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Group Specific Thromboprophylaxis Table 4. Manufacturer Prescribing Information for Thromboprophylaxis Options

Long-Distance Travel Thromboprophylaxis Spine Surgery Thromboprophylaxis Drug Prophylaxis Indication Dosage and Administration Comments
Flights > 8 h Avoidance of constrictive clothing around lower No additional VTE risk factors Early and frequent ambulation Low Dose Unfractionated
Low-dose regimen for major abdominothoracic surgery 5000 U SC 1 - 2 h before surgery, then 5000 U SC every 8 - 12 h
extremities or waist, maintenance of adequate hydration, Heparin2 (LDUH)
Additional VTE risk Postoperative LDUH, postoperative LMWH, or
and frequent calf muscle contraction Oral Direct Thrombin Inhibitor
perioperative IPC (Alternative: GCS)
Additional VTE risk factors General measures listed above; consider below-knee GCS > VTE risk factors: advanced age, malignancy, presence of dabigatran
(15 to 30 mmHg pressure at ankle), or single LMWH neurologic deficit, previous VTE, or anterior surgical approach (Pradax®, Pradaxa®)3 Hip replacement surgery 110 mg PO 1-4 h after surgery, then 220 mg PO once daily Severe renal dysfunction This Pocketcard edition is intended for the European and Canadian healthcare
dose prior to departure For patients older than 75 years or with moderate renal impairment (creatinine (CrCl < 30 mL/min): communities and contains only the European Medicines Agency (EMEA) and the
Multiple risk factors for VTE Pharmacologic prophylaxis (LDUH or LMWH) combined clearance 30-50 mL/min) 75 mg PO 1-4 h after surgery, then 150 mg PO once daily contraindicated
with mechanical method (GCS and/or IPC)
Knee replacement surgery Canadian Agency for Drugs and Technologies in Health (CADTH) approved drugs.
Long-distance travelers Recommend against the use of aspirin for VTE prevention

Prevention
Medical Conditions Thromboprophylaxis Thoracic Surgery Thromboprophylaxis Indirect Factor Xa Inhibitor
Major thoracic surgery LMWH, LDUH, or fondaparinux fondaparinux (Arixtra®)4 Abdominal surgery Abbreviations
Acutely ill medical patients with LMWH, LDUH, or fondaparinux Severe renal dysfunction
> Risk factors: active cancer, previous VTE, sepsis, acute Hip fracture surgery

of Venous
CHF, severe respiratory disease, High risk of bleeding GCS and/or IPC 2.5 mg SC once daily with initial dose 6 - 8 h after surgery (CrCl < 30 mL/min): bid, twice daily; CADTH, Canadian Agency for Drugs and Technologies in Health; CHF,
confined to bed, or ≥ 1 risk neurologic disease, or inflammatory bowel disease Hip replacement surgery congestive heart failure; CrCl, creatinine clearance; CT, computerized tomography; DUS,
contraindicated
factors Trauma Thromboprophylaxis Knee replacement surgery Doppler ultrasonography; DVT, deep vein thrombosis; EMEA, European Medicines
Agency; GCS, graduated compression stockings; h, hour(s); HFS, hip fracture surgery;
Thromboembolism
VTE risk factors and GCS or IPC Major trauma LMWH (starting when considered safe to do so) Oral Direct Factor Xa Inhibitor
> Continuation until hospital discharge INR, international normalized ratio; IPC, intermittent pneumatic compression; IU,
contraindication to anticoagulant rivaroxaban (Xarelto®)5 Hip replacement surgery Severe renal dysfunction
> For impaired mobility during inpatient rehabilitation, international units; IVC, inferior vena cava; kg, kilogram; LDUH, low-dose unfractionated
Neurosurgery Thromboprophylaxis continue LMWH or VKA 10 mg PO once daily with initial dose 6 - 10 h after surgery (CrCl < 30 mL/min): heparin; LMWH, low-molecular-weight heparin; mg, milligram; min, minute(s); mL, (for use in Europe and Canada)
Knee replacement surgery
(INR target, 2.5; INR range, 2.0 to 3.0) not recommended milliliter, MRI, magnetic resonance imaging; PE, pulmonary embolism; PO, oral; PT,
Major neurosurgery IPC Alternative: Low-Molecular-Weight Heparins (LMWH) prothrombin time; SC, subcutaneous; SCI, spinal cord injury; THR, total hip replacement;
Alternatives: > Combination LMWH and mechanical method
> Postoperative LMWH or LDUH tid, three times daily; TKR, total knee replacement; U, units; VFP, venous foot pump;
Major trauma if LMWH IPC or possibly GCS; when high bleeding risk decreases, dalteparin (Fragmin®)6 Abdominal surgery 2500 IU SC once daily, starting 1 - 2 h prior to surgery and repeated once daily VKA, vitamin K antagonist; VTE, venous thromboembolism Expert Reviewer:
High thrombosis risk GCS and/or IPC combined with postoperative contraindicated then pharmacologic prophylaxis substituted for or added to High risk of thromboembolic complications 5000 IU SC evening before surgery, then once daily William Geerts, MD, FRCPC
LMWH or LDUH mechanical method 2500 IU SC 1 to 2 h before surgery, then 2500 IU SC 12 h later, Thromboembolism Program
Alternative in malignancy Severe renal dysfunction References
Spinal Cord Injury (SCI) Thromboprophylaxis then 5000 IU SC once daily Sunnybrook Health Sciences Centre
Trauma > Recommend against routine DUS screening for (CrCl < 30 mL/min):
asymptomatic DVT 5000 IU SC 10 - 14 h before surgery, then 5000 IU SC 4 - 8 h after surgery, monitor anti-Xa levels to 1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: University of Toronto
For acute SCI LMWH (commenced once primary hemostasis evident) Hip replacement surgery: Preoperative start - evening before surgery American College of Chest Physicians evidence-based clinical practice guidelines (8th
> Recommend DUS screening in high VTE risk (eg, SCI, then 5000 IU SC once daily determine the appropriate
Alternatives: 2500 IU SC within 2 h before surgery, then 2500 IU SC 4 - 8 h after surgery, edition). Chest. 2008;133:381S-453S.
> Combined use of IPC and either LDUH or LMWH lower-extremity or pelvic fracture, or major head injury) Preoperative start - day of surgery dose
and suboptimal or no thromboprophylaxis then 5000 IU SC once daily 2. Heparin [package insert]. Schaumburg, IL: APP Pharmaceuticals LLC; 2008.
> If anticoagulant contraindicated because of high
bleeding risk, use IPC and/or GCS; when bleeding risk > Recommend against use of IVC filter as primary prophylaxis Postoperative start 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 3. Pradax [package insert]. Burlington, Ontario: Boehringer Ingelheim Canada Ltd; 2008.
decreases, pharmacologic prophylaxis substituted for or Urologic Surgery Thromboprophylaxis Medical patients 5000 IU SC once daily 4. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2008. Rationale for Thromboprophylaxis
added to mechanical method enoxaparin 5. Xarelto [package insert]. Toronto, Ontario: Bayer Inc; 2008.
Transurethral or other low-risk Early and frequent ambulation Abdominal surgery 40 mg SC once daily with initial dose 2 h prior to surgery General Risk Groups and Recommendations
(Lovenox®, Clexane®)7 Severe renal dysfunction 6. Fragmin [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2007.
Incomplete SCI associated with Mechanical methods instead of anticoagulant at least for urologic procedures
Hip replacement surgery 30 mg SC every 12 h or 40 mg SC once daily (initial dose 12 h prior to surgery) (CrCl < 30 mL/min): 7. Lovenox [package insert]. Bridgewater, NJ: sanofi-aventis US LLC; 2007.
spinal hematoma on CT or MRI first few days Major open procedures LDUH bid or tid, GCS and/or IPC just before surgery Group Specific Thromboprophylaxis
Knee replacement surgery 30 mg SC every 12 h 30 mg SC once daily 8. Fraxiparine [package insert]. Mississauga, Ontario: GlaxoSmithKline Inc; 2008.
For patients with SCI Recommend against the use of IVC filter as primary and used continuously while not ambulating, LMWH, Medical patients 40 mg SC once daily 9. Innohep [package insert]. Thornhill, Ontario: Leo Pharma Inc; 2008.
fondaparinux, or combination pharmacologic (ie, LMWH, Manufacturer Prescribing Information
prophylaxis 10. Sintrom [package insert]. Montreal, Quebec: Squire Pharmaceuticals Inc; 2007.
LDUH, or fondaparinux) with mechanical method (ie, nadroparin (Fraxiparine®)8 General surgery 2850 IU SC once daily, initial dose 2 - 4 h before surgery Severe renal dysfunction
Rehabilitation following acute Continuation of LMWH or conversion to oral VKA GCS and/or IPC) (CrCl < 30 mL/min): 11. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2007.
SCI (INR target, 2.5; INR range 2.0 to 3.0) 38 IU/kg SC 12 h before surgery, then 38 IU/kg SC 12 h after surgery, then
Hip replacement surgery Reduce dose by 25 - 33%
For patients actively bleeding or Optimal use of mechanical method with GCS and/or 38 IU/kg SC once daily up to and including Day 3, then 57 IU/kg as of Day 4
Disclaimer
at very high-risk for bleeding IPC until bleeding risk decreases; then pharmacologic tinzaparin (Innohep®)9 General surgery 3500 IU SC 2 h before surgery, then 3500 IU once daily This Guideline attempts to define principles of practice that should produce high-quality patient
prophylaxis substituted for or added to mechanical method Severe renal dysfunction care. It is applicable to specialists, primary care, and providers at all levels. This Guideline should
50 IU/kg SC 2 h before surgery followed by 50 IU/kg once daily (CrCl < 30 mL/min): not be considered exclusive of other methods of care reasonably directed at obtaining the same
Vascular Surgery Thromboprophylaxis Hip surgery or results. The ultimate judgement concerning the propriety of any course of conduct must be made
Consider dosage by the clinician after consideration of each individual patient situation.
75 IU/kg SC given post-operatively once daily
No additional risk factors Early and frequent ambulation reduction
Knee surgery 75 IU/kg SC given post-operatively once daily 5740 Executive Drive Suite 220 • Baltimore, MD 21228
Undergoing major procedure LMWH, LDUH, or fondaparinux
TEL: 410-869-3332 • FAX: 410-744-2150
with additional risk factors Vitamin K Antagonist (VKA)
Orders and inquiries: guidelines@MyGuidelinesCenter.com
Acenocoumarol (Sintrom®)10 Venous thrombosis and its extension Individualized; dose adjusted by INR response INR target of 2.5 Copyright © 2009 All rights reserved
For additional copies: www.myguidelinescenter.com For additional copies: guidelines@myguidelinescenter.com
Warfarin (Coumadin )® 11
Venous thrombosis and its extension Individualized; dose adjusted by INR response (INR range, 2.0 to 3.0)
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13662S R3 VTE Prevention.indd 1 3/19/09 10:10:56 AM
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Rationale for Thromboprophylaxis1 General Risk Groups and Recommendations1 Group Specific Thromboprophylaxis1

