophylaxis
prophylaxis
Bleeding Risk2,6
IMPROVE Bleeding risk score <7 and there are no contraindications 3
4,5,7
4,5,7
Pharmacoprophylaxis
•Enoxaparin 40 mg SC
● No thromboprophylaxis once daily OR
required during •Unfractionated Heparin •Enoxaparin 40mg SC once daily OR
admission. 5000 Units SC BID or TID •Unfractionated Heparin 5000 Units SC TID OR
OR •Fondaparinux dose 2.5 mg SC q24h
•Fondaparinux dose 2.5
mg SC q24h
*N.B: If CrCl < 30ml/min, Enoxaparin 30 mg subcutaneously once daily and avoid Fondaparinux
1
See Appendix C for VTE Risk Factors in Surgical Hospitalized Patients
2
See Appendix B for Risk Factors for Major Bleeding Complications in Surgical Hospitalized Patients
3
See Appendix D for Contraindications to Pharmacologic Options for VTE Prophylaxis
4
See Appendix E for Pharmacological Options for VTE Prophylaxis
5
See Appendix F for Dosing Recommendations for Renal Impairment, Obesity, and Underweight Patients
6
See Appendix G for General & Specific Risk Factors for Major Bleeding Complications in Surgical Patients
7
see Appendix H for Spinal Procedure and/or Epidural Placement Management
N.B Minor surgeries are generally superficial and do not require penetration of a body cavity. Patientsare often
discharged home the same day as the procedure. For example: visual inspections performed inside in rectum, vagina,
uterus, or bladder would be considered minor. They do not involve assisted breathing or anesthesia and are usually
performed by a single doctor.
5
APPENDIX A: Padua VTE Risk Assessment Model
Padua Risk Assessment Model for Medical Patients

Baseline Features Score
Active Cancer * 3
Previous VTE (excluding superficial vein thrombosis) 3
Reduced mobility ∞ 3
Already known thrombophilic condition ± 3
Recent (less than or equal to 1 month) trauma and/or surgery 2
Elderly age (70 years or older) 1
Heart and/or respiratory failure 1
Acute myocardial infarction or ischemic stroke 1
Acute infection and/or rheumatologic disorder 1
Obesity (BMI 30 kg/m2 or greater) 1
Ongoing hormonal treatment 1
Total score
*Patients with local or distant metastases and/or chemotherapy or radiation therapy in the last 6 months.
∞Bed rest with bathroom privileges (either due to patient limitation or physician order) for at least 3 days.
±Carriage of defects of antithrombin, protein C or S, factor V Leiden, G20210A prothrombin mutation, antiphospholipid
syndrome.
The total Padua Prediction Score is calculated by adding all points for the patient. The
corresponding VTE risk level can be interpreted using the table below which also shows
recommendations for VTE prophylaxis.
Total Score and VTE Risk Level for non-surgical patients based on Padua model
Total Score VTE Risk Level VTE Prophylaxis recommended?
Less than 4 Low No
4 or more High Mechanical prophylaxis or Pharmacological prophylaxis
6
APPENDIX B: The IMPROVE Bleeding Risk Assessment Tool

Risk factors Point
Moderate renal failure (Cr.Cl. 30 - 50 ml/min.) 1
Male Sex 1
Age 40 - 84 years 1.5
Active Cancer 2
Rheumatic disease 2
Central venous catheters 2
Admissions in Intensive Care 2.5
Severe Renal Failure (Cr.Cl. < 30 ml/min.) 2.5
Liver insufficiency (INR > 1.5) 2.5
Age ≥ 85 3.5
Thrombocytopenia (<50 × 109 cell/L) 4
Recent (3 months) bleeding 4

Active gastro-intestinal ulcer
High bleeding risk when total score ≥ 7
If the score ≥ 7, the overall rate of major bleedings is 7.9% and

clinically relevant non-major bleedings is 4.1%; If the score < 7, the
overall rate of major bleedings is 1.5% and clinically relevant non-
major bleedings is 0.4%.
7
APPENDIX C: Modified Caprini