ÎÎThe rationale for use of thromboprophylaxis is based on solid ÎÎAlmost all hospitalized patients have at least one risk factor ÎÎSimplification of classification system to readily identify the ÎÎImplement group-specific thromboprophylaxis routinely for all
principles and scientific evidence (Table 1). for VTE, and approximately 40% have three or more risk general patient risk group and general thromboprophylaxis patients who belong to each of the major target groups.
factors (see Table 2). recommendations. Bariatric Surgery Thromboprophylaxis General Surgery Thromboprophylaxis Hip Replacement Thromboprophylaxis
Minor procedures and no risk Early and frequent ambulation Total Hip Replacement (THR) Options:
Table 1. Rationale for Thromboprophylaxis Table 2. Risk Factors for VTE Low Risk Inpatient surgery LMWH, LDUH tid, fondaparinux, or combination of
pharmacologic prophylaxis with IPC factors >> LMWH (at a usual high-risk dose, started 12 h before
 in Hospitalized Patients Surgery Selective estrogen receptor modulators >> Higher doses of LMWH or LDUH than for nonobese surgery or 12 to 24 h after surgery, or 4 to 6 h after
Major procedure for benign LMWH, LDUH, or fondaparinux surgery at half the usual high-risk dose and then
I. High prevalence of venous thromboembolism (VTE) Trauma (major trauma or lower-extremity Minor surgery in Burns Thromboprophylaxis disease
Erythropoiesis-stimulating agents increasing to the usual high-risk dose the following day)
injury) mobile patients Approximate DVT No specific >> fondaparinux
risk without thromboprophylaxis Burn patients with additional LMWH or LDUH Major procedure for cancer LMWH, LDUH tid, or fondaparinux
ÎÎAlmost all hospitalized patients have at least one risk factor for VTE Immobility, lower-extremity paresis Acute medical illness >> Oral Factor Xa inhibitor (rivaroxaban*)
thromboprophylaxis VTE risk factors >> VTE risk factors: advanced age, morbid obesity, Multiple risk factors LMWH, LDUH tid, or fondaparinux combined with >> Oral direct thrombin inhibitor (dabigatran*)
Cancer Inflammatory bowel disease < 10% Early and “aggressive” extensive or lower-extremity burns, concomitant lower- >> Adjusted-dose VKA started preoperatively or the
ÎÎDeep vein thrombosis (DVT) is common in many hospitalized patient groups extremity trauma, femoral venous catheter, and/or GCS and/or IPC
Cancer therapy (hormonal, chemotherapy, Medical patients who are ambulation evening of the surgical day
Nephrotic syndrome prolonged immobility High risk of bleeding GCS or IPC (INR target, 2.5; INR range, 2.0 to 3.0)
ÎÎHospital-acquired DVT and pulmonary embolism (PE) are usually clinically silent angiogenesis inhibitors, radiotherapy) fully mobile
High risk of bleeding GCS and/or IPC until bleeding risk decreases Major procedure Continue until hospital discharge Recommend against use of the following alone: aspirin,
Venous compression (tumor, hematoma,
ÎÎIt is impossible to predict which at-risk patients will develop symptomatic Myeloproliferative disorders High-risk (eg, major cancer surgery or previous VTE), dextran, LDUH, GCS, or VFP
thromboembolic complications
arterial abnormality) Moderate Risk Cancer Patients Thromboprophylaxis
consider continuation after hospital discharge with
Previous VTE Paroxysmal nocturnal hemoglobinuria Surgical procedures Refer to relevant surgical subsections High risk of bleeding IPC or VFP; when high bleeding risk decreases, then
ÎÎScreening at-risk patients using physical examination or noninvasive testing is LMWH for ≤ 28 d
Increasing age Obesity pharmacologic prophylaxis substituted for or added to
neither cost-effective nor effective Most general, open LMWH Bedridden with acute medical Refer to high-risk medical patients Gynecologic Surgery Thromboprophylaxis mechanical method
Pregnancy and the postpartum period Central venous catheterization gynecologic or urologic (dalteparin, enoxaparin, illness
II. Adverse consequences of unprevented VTE surgery patients nadroparin, tinzaparin) Low-risk minor procedures Early and frequent ambulation Knee Arthroscopy Thromboprophylaxis
Estrogen-containing oral contraceptives or Indwelling central venous Do not use either prophylactic doses of LMWH or and no risk factors
Inherited or acquired thrombophilia No additional risk factors Early mobilization if appropraite
hormone replacement catheters minidose warfarin to prevent catheter-related thrombosis
ÎÎSymptomatic DVT and PE Approximate DVT Laparoscopic procedure Early and frequent ambulation
LDUH bid or tid Additional risk factors or LMWH
Medical patients, bed rest risk without Receiving chemotherapy or Recommend against routine thromboprophylaxis for
ÎÎFatal PE thromboprophylaxis hormonal therapy primary prevention of VTE Laparoscopic procedure with LMWH, LDUH, IPC, or GCS complicated procedure
ÎÎ Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired or sick 10-40% additional VTE risk factors
DVT is approximately 10 to 40% among medical or general surgical patients and 40 to For cancer patients Recommend against routine primary thromboprophylaxis Knee Replacement Thromboprophylaxis
ÎÎCosts of investigating symptomatic patients fondaparinux Major gynecologic surgery LMWH, LDUH, or IPC started just before surgery and
60% following major orthopedic surgery (Table 3) to improve survival
ÎÎ Approximately 70% of all VTE is hospital acquired for benign disease without used continuously while not ambulating Total Knee Replacement (TKR) Options:
ÎÎRisks and costs of treating unprevented VTE Moderate VTE risk Coronary Artery Bypass Thromboprophylaxis >> LMWH (at usual high-risk dose)
Therefore, prevention of VTE in hospital patients is the most appropriate method to additional risk factors >> fondaparinux
plus high bleeding risk Mechanical Graft (CABG) Surgery
reduce the burden of this disease Extensive surgery for LMWH, or LDUH tid, or IPC started just before surgery >> Oral Factor Xa inhibitor (rivaroxaban*)
ÎÎIncreased future risk of recurrent VTE >> Oral direct thrombin inhibitor (dabigatran*)
CABG surgery LMWH, LDUH, or bilateral GCS or IPC malignancy and for patients and used continuously while not ambulating
Table 3. Approximate Risks of DVT in Hospitalized Patients* High Risk >> Suggest use of LMWH over LDUH to try to reduce risk with additional VTE risk Alternatives: >> Adjusted-dose VKA
ÎÎChronic post-thrombotic syndrome of heparin-induced thrombocytopenia (HIT) (INR target, 2.5; INR range, 2.0 to 3.0)
factors Combination LMWH or LDUH plus GCS or IPC Alternative:
Patient Group DVT Prevalence, %
III. Efficacy and effectiveness of thromboprophylaxis LMWH High risk of bleeding Properly fitted bilateral GCS or IPC fondaparinux >> IPC
Medical patients 10 - 20 (dalteparin, enoxaparin,
Hip or knee arthroplasty, Critical Care Thromboprophylaxis Major procedure Continue until hospital discharge Recommend against use of the following alone: aspirin,
ÎÎThromboprophylaxis is highly efficacious at preventing DVT General surgery 15 - 40 nadroparin, tinzaparin) High-risk (eg, major cancer surgery or previous VTE),
hip fracture surgery Moderate risk for VTE LMWH or LDUH LDUH, or VFP
and proximal DVT Major gynecologic surgery 15 - 40 consider continuation after hospital discharge with
fondaparinux >> VTE risk factors: medically ill or postoperative general High risk of bleeding IPC or VFP; when high bleeding risk decreases, then
ÎÎThromboprophylaxis is highly effective at preventing symptomatic Major urologic surgery 15 - 40 surgery LMWH for ≤ 28 d 
Approximate DVT pharmacologic prophylaxis substituted for or added to
VTE and fatal PE Oral Factor Xa inhibitor Hip Fracture Surgery (HFS) Thromboprophylaxis
Neurosurgery 15 - 40 risk without Higher risk LMWH mechanical method
Major trauma, (rivaroxaban*) >> VTE risk factors: following major trauma or orthopedic
ÎÎThe prevention of DVT also prevents PE Stroke 20 - 50 thromboprophylaxis Oral direct thrombin HFS fondaparinux, LMWH, adjusted-dose VKA (INR target, Laparoscopic Surgery Thromboprophylaxis
Spinal cord injury 40-80% surgery
Hip or knee arthroplasty, hip fracture surgery 40 - 60 inhibitor (dabigatran*) 2.5; INR range, 2.0 to 3.0), or LDUH
ÎÎCost-effectiveness of thromboprophylaxis has repeatedly been demonstrated High risk of bleeding GCS and/or IPC until bleeding risk decreases; then No additional risk factors Early and frequent ambulation
Major trauma 40 - 80 Recommend against use of aspirin alone
Oral VKA pharmacologic prophylaxis substituted for or added to Additional VTE risk factors LMWH, LDUH, fondaparinux, IPC, or GCS
Spinal cord injury 60 - 80 High VTE risk plus (acenocoumarol, mechanical method Surgery likely to be delayed LMWH or LDUH initiated during time between admission
Critical care patients 10 - 80 high bleeding risk warfarin) and surgery
High risk of bleeding Optimal use of mechanical methods; when high bleeding
Mechanical
risk decreases, pharmacologic prophylaxis substituted for or
* Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving added to mechanical method
thromboprophylaxis. *Indicated for elective hip and knee replacement surgery. *Indicated for elective hip and knee replacement surgery.
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13662S R3 VTE Prevention.indd 2 3/19/09 10:10:57 AM
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Rationale for Thromboprophylaxis1 General Risk Groups and Recommendations1 Group Specific Thromboprophylaxis1

ÎÎThe rationale for use of thromboprophylaxis is based on solid ÎÎAlmost all hospitalized patients have at least one risk factor ÎÎSimplification of classification system to readily identify the ÎÎImplement group-specific thromboprophylaxis routinely for all
principles and scientific evidence (Table 1). for VTE, and approximately 40% have three or more risk general patient risk group and general thromboprophylaxis patients who belong to each of the major target groups.
factors (see Table 2). recommendations. Bariatric Surgery Thromboprophylaxis General Surgery Thromboprophylaxis Hip Replacement Thromboprophylaxis
Minor procedures and no risk Early and frequent ambulation Total Hip Replacement (THR) Options:
Table 1. Rationale for Thromboprophylaxis Table 2. Risk Factors for VTE Low Risk Inpatient surgery LMWH, LDUH tid, fondaparinux, or combination of
pharmacologic prophylaxis with IPC factors >> LMWH (at a usual high-risk dose, started 12 h before
 in Hospitalized Patients Surgery Selective estrogen receptor modulators >> Higher doses of LMWH or LDUH than for nonobese surgery or 12 to 24 h after surgery, or 4 to 6 h after
Major procedure for benign LMWH, LDUH, or fondaparinux surgery at half the usual high-risk dose and then
I. High prevalence of venous thromboembolism (VTE) Trauma (major trauma or lower-extremity Minor surgery in Burns Thromboprophylaxis disease
Erythropoiesis-stimulating agents increasing to the usual high-risk dose the following day)
injury) mobile patients Approximate DVT No specific >> fondaparinux
risk without thromboprophylaxis Burn patients with additional LMWH or LDUH Major procedure for cancer LMWH, LDUH tid, or fondaparinux
ÎÎAlmost all hospitalized patients have at least one risk factor for VTE Immobility, lower-extremity paresis Acute medical illness >> Oral Factor Xa inhibitor (rivaroxaban*)
thromboprophylaxis VTE risk factors >> VTE risk factors: advanced age, morbid obesity, Multiple risk factors LMWH, LDUH tid, or fondaparinux combined with >> Oral direct thrombin inhibitor (dabigatran*)
Cancer Inflammatory bowel disease < 10% Early and “aggressive” extensive or lower-extremity burns, concomitant lower- >> Adjusted-dose VKA started preoperatively or the
ÎÎDeep vein thrombosis (DVT) is common in many hospitalized patient groups extremity trauma, femoral venous catheter, and/or GCS and/or IPC
Cancer therapy (hormonal, chemotherapy, Medical patients who are ambulation evening of the surgical day
Nephrotic syndrome prolonged immobility High risk of bleeding GCS or IPC (INR target, 2.5; INR range, 2.0 to 3.0)
ÎÎHospital-acquired DVT and pulmonary embolism (PE) are usually clinically silent angiogenesis inhibitors, radiotherapy) fully mobile
High risk of bleeding GCS and/or IPC until bleeding risk decreases Major procedure Continue until hospital discharge Recommend against use of the following alone: aspirin,
Venous compression (tumor, hematoma,
ÎÎIt is impossible to predict which at-risk patients will develop symptomatic Myeloproliferative disorders High-risk (eg, major cancer surgery or previous VTE), dextran, LDUH, GCS, or VFP
thromboembolic complications
arterial abnormality) Moderate Risk Cancer Patients Thromboprophylaxis
consider continuation after hospital discharge with
Previous VTE Paroxysmal nocturnal hemoglobinuria Surgical procedures Refer to relevant surgical subsections High risk of bleeding IPC or VFP; when high bleeding risk decreases, then
ÎÎScreening at-risk patients using physical examination or noninvasive testing is LMWH for ≤ 28 d
Increasing age Obesity pharmacologic prophylaxis substituted for or added to
neither cost-effective nor effective Most general, open LMWH Bedridden with acute medical Refer to high-risk medical patients Gynecologic Surgery Thromboprophylaxis mechanical method
Pregnancy and the postpartum period Central venous catheterization gynecologic or urologic (dalteparin, enoxaparin, illness
II. Adverse consequences of unprevented VTE surgery patients nadroparin, tinzaparin) Low-risk minor procedures Early and frequent ambulation Knee Arthroscopy Thromboprophylaxis
Estrogen-containing oral contraceptives or Indwelling central venous Do not use either prophylactic doses of LMWH or and no risk factors
Inherited or acquired thrombophilia No additional risk factors Early mobilization if appropraite
hormone replacement catheters minidose warfarin to prevent catheter-related thrombosis
ÎÎSymptomatic DVT and PE Approximate DVT Laparoscopic procedure Early and frequent ambulation
LDUH bid or tid Additional risk factors or LMWH
Medical patients, bed rest risk without Receiving chemotherapy or Recommend against routine thromboprophylaxis for
ÎÎFatal PE thromboprophylaxis hormonal therapy primary prevention of VTE Laparoscopic procedure with LMWH, LDUH, IPC, or GCS complicated procedure
ÎÎ Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired or sick 10-40% additional VTE risk factors
DVT is approximately 10 to 40% among medical or general surgical patients and 40 to For cancer patients Recommend against routine primary thromboprophylaxis Knee Replacement Thromboprophylaxis
ÎÎCosts of investigating symptomatic patients fondaparinux Major gynecologic surgery LMWH, LDUH, or IPC started just before surgery and
60% following major orthopedic surgery (Table 3) to improve survival
ÎÎ Approximately 70% of all VTE is hospital acquired for benign disease without used continuously while not ambulating Total Knee Replacement (TKR) Options:
ÎÎRisks and costs of treating unprevented VTE Moderate VTE risk Coronary Artery Bypass Thromboprophylaxis >> LMWH (at usual high-risk dose)
Therefore, prevention of VTE in hospital patients is the most appropriate method to additional risk factors >> fondaparinux
plus high bleeding risk Mechanical Graft (CABG) Surgery
reduce the burden of this disease Extensive surgery for LMWH, or LDUH tid, or IPC started just before surgery >> Oral Factor Xa inhibitor (rivaroxaban*)
ÎÎIncreased future risk of recurrent VTE >> Oral direct thrombin inhibitor (dabigatran*)
CABG surgery LMWH, LDUH, or bilateral GCS or IPC malignancy and for patients and used continuously while not ambulating
Table 3. Approximate Risks of DVT in Hospitalized Patients* High Risk >> Suggest use of LMWH over LDUH to try to reduce risk with additional VTE risk Alternatives: >> Adjusted-dose VKA
ÎÎChronic post-thrombotic syndrome of heparin-induced thrombocytopenia (HIT) (INR target, 2.5; INR range, 2.0 to 3.0)
factors Combination LMWH or LDUH plus GCS or IPC Alternative:
Patient Group DVT Prevalence, %
III. Efficacy and effectiveness of thromboprophylaxis LMWH High risk of bleeding Properly fitted bilateral GCS or IPC fondaparinux >> IPC
Medical patients 10 - 20 (dalteparin, enoxaparin,
Hip or knee arthroplasty, Critical Care Thromboprophylaxis Major procedure Continue until hospital discharge Recommend against use of the following alone: aspirin,
ÎÎThromboprophylaxis is highly efficacious at preventing DVT General surgery 15 - 40 nadroparin, tinzaparin) High-risk (eg, major cancer surgery or previous VTE),
hip fracture surgery Moderate risk for VTE LMWH or LDUH LDUH, or VFP
and proximal DVT Major gynecologic surgery 15 - 40 consider continuation after hospital discharge with
fondaparinux >> VTE risk factors: medically ill or postoperative general High risk of bleeding IPC or VFP; when high bleeding risk decreases, then
ÎÎThromboprophylaxis is highly effective at preventing symptomatic Major urologic surgery 15 - 40 surgery LMWH for ≤ 28 d 
Approximate DVT pharmacologic prophylaxis substituted for or added to
VTE and fatal PE Oral Factor Xa inhibitor Hip Fracture Surgery (HFS) Thromboprophylaxis
Neurosurgery 15 - 40 risk without Higher risk LMWH mechanical method
Major trauma, (rivaroxaban*) >> VTE risk factors: following major trauma or orthopedic
ÎÎThe prevention of DVT also prevents PE Stroke 20 - 50 thromboprophylaxis Oral direct thrombin HFS fondaparinux, LMWH, adjusted-dose VKA (INR target, Laparoscopic Surgery Thromboprophylaxis
Spinal cord injury 40-80% surgery
Hip or knee arthroplasty, hip fracture surgery 40 - 60 inhibitor (dabigatran*) 2.5; INR range, 2.0 to 3.0), or LDUH
ÎÎCost-effectiveness of thromboprophylaxis has repeatedly been demonstrated High risk of bleeding GCS and/or IPC until bleeding risk decreases; then No additional risk factors Early and frequent ambulation
Major trauma 40 - 80 Recommend against use of aspirin alone
Oral VKA pharmacologic prophylaxis substituted for or added to Additional VTE risk factors LMWH, LDUH, fondaparinux, IPC, or GCS
Spinal cord injury 60 - 80 High VTE risk plus (acenocoumarol, mechanical method Surgery likely to be delayed LMWH or LDUH initiated during time between admission
Critical care patients 10 - 80 high bleeding risk warfarin) and surgery
High risk of bleeding Optimal use of mechanical methods; when high bleeding
Mechanical
risk decreases, pharmacologic prophylaxis substituted for or
* Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving added to mechanical method
thromboprophylaxis. *Indicated for elective hip and knee replacement surgery. *Indicated for elective hip and knee replacement surgery.
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13662S R3 VTE Prevention.indd 2 3/19/09 10:10:57 AM
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Rationale for Thromboprophylaxis1 General Risk Groups and Recommendations1 Group Specific Thromboprophylaxis1