RISK FACTORS
1 Score For Each 2 Score For Each 3 Score For Each 5 Score For Each
❑ Age 41-60 years ❑ Age: 61-74 years ❑ Age≥ 75 years ❑ Hip, pelvis or
❑ BMI > 25 Kg/m2 ❑ Arthroscopic ❑ History of DVT/PE leg fracture
❑ Minor surgery Surgery ❑ Family history of (within the
❑ Swollen legs (current) ❑ Laparoscopy VTE past month)
❑ Varicose veins Surgery (>45 ❑ Factor V Leiden ❑ Stroke (within past
❑ Major Surgery (in the min) ❑ Prothrombin month)

past month) ❑ Major open 20210A ❑ Multiple trauma
❑ lung disease (e.g., Surgery (>45 ❑ Lupus (within past

emphysema or COPD) min) anticoagulant month)
❑ Currently on bed rest or ❑ Cancer (current or ❑ Anticardiolipin ❑ Elective major
restricted mobility previous) antibodies lower extremity

❑ History of ❑ Immobilizing ❑ Elevated serum arthroplasty
Inflammatory bowel Plaster cast homocysteine ❑ Acute Spinal
disease ❑ Bed bound for ❑ Heparin- cord injury –

❑ Acute myocardial more than 72 hrs. induced paralysis
❑ Central venous (within the
infarction access thrombocyt
❑ Congestive heart openia past month)
failure (<1 month) ❑ Other congenital
❑ Sepsis/ Pneumonia or acquired

(<1month) thrombophilia
❑ History of unexplained
or recurrent
spontaneous abortion
(>3)
❑ Pregnant or post-
partum (<1 month)

❑ Oral contraceptives
or hormone
replacement
8
APPENDIX D: Contraindications to Pharmacological Options

for VTE Prophylaxis
❑ Active bleeding
❑ Patient currently on treatment dose anticoagulation
❑ Thrombocytopenia (platelets < 20 K/microliter or clinical judgment)
❑ Anticipated thrombocytopenia
❑ Recent high-risk surgery or bleeding event
1
❑ Recent CNS bleed
1
❑ Recent neurosurgery
❑ Intracranial or spinal lesion at high risk of bleeding
❑ Underlying coagulopathy
❑ Patient on protocol that prohibits anticoagulation
❑ Severe uncontrolled malignant hypertension
❑ Risk outweighs benefit in patients when death is imminent
1
Consult/refer to Neurosurgery if any evidence of acute bleed on CT scans. For any other concerns about starting
VTE prophylaxis, consult/refer to Benign Hematology.
APPENDIX E: Pharmacological Options for VTE Prophylaxis
I- ORTHOPEDIC Surgery:
Category Supportive Care Pharmacotherapy Precautions
A. Elective Hip Replacement
For patient undergoing elective total hip Recommended thromboprophylaxis either:

replacement (THR) a. LMWH:
- At a usual high-risk dose 40 mg SC q24h initiated 12 h
before surgery OR
- At a usual high-risk dose 30 mg SC q24h initiated 12
to 24 h after surgery OR
. Fondaparinux dose 2.5 mg SC q24h initiated 6-8 hr
after surgery
OR
. Apixaban 2.5 mg twice daily initiated 12-24 hr after
surgery
OR
. Adjusted-dose VKA (Warfarin) started preoperatively
the evening of the surgical day (INR target 2.5, INR
range:
2.0 – 3.0 for 35 days)
9
For patient undergoing THR who have a Optimal use of a When the high bleeding risk decreases, pharmacologic Patients placed on
high risk of bleeding mechanical method thrombo-prophylaxis be substituted for or added to the mechanical prophylaxis
with IPC mechanical thrombo-prophylaxis after surgery because of a
high risk of bleeding
should have their risk of
bleeding consistently
reassessed, with
pharmacologic prophylaxis
started as soon as the
bleeding risk is decreased
B. Elective Knee Replacement