ÎÎThe rationale for use of thromboprophylaxis is based on solid ÎÎAlmost all hospitalized patients have at least one risk factor ÎÎSimplification of classification system to readily identify the ÎÎImplement group-specific thromboprophylaxis routinely for all
principles and scientific evidence (Table 1). for VTE, and approximately 40% have three or more risk general patient risk group and general thromboprophylaxis patients who belong to each of the major target groups.
factors (see Table 2). recommendations. Bariatric Surgery Thromboprophylaxis General Surgery Thromboprophylaxis Hip Replacement Thromboprophylaxis
Minor procedures and no risk Early and frequent ambulation Total Hip Replacement (THR) Options:
Table 1. Rationale for Thromboprophylaxis Table 2. Risk Factors for VTE Low Risk Inpatient surgery LMWH, LDUH tid, fondaparinux, or combination of
pharmacologic prophylaxis with IPC factors >> LMWH (at a usual high-risk dose, started 12 h before
 in Hospitalized Patients Surgery Selective estrogen receptor modulators >> Higher doses of LMWH or LDUH than for nonobese surgery or 12 to 24 h after surgery, or 4 to 6 h after
Major procedure for benign LMWH, LDUH, or fondaparinux surgery at half the usual high-risk dose and then
I. High prevalence of venous thromboembolism (VTE) Trauma (major trauma or lower-extremity Minor surgery in Burns Thromboprophylaxis disease
Erythropoiesis-stimulating agents increasing to the usual high-risk dose the following day)
injury) mobile patients Approximate DVT No specific >> fondaparinux
risk without thromboprophylaxis Burn patients with additional LMWH or LDUH Major procedure for cancer LMWH, LDUH tid, or fondaparinux
ÎÎAlmost all hospitalized patients have at least one risk factor for VTE Immobility, lower-extremity paresis Acute medical illness >> Oral Factor Xa inhibitor (rivaroxaban*)
thromboprophylaxis VTE risk factors >> VTE risk factors: advanced age, morbid obesity, Multiple risk factors LMWH, LDUH tid, or fondaparinux combined with >> Oral direct thrombin inhibitor (dabigatran*)
Cancer Inflammatory bowel disease < 10% Early and “aggressive” extensive or lower-extremity burns, concomitant lower- >> Adjusted-dose VKA started preoperatively or the
ÎÎDeep vein thrombosis (DVT) is common in many hospitalized patient groups extremity trauma, femoral venous catheter, and/or GCS and/or IPC
Cancer therapy (hormonal, chemotherapy, Medical patients who are ambulation evening of the surgical day
Nephrotic syndrome prolonged immobility High risk of bleeding GCS or IPC (INR target, 2.5; INR range, 2.0 to 3.0)
ÎÎHospital-acquired DVT and pulmonary embolism (PE) are usually clinically silent angiogenesis inhibitors, radiotherapy) fully mobile
High risk of bleeding GCS and/or IPC until bleeding risk decreases Major procedure Continue until hospital discharge Recommend against use of the following alone: aspirin,
Venous compression (tumor, hematoma,
ÎÎIt is impossible to predict which at-risk patients will develop symptomatic Myeloproliferative disorders High-risk (eg, major cancer surgery or previous VTE), dextran, LDUH, GCS, or VFP
thromboembolic complications
arterial abnormality) Moderate Risk Cancer Patients Thromboprophylaxis
consider continuation after hospital discharge with
Previous VTE Paroxysmal nocturnal hemoglobinuria Surgical procedures Refer to relevant surgical subsections High risk of bleeding IPC or VFP; when high bleeding risk decreases, then
ÎÎScreening at-risk patients using physical examination or noninvasive testing is LMWH for ≤ 28 d
Increasing age Obesity pharmacologic prophylaxis substituted for or added to
neither cost-effective nor effective Most general, open LMWH Bedridden with acute medical Refer to high-risk medical patients Gynecologic Surgery Thromboprophylaxis mechanical method
Pregnancy and the postpartum period Central venous catheterization gynecologic or urologic (dalteparin, enoxaparin, illness
II. Adverse consequences of unprevented VTE surgery patients nadroparin, tinzaparin) Low-risk minor procedures Early and frequent ambulation Knee Arthroscopy Thromboprophylaxis
Estrogen-containing oral contraceptives or Indwelling central venous Do not use either prophylactic doses of LMWH or and no risk factors
Inherited or acquired thrombophilia No additional risk factors Early mobilization if appropraite
hormone replacement catheters minidose warfarin to prevent catheter-related thrombosis
ÎÎSymptomatic DVT and PE Approximate DVT Laparoscopic procedure Early and frequent ambulation
LDUH bid or tid Additional risk factors or LMWH
Medical patients, bed rest risk without Receiving chemotherapy or Recommend against routine thromboprophylaxis for
ÎÎFatal PE thromboprophylaxis hormonal therapy primary prevention of VTE Laparoscopic procedure with LMWH, LDUH, IPC, or GCS complicated procedure
ÎÎ Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired or sick 10-40% additional VTE risk factors
DVT is approximately 10 to 40% among medical or general surgical patients and 40 to For cancer patients Recommend against routine primary thromboprophylaxis Knee Replacement Thromboprophylaxis
ÎÎCosts of investigating symptomatic patients fondaparinux Major gynecologic surgery LMWH, LDUH, or IPC started just before surgery and
60% following major orthopedic surgery (Table 3) to improve survival
ÎÎ Approximately 70% of all VTE is hospital acquired for benign disease without used continuously while not ambulating Total Knee Replacement (TKR) Options:
ÎÎRisks and costs of treating unprevented VTE Moderate VTE risk Coronary Artery Bypass Thromboprophylaxis >> LMWH (at usual high-risk dose)
Therefore, prevention of VTE in hospital patients is the most appropriate method to additional risk factors >> fondaparinux
plus high bleeding risk Mechanical Graft (CABG) Surgery
reduce the burden of this disease Extensive surgery for LMWH, or LDUH tid, or IPC started just before surgery >> Oral Factor Xa inhibitor (rivaroxaban*)
ÎÎIncreased future risk of recurrent VTE >> Oral direct thrombin inhibitor (dabigatran*)
CABG surgery LMWH, LDUH, or bilateral GCS or IPC malignancy and for patients and used continuously while not ambulating
Table 3. Approximate Risks of DVT in Hospitalized Patients* High Risk >> Suggest use of LMWH over LDUH to try to reduce risk with additional VTE risk Alternatives: >> Adjusted-dose VKA
ÎÎChronic post-thrombotic syndrome of heparin-induced thrombocytopenia (HIT) (INR target, 2.5; INR range, 2.0 to 3.0)
factors Combination LMWH or LDUH plus GCS or IPC Alternative:
Patient Group DVT Prevalence, %
III. Efficacy and effectiveness of thromboprophylaxis LMWH High risk of bleeding Properly fitted bilateral GCS or IPC fondaparinux >> IPC
Medical patients 10 - 20 (dalteparin, enoxaparin,
Hip or knee arthroplasty, Critical Care Thromboprophylaxis Major procedure Continue until hospital discharge Recommend against use of the following alone: aspirin,
ÎÎThromboprophylaxis is highly efficacious at preventing DVT General surgery 15 - 40 nadroparin, tinzaparin) High-risk (eg, major cancer surgery or previous VTE),
hip fracture surgery Moderate risk for VTE LMWH or LDUH LDUH, or VFP
and proximal DVT Major gynecologic surgery 15 - 40 consider continuation after hospital discharge with
fondaparinux >> VTE risk factors: medically ill or postoperative general High risk of bleeding IPC or VFP; when high bleeding risk decreases, then
ÎÎThromboprophylaxis is highly effective at preventing symptomatic Major urologic surgery 15 - 40 surgery LMWH for ≤ 28 d 
Approximate DVT pharmacologic prophylaxis substituted for or added to
VTE and fatal PE Oral Factor Xa inhibitor Hip Fracture Surgery (HFS) Thromboprophylaxis
Neurosurgery 15 - 40 risk without Higher risk LMWH mechanical method
Major trauma, (rivaroxaban*) >> VTE risk factors: following major trauma or orthopedic
ÎÎThe prevention of DVT also prevents PE Stroke 20 - 50 thromboprophylaxis Oral direct thrombin HFS fondaparinux, LMWH, adjusted-dose VKA (INR target, Laparoscopic Surgery Thromboprophylaxis
Spinal cord injury 40-80% surgery
Hip or knee arthroplasty, hip fracture surgery 40 - 60 inhibitor (dabigatran*) 2.5; INR range, 2.0 to 3.0), or LDUH
ÎÎCost-effectiveness of thromboprophylaxis has repeatedly been demonstrated High risk of bleeding GCS and/or IPC until bleeding risk decreases; then No additional risk factors Early and frequent ambulation
Major trauma 40 - 80 Recommend against use of aspirin alone
Oral VKA pharmacologic prophylaxis substituted for or added to Additional VTE risk factors LMWH, LDUH, fondaparinux, IPC, or GCS
Spinal cord injury 60 - 80 High VTE risk plus (acenocoumarol, mechanical method Surgery likely to be delayed LMWH or LDUH initiated during time between admission
Critical care patients 10 - 80 high bleeding risk warfarin) and surgery
High risk of bleeding Optimal use of mechanical methods; when high bleeding
Mechanical
risk decreases, pharmacologic prophylaxis substituted for or
* Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving added to mechanical method
thromboprophylaxis. *Indicated for elective hip and knee replacement surgery. *Indicated for elective hip and knee replacement surgery.
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13662S R3 VTE Prevention.indd 2 3/19/09 10:10:57 AM
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Rationale for Thromboprophylaxis1 General Risk Groups and Recommendations1 Group Specific Thromboprophylaxis1

ÎÎThe rationale for use of thromboprophylaxis is based on solid ÎÎAlmost all hospitalized patients have at least one risk factor ÎÎSimplification of classification system to readily identify the ÎÎImplement group-specific thromboprophylaxis routinely for all
principles and scientific evidence (Table 1). for VTE, and approximately 40% have three or more risk general patient risk group and general thromboprophylaxis patients who belong to each of the major target groups.
factors (see Table 2). recommendations. Bariatric Surgery Thromboprophylaxis General Surgery Thromboprophylaxis Hip Replacement Thromboprophylaxis
Minor procedures and no risk Early and frequent ambulation Total Hip Replacement (THR) Options:
Table 1. Rationale for Thromboprophylaxis Table 2. Risk Factors for VTE Low Risk Inpatient surgery LMWH, LDUH tid, fondaparinux, or combination of
pharmacologic prophylaxis with IPC factors >> LMWH (at a usual high-risk dose, started 12 h before
 in Hospitalized Patients Surgery Selective estrogen receptor modulators >> Higher doses of LMWH or LDUH than for nonobese surgery or 12 to 24 h after surgery, or 4 to 6 h after
Major procedure for benign LMWH, LDUH, or fondaparinux surgery at half the usual high-risk dose and then
I. High prevalence of venous thromboembolism (VTE) Trauma (major trauma or lower-extremity Minor surgery in Burns Thromboprophylaxis disease
Erythropoiesis-stimulating agents increasing to the usual high-risk dose the following day)
injury) mobile patients Approximate DVT No specific >> fondaparinux
risk without thromboprophylaxis Burn patients with additional LMWH or LDUH Major procedure for cancer LMWH, LDUH tid, or fondaparinux
ÎÎAlmost all hospitalized patients have at least one risk factor for VTE Immobility, lower-extremity paresis Acute medical illness >> Oral Factor Xa inhibitor (rivaroxaban*)
thromboprophylaxis VTE risk factors >> VTE risk factors: advanced age, morbid obesity, Multiple risk factors LMWH, LDUH tid, or fondaparinux combined with >> Oral direct thrombin inhibitor (dabigatran*)
Cancer Inflammatory bowel disease < 10% Early and “aggressive” extensive or lower-extremity burns, concomitant lower- >> Adjusted-dose VKA started preoperatively or the
ÎÎDeep vein thrombosis (DVT) is common in many hospitalized patient groups extremity trauma, femoral venous catheter, and/or GCS and/or IPC
Cancer therapy (hormonal, chemotherapy, Medical patients who are ambulation evening of the surgical day
Nephrotic syndrome prolonged immobility High risk of bleeding GCS or IPC (INR target, 2.5; INR range, 2.0 to 3.0)
ÎÎHospital-acquired DVT and pulmonary embolism (PE) are usually clinically silent angiogenesis inhibitors, radiotherapy) fully mobile
High risk of bleeding GCS and/or IPC until bleeding risk decreases Major procedure Continue until hospital discharge Recommend against use of the following alone: aspirin,
Venous compression (tumor, hematoma,
ÎÎIt is impossible to predict which at-risk patients will develop symptomatic Myeloproliferative disorders High-risk (eg, major cancer surgery or previous VTE), dextran, LDUH, GCS, or VFP
thromboembolic complications
arterial abnormality) Moderate Risk Cancer Patients Thromboprophylaxis
consider continuation after hospital discharge with
Previous VTE Paroxysmal nocturnal hemoglobinuria Surgical procedures Refer to relevant surgical subsections High risk of bleeding IPC or VFP; when high bleeding risk decreases, then
ÎÎScreening at-risk patients using physical examination or noninvasive testing is LMWH for ≤ 28 d
Increasing age Obesity pharmacologic prophylaxis substituted for or added to
neither cost-effective nor effective Most general, open LMWH Bedridden with acute medical Refer to high-risk medical patients Gynecologic Surgery Thromboprophylaxis mechanical method
Pregnancy and the postpartum period Central venous catheterization gynecologic or urologic (dalteparin, enoxaparin, illness
II. Adverse consequences of unprevented VTE surgery patients nadroparin, tinzaparin) Low-risk minor procedures Early and frequent ambulation Knee Arthroscopy Thromboprophylaxis
Estrogen-containing oral contraceptives or Indwelling central venous Do not use either prophylactic doses of LMWH or and no risk factors
Inherited or acquired thrombophilia No additional risk factors Early mobilization if appropraite
hormone replacement catheters minidose warfarin to prevent catheter-related thrombosis
ÎÎSymptomatic DVT and PE Approximate DVT Laparoscopic procedure Early and frequent ambulation
LDUH bid or tid Additional risk factors or LMWH
Medical patients, bed rest risk without Receiving chemotherapy or Recommend against routine thromboprophylaxis for
ÎÎFatal PE thromboprophylaxis hormonal therapy primary prevention of VTE Laparoscopic procedure with LMWH, LDUH, IPC, or GCS complicated procedure
ÎÎ Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired or sick 10-40% additional VTE risk factors
DVT is approximately 10 to 40% among medical or general surgical patients and 40 to For cancer patients Recommend against routine primary thromboprophylaxis Knee Replacement Thromboprophylaxis
ÎÎCosts of investigating symptomatic patients fondaparinux Major gynecologic surgery LMWH, LDUH, or IPC started just before surgery and
60% following major orthopedic surgery (Table 3) to improve survival
ÎÎ Approximately 70% of all VTE is hospital acquired for benign disease without used continuously while not ambulating Total Knee Replacement (TKR) Options:
ÎÎRisks and costs of treating unprevented VTE Moderate VTE risk Coronary Artery Bypass Thromboprophylaxis >> LMWH (at usual high-risk dose)
Therefore, prevention of VTE in hospital patients is the most appropriate method to additional risk factors >> fondaparinux
plus high bleeding risk Mechanical Graft (CABG) Surgery
reduce the burden of this disease Extensive surgery for LMWH, or LDUH tid, or IPC started just before surgery >> Oral Factor Xa inhibitor (rivaroxaban*)
ÎÎIncreased future risk of recurrent VTE >> Oral direct thrombin inhibitor (dabigatran*)
CABG surgery LMWH, LDUH, or bilateral GCS or IPC malignancy and for patients and used continuously while not ambulating
Table 3. Approximate Risks of DVT in Hospitalized Patients* High Risk >> Suggest use of LMWH over LDUH to try to reduce risk with additional VTE risk Alternatives: >> Adjusted-dose VKA
ÎÎChronic post-thrombotic syndrome of heparin-induced thrombocytopenia (HIT) (INR target, 2.5; INR range, 2.0 to 3.0)
factors Combination LMWH or LDUH plus GCS or IPC Alternative:
Patient Group DVT Prevalence, %
III. Efficacy and effectiveness of thromboprophylaxis LMWH High risk of bleeding Properly fitted bilateral GCS or IPC fondaparinux >> IPC
Medical patients 10 - 20 (dalteparin, enoxaparin,
Hip or knee arthroplasty, Critical Care Thromboprophylaxis Major procedure Continue until hospital discharge Recommend against use of the following alone: aspirin,
ÎÎThromboprophylaxis is highly efficacious at preventing DVT General surgery 15 - 40 nadroparin, tinzaparin) High-risk (eg, major cancer surgery or previous VTE),
hip fracture surgery Moderate risk for VTE LMWH or LDUH LDUH, or VFP
and proximal DVT Major gynecologic surgery 15 - 40 consider continuation after hospital discharge with
fondaparinux >> VTE risk factors: medically ill or postoperative general High risk of bleeding IPC or VFP; when high bleeding risk decreases, then
ÎÎThromboprophylaxis is highly effective at preventing symptomatic Major urologic surgery 15 - 40 surgery LMWH for ≤ 28 d 
Approximate DVT pharmacologic prophylaxis substituted for or added to
VTE and fatal PE Oral Factor Xa inhibitor Hip Fracture Surgery (HFS) Thromboprophylaxis
Neurosurgery 15 - 40 risk without Higher risk LMWH mechanical method
Major trauma, (rivaroxaban*) >> VTE risk factors: following major trauma or orthopedic
ÎÎThe prevention of DVT also prevents PE Stroke 20 - 50 thromboprophylaxis Oral direct thrombin HFS fondaparinux, LMWH, adjusted-dose VKA (INR target, Laparoscopic Surgery Thromboprophylaxis
Spinal cord injury 40-80% surgery
Hip or knee arthroplasty, hip fracture surgery 40 - 60 inhibitor (dabigatran*) 2.5; INR range, 2.0 to 3.0), or LDUH
ÎÎCost-effectiveness of thromboprophylaxis has repeatedly been demonstrated High risk of bleeding GCS and/or IPC until bleeding risk decreases; then No additional risk factors Early and frequent ambulation
Major trauma 40 - 80 Recommend against use of aspirin alone
Oral VKA pharmacologic prophylaxis substituted for or added to Additional VTE risk factors LMWH, LDUH, fondaparinux, IPC, or GCS
Spinal cord injury 60 - 80 High VTE risk plus (acenocoumarol, mechanical method Surgery likely to be delayed LMWH or LDUH initiated during time between admission
Critical care patients 10 - 80 high bleeding risk warfarin) and surgery
High risk of bleeding Optimal use of mechanical methods; when high bleeding
Mechanical
risk decreases, pharmacologic prophylaxis substituted for or
* Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving added to mechanical method
thromboprophylaxis. *Indicated for elective hip and knee replacement surgery. *Indicated for elective hip and knee replacement surgery.
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13662S R3 VTE Prevention.indd 2 3/19/09 10:10:57 AM
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Rationale for Thromboprophylaxis1 General Risk Groups and Recommendations1 Group Specific Thromboprophylaxis1