For patient undergoing total knee Recommended thromboprophylaxis either:
replacement (TKR) a. LMWH:
- At a usual high-risk dose 30 mg SC q24h initiated 12
to 24 h after surgery OR
. Fondaparinux dose 2.5 mg SC q24h initiated 6-8 hr
after surgery
OR
. Apixaban 2.5 mg twice daily initiated 12-24 hr after
surgery
OR
. Adjusted-dose VKA (Warfarin) started preoperatively
of the evening of the surgical day (INR target 2.5, INR
range:
2.0 – 3.0 for 35 days)
For patient undergoing TKR who have a Optimal use of a When the high bleeding risk decreases, pharmacologic
high risk of bleeding mechanical method thrombo-prophylaxis be substituted for or added to the
with IPC mechanical thrombo-prophylaxis to extend
pharmacological prophylaxis
beyond 10 days after discharge
C. Hip Fracture Surgery (HFS)

For patient undergoing HFS Routine thromboprophylaxis minimum 10 days up to 35
days is recommended:
. Fondaparinux 2.5 mg SC q24h initiated 6-8h after
surgery
OR
. LMWH 30mg SC q12h initiated 12- 24hr after surgery
OR
. Adjusted dose VKA (Warfarin) preoperatively (INR
target. 2.5. INR range. 2.0 to 3.0)
D. Elective Spine Surgery

Low risk Encourage ambulation No thromboprophylaxis is required
Moderate Risk such as: Optimal use of peri- The recommended thromboprphylaxis options: VTE prophylaxis after
Advanced age operative IPC Enoxaparin 40 mg SC once daily OR elective spinal surgery can
Malignancy Unfractionated Heparin 5000 Units SC or TID typically be initiated 12–
Neurological deficit 24 hours postoperatively.
Previous VT Prophylaxis may need to
An anterior surgical approach be
delayed if the surgical site
remains open
10
Highest Risk Optimal use of a The recommended thromboprophylaxis is one of the

mechanical method pharmacological thromboprophylaxis options combined
(i.e. GCS and/or IPC) with mechanical method:
Enoxaparin 40 mg SC once daily OR
Unfractionated Heparin 5000 Units
SC or TID
E. Knee arthroscopy
Low risk Encourage ambulation No thromboprophylaxis required
High risk (multiple risk factors or Early mobilization The recommended thromboprophylaxis is one of the
following a complicated procedure) pharmacological thromboprophylaxis options combined
with mechanical method:
LMWH minimum of 10 days.
Enoxaparin 40 mg SC once daily OR
Unfractionated Heparin 5000 Units
SC or TID
F. Isolated Lower Extremity Injuries Distal to the Knee
For patient with Isolated Lower Extremity Routine use of thromboprophylaxis is NOT suggested
Injuries Distal to the
Knee
II- UROLOGIC Surgery:

For patient undergoing transurethral or Early mobilization The recommendation is against

other low risk procedures the useof thromboprophylaxis
The recommendation is to use Patients with very high

For patient undergoing major open routinethromboprophylaxis risk for bleeding, we
urologic procedure with: Pharmacological recommend the optimal
s prophylaxis alone: use of mechanical
a. Enoxaparin 40 mg SC thromboprophylaxis
once dailyOR with GCS and/or IPC at
b. Unfractionated Heparin least untilthe bleeding
5000 UnitsSC TID risk decreases.
When the high bleeding
risk decreases, we
OR recommend
Pharmacological plus mechanical pharmacologic thrombo-
prophylaxis prophylaxis substituted
for or added to the
mechanical thrombo-
prophylaxis.
11
III. LAPRAROSCOPIC Surgery:

For patient undergoing entirely Early mobilization The recommendation is
laparoscopic procedures who against the use of
don’thave additional risk factors thromboprophylaxis
For patient undergoing entirely Optimal use of a The recommendation is the

laparoscopic procedures who mechanical use of routine
don’thave additional risk factors method (i.e.,GCS thromboprophylaxis with
and/or IPC) either: Pharmacological
prophylaxis alone:
a. Enoxaparin 40 mg SC
once daily OR
b. Unfractionated Heparin
5000 Units SCTID
OR
Pharmacological plus
mechanicalprophylaxis
IV. BARIATRIC Surgery:

For patient undergoing Optimal use of a The recommendation is the
inpatientbariatric surgery mechanical use of routine
method (i.e.,GCS thromboprophylaxis with
and/or IPC) either: Pharmacological
prophylaxis alone:
a. Enoxaparin 40 mg SC
once daily OR
b. Unfractionated Heparin
5000 Units SCTID
OR
Pharmacological plus
mechanicalprophylaxis
12
APPENDIX F: Dosing Recommendations for Renal Impairment,

Obesity, and Underweight Patients
Creatinine Clearance
Patient population
Cr.Cl. > 30 ml/min Cr.Cl. 20-30 ml/min Cr.Cl. < 20 ml/min / dialysis
BMI < 40 and weight ≥ ● Enoxaparin 40 mg SQ every 24 hours or ● Enoxaparin 30 mg SQ every 24 hours or ● Heparin 5,000 units SQ
55 kg ● Enoxaparin 30 mg SQ every 12 hours or ● Heparin 5,000 units SQ every 8 hours or every 8 hours or
● Heparin 5,000 units SQ every 8 hours or ● Rivaroxaban 10 mg PO every 24 ● Apixaban 2.5 mg PO
● Fondaparinux 2.5 mg SQ every 24 hours1 or hours2,3 or every 12 hours2,3
2,3 ● Apixaban 2.5 mg PO every 12 hours2,3
● Rivaroxaban 10 mg PO every 24 hours or
2,3
● Apixaban 2.5 mg PO every 12 hours
Patient with BMI ≥ 40 ● Enoxaparin 40 mg SQ every 12 hours or Heparin 7,500 units SQ every 8 hours
kg/m2 ● Heparin 7,500 units SQ every 8 hours
Patient with weight < ● Enoxaparin 30 mg SQ every 24 hours or Heparin 5,000 units SQ every 8-12 hours
55 kg ● Heparin 5,000 units SQ every 8-12 hours
1
Contraindicated if total body weight < 50 kg and/or CrCl < 30 mL/minute
2
Check for drug interactions prior to use
3
Both apixaban and rivaroxaban should be avoided in patient with severe liver dysfunction (Child Pugh score C). Rivaroxaban is contraindicated
with Child Pugh score B and apixaban should be used with caution.
Note: Currently apixaban and rivaroxaban are indicated for VTE prophylaxis in patients undergoing knee or hip replacement surgery.
Rivaroxaban is also indicated in medical patients who are not at high risk of bleeding. There is limited data to support apixaban or rivaroxaban use
if patients with CrCl <30 mL/min as these patients were excluded from the trials for VTE
prophylaxis. Both apixaban and rivaroxaban appear to be safe and effective compared to warfarin in patients being treated for non-valvular atrial
fibrillation with end stage renal disease and can
be considered for VTE prophylaxis in this population.
APPENDIX G: Risk Factors for Major Bleeding Complications

in Surgical Patients
General Risk Factors

● Active bleeding
● Previous major bleeding
● Known, untreated bleeding disorder
● Severe renal or hepatic failure
● Thrombocytopenia
● Acute stroke
● Uncontrolled systemic hypertension
● Lumbar puncture, epidural, or spinal anesthesia within previous 4 hours or next 12 hours
● Concomitant use of anticoagulants, antiplatelet therapy, or thrombolytic drugs
13
Procedure-specific risk factors