ÎÎThe rationale for use of thromboprophylaxis is based on solid ÎÎAlmost all hospitalized patients have at least one risk factor ÎÎSimplification of classification system to readily identify the ÎÎImplement group-specific thromboprophylaxis routinely for all
principles and scientific evidence (Table 1). for VTE, and approximately 40% have three or more risk general patient risk group and general thromboprophylaxis patients who belong to each of the major target groups.
factors (see Table 2). recommendations. Bariatric Surgery Thromboprophylaxis General Surgery Thromboprophylaxis Hip Replacement Thromboprophylaxis
Minor procedures and no risk Early and frequent ambulation Total Hip Replacement (THR) Options:
Table 1. Rationale for Thromboprophylaxis Table 2. Risk Factors for VTE Low Risk Inpatient surgery LMWH, LDUH tid, fondaparinux, or combination of
pharmacologic prophylaxis with IPC factors >> LMWH (at a usual high-risk dose, started 12 h before
 in Hospitalized Patients Surgery Selective estrogen receptor modulators >> Higher doses of LMWH or LDUH than for nonobese surgery or 12 to 24 h after surgery, or 4 to 6 h after
Major procedure for benign LMWH, LDUH, or fondaparinux surgery at half the usual high-risk dose and then
I. High prevalence of venous thromboembolism (VTE) Trauma (major trauma or lower-extremity Minor surgery in Burns Thromboprophylaxis disease
Erythropoiesis-stimulating agents increasing to the usual high-risk dose the following day)
injury) mobile patients Approximate DVT No specific >> fondaparinux
risk without thromboprophylaxis Burn patients with additional LMWH or LDUH Major procedure for cancer LMWH, LDUH tid, or fondaparinux
ÎÎAlmost all hospitalized patients have at least one risk factor for VTE Immobility, lower-extremity paresis Acute medical illness >> Oral Factor Xa inhibitor (rivaroxaban*)
thromboprophylaxis VTE risk factors >> VTE risk factors: advanced age, morbid obesity, Multiple risk factors LMWH, LDUH tid, or fondaparinux combined with >> Oral direct thrombin inhibitor (dabigatran*)
Cancer Inflammatory bowel disease < 10% Early and “aggressive” extensive or lower-extremity burns, concomitant lower- >> Adjusted-dose VKA started preoperatively or the
ÎÎDeep vein thrombosis (DVT) is common in many hospitalized patient groups extremity trauma, femoral venous catheter, and/or GCS and/or IPC
Cancer therapy (hormonal, chemotherapy, Medical patients who are ambulation evening of the surgical day
Nephrotic syndrome prolonged immobility High risk of bleeding GCS or IPC (INR target, 2.5; INR range, 2.0 to 3.0)
ÎÎHospital-acquired DVT and pulmonary embolism (PE) are usually clinically silent angiogenesis inhibitors, radiotherapy) fully mobile
High risk of bleeding GCS and/or IPC until bleeding risk decreases Major procedure Continue until hospital discharge Recommend against use of the following alone: aspirin,
Venous compression (tumor, hematoma,
ÎÎIt is impossible to predict which at-risk patients will develop symptomatic Myeloproliferative disorders High-risk (eg, major cancer surgery or previous VTE), dextran, LDUH, GCS, or VFP
thromboembolic complications
arterial abnormality) Moderate Risk Cancer Patients Thromboprophylaxis
consider continuation after hospital discharge with
Previous VTE Paroxysmal nocturnal hemoglobinuria Surgical procedures Refer to relevant surgical subsections High risk of bleeding IPC or VFP; when high bleeding risk decreases, then
ÎÎScreening at-risk patients using physical examination or noninvasive testing is LMWH for ≤ 28 d
Increasing age Obesity pharmacologic prophylaxis substituted for or added to
neither cost-effective nor effective Most general, open LMWH Bedridden with acute medical Refer to high-risk medical patients Gynecologic Surgery Thromboprophylaxis mechanical method
Pregnancy and the postpartum period Central venous catheterization gynecologic or urologic (dalteparin, enoxaparin, illness
II. Adverse consequences of unprevented VTE surgery patients nadroparin, tinzaparin) Low-risk minor procedures Early and frequent ambulation Knee Arthroscopy Thromboprophylaxis
Estrogen-containing oral contraceptives or Indwelling central venous Do not use either prophylactic doses of LMWH or and no risk factors
Inherited or acquired thrombophilia No additional risk factors Early mobilization if appropraite
hormone replacement catheters minidose warfarin to prevent catheter-related thrombosis
ÎÎSymptomatic DVT and PE Approximate DVT Laparoscopic procedure Early and frequent ambulation
LDUH bid or tid Additional risk factors or LMWH
Medical patients, bed rest risk without Receiving chemotherapy or Recommend against routine thromboprophylaxis for
ÎÎFatal PE thromboprophylaxis hormonal therapy primary prevention of VTE Laparoscopic procedure with LMWH, LDUH, IPC, or GCS complicated procedure
ÎÎ Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired or sick 10-40% additional VTE risk factors
DVT is approximately 10 to 40% among medical or general surgical patients and 40 to For cancer patients Recommend against routine primary thromboprophylaxis Knee Replacement Thromboprophylaxis
ÎÎCosts of investigating symptomatic patients fondaparinux Major gynecologic surgery LMWH, LDUH, or IPC started just before surgery and
60% following major orthopedic surgery (Table 3) to improve survival
ÎÎ Approximately 70% of all VTE is hospital acquired for benign disease without used continuously while not ambulating Total Knee Replacement (TKR) Options:
ÎÎRisks and costs of treating unprevented VTE Moderate VTE risk Coronary Artery Bypass Thromboprophylaxis >> LMWH (at usual high-risk dose)
Therefore, prevention of VTE in hospital patients is the most appropriate method to additional risk factors >> fondaparinux
plus high bleeding risk Mechanical Graft (CABG) Surgery
reduce the burden of this disease Extensive surgery for LMWH, or LDUH tid, or IPC started just before surgery >> Oral Factor Xa inhibitor (rivaroxaban*)
ÎÎIncreased future risk of recurrent VTE >> Oral direct thrombin inhibitor (dabigatran*)
CABG surgery LMWH, LDUH, or bilateral GCS or IPC malignancy and for patients and used continuously while not ambulating
Table 3. Approximate Risks of DVT in Hospitalized Patients* High Risk >> Suggest use of LMWH over LDUH to try to reduce risk with additional VTE risk Alternatives: >> Adjusted-dose VKA
ÎÎChronic post-thrombotic syndrome of heparin-induced thrombocytopenia (HIT) (INR target, 2.5; INR range, 2.0 to 3.0)
factors Combination LMWH or LDUH plus GCS or IPC Alternative:
Patient Group DVT Prevalence, %
III. Efficacy and effectiveness of thromboprophylaxis LMWH High risk of bleeding Properly fitted bilateral GCS or IPC fondaparinux >> IPC
Medical patients 10 - 20 (dalteparin, enoxaparin,
Hip or knee arthroplasty, Critical Care Thromboprophylaxis Major procedure Continue until hospital discharge Recommend against use of the following alone: aspirin,
ÎÎThromboprophylaxis is highly efficacious at preventing DVT General surgery 15 - 40 nadroparin, tinzaparin) High-risk (eg, major cancer surgery or previous VTE),
hip fracture surgery Moderate risk for VTE LMWH or LDUH LDUH, or VFP
and proximal DVT Major gynecologic surgery 15 - 40 consider continuation after hospital discharge with
fondaparinux >> VTE risk factors: medically ill or postoperative general High risk of bleeding IPC or VFP; when high bleeding risk decreases, then
ÎÎThromboprophylaxis is highly effective at preventing symptomatic Major urologic surgery 15 - 40 surgery LMWH for ≤ 28 d 
Approximate DVT pharmacologic prophylaxis substituted for or added to
VTE and fatal PE Oral Factor Xa inhibitor Hip Fracture Surgery (HFS) Thromboprophylaxis
Neurosurgery 15 - 40 risk without Higher risk LMWH mechanical method
Major trauma, (rivaroxaban*) >> VTE risk factors: following major trauma or orthopedic
ÎÎThe prevention of DVT also prevents PE Stroke 20 - 50 thromboprophylaxis Oral direct thrombin HFS fondaparinux, LMWH, adjusted-dose VKA (INR target, Laparoscopic Surgery Thromboprophylaxis
Spinal cord injury 40-80% surgery
Hip or knee arthroplasty, hip fracture surgery 40 - 60 inhibitor (dabigatran*) 2.5; INR range, 2.0 to 3.0), or LDUH
ÎÎCost-effectiveness of thromboprophylaxis has repeatedly been demonstrated High risk of bleeding GCS and/or IPC until bleeding risk decreases; then No additional risk factors Early and frequent ambulation
Major trauma 40 - 80 Recommend against use of aspirin alone
Oral VKA pharmacologic prophylaxis substituted for or added to Additional VTE risk factors LMWH, LDUH, fondaparinux, IPC, or GCS
Spinal cord injury 60 - 80 High VTE risk plus (acenocoumarol, mechanical method Surgery likely to be delayed LMWH or LDUH initiated during time between admission
Critical care patients 10 - 80 high bleeding risk warfarin) and surgery
High risk of bleeding Optimal use of mechanical methods; when high bleeding
Mechanical
risk decreases, pharmacologic prophylaxis substituted for or
* Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving added to mechanical method
thromboprophylaxis. *Indicated for elective hip and knee replacement surgery. *Indicated for elective hip and knee replacement surgery.
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13662S R3 VTE Prevention.indd 2 3/19/09 10:10:57 AM
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Rationale for Thromboprophylaxis1 General Risk Groups and Recommendations1 Group Specific Thromboprophylaxis1

ÎÎThe rationale for use of thromboprophylaxis is based on solid ÎÎAlmost all hospitalized patients have at least one risk factor ÎÎSimplification of classification system to readily identify the ÎÎImplement group-specific thromboprophylaxis routinely for all
principles and scientific evidence (Table 1). for VTE, and approximately 40% have three or more risk general patient risk group and general thromboprophylaxis patients who belong to each of the major target groups.
factors (see Table 2). recommendations. Bariatric Surgery Thromboprophylaxis General Surgery Thromboprophylaxis Hip Replacement Thromboprophylaxis
Minor procedures and no risk Early and frequent ambulation Total Hip Replacement (THR) Options:
Table 1. Rationale for Thromboprophylaxis Table 2. Risk Factors for VTE Low Risk Inpatient surgery LMWH, LDUH tid, fondaparinux, or combination of
pharmacologic prophylaxis with IPC factors >> LMWH (at a usual high-risk dose, started 12 h before
 in Hospitalized Patients Surgery Selective estrogen receptor modulators >> Higher doses of LMWH or LDUH than for nonobese surgery or 12 to 24 h after surgery, or 4 to 6 h after
Major procedure for benign LMWH, LDUH, or fondaparinux surgery at half the usual high-risk dose and then
I. High prevalence of venous thromboembolism (VTE) Trauma (major trauma or lower-extremity Minor surgery in Burns Thromboprophylaxis disease
Erythropoiesis-stimulating agents increasing to the usual high-risk dose the following day)
injury) mobile patients Approximate DVT No specific >> fondaparinux
risk without thromboprophylaxis Burn patients with additional LMWH or LDUH Major procedure for cancer LMWH, LDUH tid, or fondaparinux
ÎÎAlmost all hospitalized patients have at least one risk factor for VTE Immobility, lower-extremity paresis Acute medical illness >> Oral Factor Xa inhibitor (rivaroxaban*)
thromboprophylaxis VTE risk factors >> VTE risk factors: advanced age, morbid obesity, Multiple risk factors LMWH, LDUH tid, or fondaparinux combined with >> Oral direct thrombin inhibitor (dabigatran*)
Cancer Inflammatory bowel disease < 10% Early and “aggressive” extensive or lower-extremity burns, concomitant lower- >> Adjusted-dose VKA started preoperatively or the
ÎÎDeep vein thrombosis (DVT) is common in many hospitalized patient groups extremity trauma, femoral venous catheter, and/or GCS and/or IPC
Cancer therapy (hormonal, chemotherapy, Medical patients who are ambulation evening of the surgical day
Nephrotic syndrome prolonged immobility High risk of bleeding GCS or IPC (INR target, 2.5; INR range, 2.0 to 3.0)
ÎÎHospital-acquired DVT and pulmonary embolism (PE) are usually clinically silent angiogenesis inhibitors, radiotherapy) fully mobile
High risk of bleeding GCS and/or IPC until bleeding risk decreases Major procedure Continue until hospital discharge Recommend against use of the following alone: aspirin,
Venous compression (tumor, hematoma,
ÎÎIt is impossible to predict which at-risk patients will develop symptomatic Myeloproliferative disorders High-risk (eg, major cancer surgery or previous VTE), dextran, LDUH, GCS, or VFP
thromboembolic complications
arterial abnormality) Moderate Risk Cancer Patients Thromboprophylaxis
consider continuation after hospital discharge with
Previous VTE Paroxysmal nocturnal hemoglobinuria Surgical procedures Refer to relevant surgical subsections High risk of bleeding IPC or VFP; when high bleeding risk decreases, then
ÎÎScreening at-risk patients using physical examination or noninvasive testing is LMWH for ≤ 28 d
Increasing age Obesity pharmacologic prophylaxis substituted for or added to
neither cost-effective nor effective Most general, open LMWH Bedridden with acute medical Refer to high-risk medical patients Gynecologic Surgery Thromboprophylaxis mechanical method
Pregnancy and the postpartum period Central venous catheterization gynecologic or urologic (dalteparin, enoxaparin, illness
II. Adverse consequences of unprevented VTE surgery patients nadroparin, tinzaparin) Low-risk minor procedures Early and frequent ambulation Knee Arthroscopy Thromboprophylaxis
Estrogen-containing oral contraceptives or Indwelling central venous Do not use either prophylactic doses of LMWH or and no risk factors
Inherited or acquired thrombophilia No additional risk factors Early mobilization if appropraite
hormone replacement catheters minidose warfarin to prevent catheter-related thrombosis
ÎÎSymptomatic DVT and PE Approximate DVT Laparoscopic procedure Early and frequent ambulation
LDUH bid or tid Additional risk factors or LMWH
Medical patients, bed rest risk without Receiving chemotherapy or Recommend against routine thromboprophylaxis for
ÎÎFatal PE thromboprophylaxis hormonal therapy primary prevention of VTE Laparoscopic procedure with LMWH, LDUH, IPC, or GCS complicated procedure
ÎÎ Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired or sick 10-40% additional VTE risk factors
DVT is approximately 10 to 40% among medical or general surgical patients and 40 to For cancer patients Recommend against routine primary thromboprophylaxis Knee Replacement Thromboprophylaxis
ÎÎCosts of investigating symptomatic patients fondaparinux Major gynecologic surgery LMWH, LDUH, or IPC started just before surgery and
60% following major orthopedic surgery (Table 3) to improve survival
ÎÎ Approximately 70% of all VTE is hospital acquired for benign disease without used continuously while not ambulating Total Knee Replacement (TKR) Options:
ÎÎRisks and costs of treating unprevented VTE Moderate VTE risk Coronary Artery Bypass Thromboprophylaxis >> LMWH (at usual high-risk dose)
Therefore, prevention of VTE in hospital patients is the most appropriate method to additional risk factors >> fondaparinux
plus high bleeding risk Mechanical Graft (CABG) Surgery
reduce the burden of this disease Extensive surgery for LMWH, or LDUH tid, or IPC started just before surgery >> Oral Factor Xa inhibitor (rivaroxaban*)
ÎÎIncreased future risk of recurrent VTE >> Oral direct thrombin inhibitor (dabigatran*)
CABG surgery LMWH, LDUH, or bilateral GCS or IPC malignancy and for patients and used continuously while not ambulating
Table 3. Approximate Risks of DVT in Hospitalized Patients* High Risk >> Suggest use of LMWH over LDUH to try to reduce risk with additional VTE risk Alternatives: >> Adjusted-dose VKA
ÎÎChronic post-thrombotic syndrome of heparin-induced thrombocytopenia (HIT) (INR target, 2.5; INR range, 2.0 to 3.0)
factors Combination LMWH or LDUH plus GCS or IPC Alternative:
Patient Group DVT Prevalence, %
III. Efficacy and effectiveness of thromboprophylaxis LMWH High risk of bleeding Properly fitted bilateral GCS or IPC fondaparinux >> IPC
Medical patients 10 - 20 (dalteparin, enoxaparin,
Hip or knee arthroplasty, Critical Care Thromboprophylaxis Major procedure Continue until hospital discharge Recommend against use of the following alone: aspirin,
ÎÎThromboprophylaxis is highly efficacious at preventing DVT General surgery 15 - 40 nadroparin, tinzaparin) High-risk (eg, major cancer surgery or previous VTE),
hip fracture surgery Moderate risk for VTE LMWH or LDUH LDUH, or VFP
and proximal DVT Major gynecologic surgery 15 - 40 consider continuation after hospital discharge with
fondaparinux >> VTE risk factors: medically ill or postoperative general High risk of bleeding IPC or VFP; when high bleeding risk decreases, then
ÎÎThromboprophylaxis is highly effective at preventing symptomatic Major urologic surgery 15 - 40 surgery LMWH for ≤ 28 d 
Approximate DVT pharmacologic prophylaxis substituted for or added to
VTE and fatal PE Oral Factor Xa inhibitor Hip Fracture Surgery (HFS) Thromboprophylaxis
Neurosurgery 15 - 40 risk without Higher risk LMWH mechanical method
Major trauma, (rivaroxaban*) >> VTE risk factors: following major trauma or orthopedic
ÎÎThe prevention of DVT also prevents PE Stroke 20 - 50 thromboprophylaxis Oral direct thrombin HFS fondaparinux, LMWH, adjusted-dose VKA (INR target, Laparoscopic Surgery Thromboprophylaxis
Spinal cord injury 40-80% surgery
Hip or knee arthroplasty, hip fracture surgery 40 - 60 inhibitor (dabigatran*) 2.5; INR range, 2.0 to 3.0), or LDUH
ÎÎCost-effectiveness of thromboprophylaxis has repeatedly been demonstrated High risk of bleeding GCS and/or IPC until bleeding risk decreases; then No additional risk factors Early and frequent ambulation
Major trauma 40 - 80 Recommend against use of aspirin alone
Oral VKA pharmacologic prophylaxis substituted for or added to Additional VTE risk factors LMWH, LDUH, fondaparinux, IPC, or GCS
Spinal cord injury 60 - 80 High VTE risk plus (acenocoumarol, mechanical method Surgery likely to be delayed LMWH or LDUH initiated during time between admission
Critical care patients 10 - 80 high bleeding risk warfarin) and surgery
High risk of bleeding Optimal use of mechanical methods; when high bleeding
Mechanical
risk decreases, pharmacologic prophylaxis substituted for or
* Rates based on objective diagnostic screening for asymptomatic DVT in patients not receiving added to mechanical method
thromboprophylaxis. *Indicated for elective hip and knee replacement surgery. *Indicated for elective hip and knee replacement surgery.
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Group Specific Thromboprophylaxis Table 4. Manufacturer Prescribing Information for Thromboprophylaxis Options

Long-Distance Travel Thromboprophylaxis Spine Surgery Thromboprophylaxis Drug Prophylaxis Indication Dosage and Administration Comments
Flights > 8 h Avoidance of constrictive clothing around lower No additional VTE risk factors Early and frequent ambulation Low Dose Unfractionated
Low-dose regimen for major abdominothoracic surgery 5000 U SC 1 - 2 h before surgery, then 5000 U SC every 8 - 12 h
extremities or waist, maintenance of adequate hydration, Heparin2 (LDUH)
Additional VTE risk Postoperative LDUH, postoperative LMWH, or
and frequent calf muscle contraction Oral Direct Thrombin Inhibitor
perioperative IPC (Alternative: GCS)
Additional VTE risk factors General measures listed above; consider below-knee GCS > VTE risk factors: advanced age, malignancy, presence of dabigatran
(15 to 30 mmHg pressure at ankle), or single LMWH neurologic deficit, previous VTE, or anterior surgical approach (Pradax®, Pradaxa®)3 Hip replacement surgery 110 mg PO 1-4 h after surgery, then 220 mg PO once daily Severe renal dysfunction This Pocketcard edition is intended for the European and Canadian healthcare
dose prior to departure For patients older than 75 years or with moderate renal impairment (creatinine (CrCl < 30 mL/min): communities and contains only the European Medicines Agency (EMEA) and the
Multiple risk factors for VTE Pharmacologic prophylaxis (LDUH or LMWH) combined clearance 30-50 mL/min) 75 mg PO 1-4 h after surgery, then 150 mg PO once daily contraindicated
with mechanical method (GCS and/or IPC)
Knee replacement surgery Canadian Agency for Drugs and Technologies in Health (CADTH) approved drugs.
Long-distance travelers Recommend against the use of aspirin for VTE prevention

Prevention
Medical Conditions Thromboprophylaxis Thoracic Surgery Thromboprophylaxis Indirect Factor Xa Inhibitor
Major thoracic surgery LMWH, LDUH, or fondaparinux fondaparinux (Arixtra®)4 Abdominal surgery Abbreviations
Acutely ill medical patients with LMWH, LDUH, or fondaparinux Severe renal dysfunction
> Risk factors: active cancer, previous VTE, sepsis, acute Hip fracture surgery

of Venous
CHF, severe respiratory disease, High risk of bleeding GCS and/or IPC 2.5 mg SC once daily with initial dose 6 - 8 h after surgery (CrCl < 30 mL/min): bid, twice daily; CADTH, Canadian Agency for Drugs and Technologies in Health; CHF,
confined to bed, or ≥ 1 risk neurologic disease, or inflammatory bowel disease Hip replacement surgery congestive heart failure; CrCl, creatinine clearance; CT, computerized tomography; DUS,
contraindicated
factors Trauma Thromboprophylaxis Knee replacement surgery Doppler ultrasonography; DVT, deep vein thrombosis; EMEA, European Medicines
Agency; GCS, graduated compression stockings; h, hour(s); HFS, hip fracture surgery;
Thromboembolism
VTE risk factors and GCS or IPC Major trauma LMWH (starting when considered safe to do so) Oral Direct Factor Xa Inhibitor
> Continuation until hospital discharge INR, international normalized ratio; IPC, intermittent pneumatic compression; IU,
contraindication to anticoagulant rivaroxaban (Xarelto®)5 Hip replacement surgery Severe renal dysfunction
> For impaired mobility during inpatient rehabilitation, international units; IVC, inferior vena cava; kg, kilogram; LDUH, low-dose unfractionated
Neurosurgery Thromboprophylaxis continue LMWH or VKA 10 mg PO once daily with initial dose 6 - 10 h after surgery (CrCl < 30 mL/min): heparin; LMWH, low-molecular-weight heparin; mg, milligram; min, minute(s); mL, (for use in Europe and Canada)
Knee replacement surgery
(INR target, 2.5; INR range, 2.0 to 3.0) not recommended milliliter, MRI, magnetic resonance imaging; PE, pulmonary embolism; PO, oral; PT,
Major neurosurgery IPC Alternative: Low-Molecular-Weight Heparins (LMWH) prothrombin time; SC, subcutaneous; SCI, spinal cord injury; THR, total hip replacement;
Alternatives: > Combination LMWH and mechanical method
> Postoperative LMWH or LDUH tid, three times daily; TKR, total knee replacement; U, units; VFP, venous foot pump;
Major trauma if LMWH IPC or possibly GCS; when high bleeding risk decreases, dalteparin (Fragmin®)6 Abdominal surgery 2500 IU SC once daily, starting 1 - 2 h prior to surgery and repeated once daily VKA, vitamin K antagonist; VTE, venous thromboembolism Expert Reviewer:
High thrombosis risk GCS and/or IPC combined with postoperative contraindicated then pharmacologic prophylaxis substituted for or added to High risk of thromboembolic complications 5000 IU SC evening before surgery, then once daily William Geerts, MD, FRCPC
LMWH or LDUH mechanical method 2500 IU SC 1 to 2 h before surgery, then 2500 IU SC 12 h later, Thromboembolism Program
Alternative in malignancy Severe renal dysfunction References
Spinal Cord Injury (SCI) Thromboprophylaxis then 5000 IU SC once daily Sunnybrook Health Sciences Centre
Trauma > Recommend against routine DUS screening for (CrCl < 30 mL/min):
asymptomatic DVT 5000 IU SC 10 - 14 h before surgery, then 5000 IU SC 4 - 8 h after surgery, monitor anti-Xa levels to 1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: University of Toronto
For acute SCI LMWH (commenced once primary hemostasis evident) Hip replacement surgery: Preoperative start - evening before surgery American College of Chest Physicians evidence-based clinical practice guidelines (8th
> Recommend DUS screening in high VTE risk (eg, SCI, then 5000 IU SC once daily determine the appropriate
Alternatives: 2500 IU SC within 2 h before surgery, then 2500 IU SC 4 - 8 h after surgery, edition). Chest. 2008;133:381S-453S.
> Combined use of IPC and either LDUH or LMWH lower-extremity or pelvic fracture, or major head injury) Preoperative start - day of surgery dose
and suboptimal or no thromboprophylaxis then 5000 IU SC once daily 2. Heparin [package insert]. Schaumburg, IL: APP Pharmaceuticals LLC; 2008.
> If anticoagulant contraindicated because of high
bleeding risk, use IPC and/or GCS; when bleeding risk > Recommend against use of IVC filter as primary prophylaxis Postoperative start 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 3. Pradax [package insert]. Burlington, Ontario: Boehringer Ingelheim Canada Ltd; 2008.
decreases, pharmacologic prophylaxis substituted for or Urologic Surgery Thromboprophylaxis Medical patients 5000 IU SC once daily 4. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2008. Rationale for Thromboprophylaxis
added to mechanical method enoxaparin 5. Xarelto [package insert]. Toronto, Ontario: Bayer Inc; 2008.
Transurethral or other low-risk Early and frequent ambulation Abdominal surgery 40 mg SC once daily with initial dose 2 h prior to surgery General Risk Groups and Recommendations
(Lovenox®, Clexane®)7 Severe renal dysfunction 6. Fragmin [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2007.
Incomplete SCI associated with Mechanical methods instead of anticoagulant at least for urologic procedures
Hip replacement surgery 30 mg SC every 12 h or 40 mg SC once daily (initial dose 12 h prior to surgery) (CrCl < 30 mL/min): 7. Lovenox [package insert]. Bridgewater, NJ: sanofi-aventis US LLC; 2007.
spinal hematoma on CT or MRI first few days Major open procedures LDUH bid or tid, GCS and/or IPC just before surgery Group Specific Thromboprophylaxis
Knee replacement surgery 30 mg SC every 12 h 30 mg SC once daily 8. Fraxiparine [package insert]. Mississauga, Ontario: GlaxoSmithKline Inc; 2008.
For patients with SCI Recommend against the use of IVC filter as primary and used continuously while not ambulating, LMWH, Medical patients 40 mg SC once daily 9. Innohep [package insert]. Thornhill, Ontario: Leo Pharma Inc; 2008.
fondaparinux, or combination pharmacologic (ie, LMWH, Manufacturer Prescribing Information
prophylaxis 10. Sintrom [package insert]. Montreal, Quebec: Squire Pharmaceuticals Inc; 2007.
LDUH, or fondaparinux) with mechanical method (ie, nadroparin (Fraxiparine®)8 General surgery 2850 IU SC once daily, initial dose 2 - 4 h before surgery Severe renal dysfunction
Rehabilitation following acute Continuation of LMWH or conversion to oral VKA GCS and/or IPC) (CrCl < 30 mL/min): 11. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2007.
SCI (INR target, 2.5; INR range 2.0 to 3.0) 38 IU/kg SC 12 h before surgery, then 38 IU/kg SC 12 h after surgery, then
Hip replacement surgery Reduce dose by 25 - 33%
For patients actively bleeding or Optimal use of mechanical method with GCS and/or 38 IU/kg SC once daily up to and including Day 3, then 57 IU/kg as of Day 4
Disclaimer
at very high-risk for bleeding IPC until bleeding risk decreases; then pharmacologic tinzaparin (Innohep®)9 General surgery 3500 IU SC 2 h before surgery, then 3500 IU once daily This Guideline attempts to define principles of practice that should produce high-quality patient
prophylaxis substituted for or added to mechanical method Severe renal dysfunction care. It is applicable to specialists, primary care, and providers at all levels. This Guideline should
50 IU/kg SC 2 h before surgery followed by 50 IU/kg once daily (CrCl < 30 mL/min): not be considered exclusive of other methods of care reasonably directed at obtaining the same
Vascular Surgery Thromboprophylaxis Hip surgery or results. The ultimate judgement concerning the propriety of any course of conduct must be made
Consider dosage by the clinician after consideration of each individual patient situation.
75 IU/kg SC given post-operatively once daily
No additional risk factors Early and frequent ambulation reduction
Knee surgery 75 IU/kg SC given post-operatively once daily 5740 Executive Drive Suite 220 • Baltimore, MD 21228
Undergoing major procedure LMWH, LDUH, or fondaparinux
TEL: 410-869-3332 • FAX: 410-744-2150
with additional risk factors Vitamin K Antagonist (VKA)
Orders and inquiries: guidelines@MyGuidelinesCenter.com
Acenocoumarol (Sintrom®)10 Venous thrombosis and its extension Individualized; dose adjusted by INR response INR target of 2.5 Copyright © 2009 All rights reserved
For additional copies: www.myguidelinescenter.com For additional copies: guidelines@myguidelinescenter.com
Warfarin (Coumadin )® 11
Venous thrombosis and its extension Individualized; dose adjusted by INR response (INR range, 2.0 to 3.0)
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13662S R3 VTE Prevention.indd 1 3/19/09 10:10:56 AM
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Group Specific Thromboprophylaxis Table 4. Manufacturer Prescribing Information for Thromboprophylaxis Options