● Abdominal surgery
○ Male sex, preoperative hemoglobin level < 13 g/dL, malignancy, and complex surgery defined as two or
more procedures, difficult dissection, or more than one anastomosis
● Pancreaticoduodenectomy
○ Sepsis, pancreatic leak, sentinel bleed
● Hepatic resection
○ Number of segments, concomitant extrahepatic organ resection, primary liver malignancy, lower
preoperative level, and platelet counts
● Cardiac surgery
○ Use of aspirin
○ Use of clopidogrel within 3 days before surgery
○ BMI > 252 kg/m , nonelective surgery, placement of five or more grafts, older age
○ Older age, renal insufficiency, operation other than CABC, longer bypass time
● Thoracic surgery
○ Pneumonectomy or extended resection
Procedures in which bleeding complications may have especially severe

consequences
● Craniotomy ● Spinal surgery ● Spinal trauma
● Reconstructive procedures involving free flap
Special consideration:
Critical cases:
 For patient admitted to critical care units, routine assessment for VTE & bleeding risk is recommended and routine
thromboprophylaxis is administered for at risk patients.
 For critical care patients who are at high-risk of bleeding, we recommend the optimal use of mechanical
thromboprophylaxis at least until the bleeding risk decreases.
 When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or
added to the mechanical thromboprophylaxis.
14
APPENDIX H: Spinal Procedure and/or Epidural Placement

Management
Neuraxial catheters
The following medications and doses can be given while a neuraxial catheter is in place. Higher dosages or alternative
medications must obtain approval from Acute Pain service.
● Enoxaparin ≤ 40 mg SQ every 24 hours
● Heparin ≤ 5,000 units SQ every 8 hours
Hold times prior to catheter removal or placement:

● Heparin : No1 time restrictions
● Enoxaparin with CrCl ≥ 30ml/min: 12 hours
● Enoxaparin with CrCl < 30 ml/min: 24 hours
Hold time after catheter removal or placement:

● Heparin : No1 time restrictions
● Enoxaparin: 4 hours after catheter removal and 8 hours after catheter placement
1
Only for heparin dosing ≤ 5,000 SQ every 8 hours
15
References:
1. American College of Chest Physician VTE prevention guideline 2012
2. Ay C, Dunkler D, Marosi C, et al. Prediction of venous thromboembolism in cancer patients. Blood 2010;
116:5377.
3. 3. Mandala M, Clerici M, Corradino I, et al. Incidence, risk factors and clinical implications of venous
thromboembolism in cancer patients treated within the context of phase I studies: the 'SENDO experience'. Ann
Oncol 2012; 23:1416
4. Micromedex last access Jun 2021.

5. Barbar S , Noventa F , Rossetto V , et al . A risk assessment model for the identification of hospitalized medical
patients at risk for venous thromboembolism: the Padua Prediction Score . J Thromb Haemost.2010;8(11):2450-
2457
6. Susan R. Kahn, et al, “Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines”, Chest
2012;141;e195S-e226S.Samana MM et al. N Engl J Med 199;341:793-800.
7. Leizorovicz A et al. Circulation 2004;110:873-9.

8. Cohen AT et al. J Thromb Haemost. 2003;1(suppl 1):P2046.
9. Lechler E, Schramm W, Flosbach CW. THE PRIME study group. The venous thrombotic risk in non-surgical
patients: epidemiological data and efficacy/safety profile of a low-molecular-weight heparin (enoxaparin).
Haemostasis 1996;26(Suppl 2):49-56
10. Kleber FX et al. Randomized comparison of enoxaparin with unfractionated heparin for the prevention ofvenous
thromboembolism in medical patients with heart failure or severe respiratory disease. Am Heart J. 2003
Apr;145(4):614-21.
11. Hillbom M, Erilä T, Sotaniemi K, Tatlisumak T, Sarna S, Kaste M. Enoxaparin vs heparin for prevention of deep-vein
thrombosis in acute ischaemic stroke: a randomized, double-blind study. Acta Neurol Scand. 2002
Aug;106(2):84-92.
12. Sherman DG. et al. The efficacy and safety of enoxaparin versus unfractionated heparin for the preventionof venous
thromboembolism after acute ischaemic stroke (PREVAIL Study): an open-label randomised comparison. Lancet.
2007;369:1347–55.
13. Mandalà M, Falanga A, Roila F. Management of venous thromboembolism (VTE) in cancer patients: ESMOClinical
Practice Guidelines. Annals of Oncology 2011; 22 (6): vi85-vi92.
‫ﻣﺪﯾﺮ اﻟﻤﺴﺘﺸﻔﻰ‬ ‫رﺋﯿﺲ اﻟﻘﺴﻢ‬ ‫ﻣﺪﯾﺮة اﻟﺼﯿﺎدﻟﺔ‬ ‫رﺋﯿﺲ اﻟﺼﯿﺪﻟﺔ اﻻﻛﻠﯿﻨﯿﻜﯿﺔ‬ ‫ﺻﯿﺪﻟﻲ اﻛﻠﯿﻨﯿﻜﻲ‬
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Ministry of Health ‫وزارة اﻟﺻﺣﺔ‬

Specialized Medical center ‫أﻣﺎﻧﺔ اﻟﻣراﻛز اﻟطﺑﯾﺔ اﻟﻣﺗﺧﺻﺻﺔ‬

Protocol for adult inpatients

No. Headlines Page

Aim and scope:

Targeted end users:

Protocol written by:

Next Review Date:

1-NON-SURGICAL HOSPITALIZED PATIENTS

LOW VTE RISK High VTE RISK

Padua Score Less than 4 Padua Score 4 or more

Are there contraindications?3

Encourage ambulation if not Suggest mechanical

2-SURGICAL HOSPITALIZED PATIENTS

Encourage ambulation if not restricted

IMPROVE Bleeding risk score <7 and there are no contraindications 3

APPENDIX A: Padua VTE Risk Assessment Model

Padua Risk Assessment Model for Medical Patients

Previous VTE (excluding superficial vein thrombosis) 3

Already known thrombophilic condition ± 3

Recent (less than or equal to 1 month) trauma and/or surgery 2

Elderly age (70 years or older) 1

Heart and/or respiratory failure 1

Acute myocardial infarction or ischemic stroke 1

Acute infection and/or rheumatologic disorder 1

Obesity (BMI 30 kg/m2 or greater) 1

Ongoing hormonal treatment 1

APPENDIX B: The IMPROVE Bleeding Risk Assessment Tool

Moderate renal failure (Cr.Cl. 30 - 50 ml/min.) 1

Age 40 - 84 years 1.5

Central venous catheters 2

Admissions in Intensive Care 2.5

Severe Renal Failure (Cr.Cl. < 30 ml/min.) 2.5

Liver insufficiency (INR > 1.5) 2.5

Recent (3 months) bleeding 4

If the score ≥ 7, the overall rate of major bleedings is 7.9% and

APPENDIX C: Modified Caprini

❑ Major Surgery (in the min) ❑ Prothrombin month)

❑ lung disease (e.g., Surgery (>45 ❑ Lupus (within past

restricted mobility previous) antibodies lower extremity

disease ❑ Bed bound for ❑ Heparin- cord injury –

❑ Sepsis/ Pneumonia or acquired

partum (<1 month)

APPENDIX D: Contraindications to Pharmacological Options

APPENDIX E: Pharmacological Options for VTE Prophylaxis

Category Supportive Care Pharmacotherapy Precautions

A. Elective Hip Replacement

For patient undergoing elective total hip Recommended thromboprophylaxis either:

B. Elective Knee Replacement

C. Hip Fracture Surgery (HFS)

Category Supportive Care Pharmacotherapy Precautions

D. Elective Spine Surgery

Highest Risk Optimal use of a The recommended thromboprophylaxis is one of the

F. Isolated Lower Extremity Injuries Distal to the Knee

II- UROLOGIC Surgery:

For patient undergoing transurethral or Early mobilization The recommendation is against

The recommendation is to use Patients with very high

III. LAPRAROSCOPIC Surgery:

For patient undergoing entirely Optimal use of a The recommendation is the

IV. BARIATRIC Surgery:

Category Supportive Care Pharmacotherapy Precautions

APPENDIX F: Dosing Recommendations for Renal Impairment,

APPENDIX G: Risk Factors for Major Bleeding Complications