Long-Distance Travel Thromboprophylaxis Spine Surgery Thromboprophylaxis Drug Prophylaxis Indication Dosage and Administration Comments
Flights > 8 h Avoidance of constrictive clothing around lower No additional VTE risk factors Early and frequent ambulation Low Dose Unfractionated
Low-dose regimen for major abdominothoracic surgery 5000 U SC 1 - 2 h before surgery, then 5000 U SC every 8 - 12 h
extremities or waist, maintenance of adequate hydration, Heparin2 (LDUH)
Additional VTE risk Postoperative LDUH, postoperative LMWH, or
and frequent calf muscle contraction Oral Direct Thrombin Inhibitor
perioperative IPC (Alternative: GCS)
Additional VTE risk factors General measures listed above; consider below-knee GCS > VTE risk factors: advanced age, malignancy, presence of dabigatran
(15 to 30 mmHg pressure at ankle), or single LMWH neurologic deficit, previous VTE, or anterior surgical approach (Pradax®, Pradaxa®)3 Hip replacement surgery 110 mg PO 1-4 h after surgery, then 220 mg PO once daily Severe renal dysfunction This Pocketcard edition is intended for the European and Canadian healthcare
dose prior to departure For patients older than 75 years or with moderate renal impairment (creatinine (CrCl < 30 mL/min): communities and contains only the European Medicines Agency (EMEA) and the
Multiple risk factors for VTE Pharmacologic prophylaxis (LDUH or LMWH) combined clearance 30-50 mL/min) 75 mg PO 1-4 h after surgery, then 150 mg PO once daily contraindicated
with mechanical method (GCS and/or IPC)
Knee replacement surgery Canadian Agency for Drugs and Technologies in Health (CADTH) approved drugs.
Long-distance travelers Recommend against the use of aspirin for VTE prevention

Prevention
Medical Conditions Thromboprophylaxis Thoracic Surgery Thromboprophylaxis Indirect Factor Xa Inhibitor
Major thoracic surgery LMWH, LDUH, or fondaparinux fondaparinux (Arixtra®)4 Abdominal surgery Abbreviations
Acutely ill medical patients with LMWH, LDUH, or fondaparinux Severe renal dysfunction
> Risk factors: active cancer, previous VTE, sepsis, acute Hip fracture surgery

of Venous
CHF, severe respiratory disease, High risk of bleeding GCS and/or IPC 2.5 mg SC once daily with initial dose 6 - 8 h after surgery (CrCl < 30 mL/min): bid, twice daily; CADTH, Canadian Agency for Drugs and Technologies in Health; CHF,
confined to bed, or ≥ 1 risk neurologic disease, or inflammatory bowel disease Hip replacement surgery congestive heart failure; CrCl, creatinine clearance; CT, computerized tomography; DUS,
contraindicated
factors Trauma Thromboprophylaxis Knee replacement surgery Doppler ultrasonography; DVT, deep vein thrombosis; EMEA, European Medicines
Agency; GCS, graduated compression stockings; h, hour(s); HFS, hip fracture surgery;
Thromboembolism
VTE risk factors and GCS or IPC Major trauma LMWH (starting when considered safe to do so) Oral Direct Factor Xa Inhibitor
> Continuation until hospital discharge INR, international normalized ratio; IPC, intermittent pneumatic compression; IU,
contraindication to anticoagulant rivaroxaban (Xarelto®)5 Hip replacement surgery Severe renal dysfunction
> For impaired mobility during inpatient rehabilitation, international units; IVC, inferior vena cava; kg, kilogram; LDUH, low-dose unfractionated
Neurosurgery Thromboprophylaxis continue LMWH or VKA 10 mg PO once daily with initial dose 6 - 10 h after surgery (CrCl < 30 mL/min): heparin; LMWH, low-molecular-weight heparin; mg, milligram; min, minute(s); mL, (for use in Europe and Canada)
Knee replacement surgery
(INR target, 2.5; INR range, 2.0 to 3.0) not recommended milliliter, MRI, magnetic resonance imaging; PE, pulmonary embolism; PO, oral; PT,
Major neurosurgery IPC Alternative: Low-Molecular-Weight Heparins (LMWH) prothrombin time; SC, subcutaneous; SCI, spinal cord injury; THR, total hip replacement;
Alternatives: > Combination LMWH and mechanical method
> Postoperative LMWH or LDUH tid, three times daily; TKR, total knee replacement; U, units; VFP, venous foot pump;
Major trauma if LMWH IPC or possibly GCS; when high bleeding risk decreases, dalteparin (Fragmin®)6 Abdominal surgery 2500 IU SC once daily, starting 1 - 2 h prior to surgery and repeated once daily VKA, vitamin K antagonist; VTE, venous thromboembolism Expert Reviewer:
High thrombosis risk GCS and/or IPC combined with postoperative contraindicated then pharmacologic prophylaxis substituted for or added to High risk of thromboembolic complications 5000 IU SC evening before surgery, then once daily William Geerts, MD, FRCPC
LMWH or LDUH mechanical method 2500 IU SC 1 to 2 h before surgery, then 2500 IU SC 12 h later, Thromboembolism Program
Alternative in malignancy Severe renal dysfunction References
Spinal Cord Injury (SCI) Thromboprophylaxis then 5000 IU SC once daily Sunnybrook Health Sciences Centre
Trauma > Recommend against routine DUS screening for (CrCl < 30 mL/min):
asymptomatic DVT 5000 IU SC 10 - 14 h before surgery, then 5000 IU SC 4 - 8 h after surgery, monitor anti-Xa levels to 1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: University of Toronto
For acute SCI LMWH (commenced once primary hemostasis evident) Hip replacement surgery: Preoperative start - evening before surgery American College of Chest Physicians evidence-based clinical practice guidelines (8th
> Recommend DUS screening in high VTE risk (eg, SCI, then 5000 IU SC once daily determine the appropriate
Alternatives: 2500 IU SC within 2 h before surgery, then 2500 IU SC 4 - 8 h after surgery, edition). Chest. 2008;133:381S-453S.
> Combined use of IPC and either LDUH or LMWH lower-extremity or pelvic fracture, or major head injury) Preoperative start - day of surgery dose
and suboptimal or no thromboprophylaxis then 5000 IU SC once daily 2. Heparin [package insert]. Schaumburg, IL: APP Pharmaceuticals LLC; 2008.
> If anticoagulant contraindicated because of high
bleeding risk, use IPC and/or GCS; when bleeding risk > Recommend against use of IVC filter as primary prophylaxis Postoperative start 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 3. Pradax [package insert]. Burlington, Ontario: Boehringer Ingelheim Canada Ltd; 2008.
decreases, pharmacologic prophylaxis substituted for or Urologic Surgery Thromboprophylaxis Medical patients 5000 IU SC once daily 4. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2008. Rationale for Thromboprophylaxis
added to mechanical method enoxaparin 5. Xarelto [package insert]. Toronto, Ontario: Bayer Inc; 2008.
Transurethral or other low-risk Early and frequent ambulation Abdominal surgery 40 mg SC once daily with initial dose 2 h prior to surgery General Risk Groups and Recommendations
(Lovenox®, Clexane®)7 Severe renal dysfunction 6. Fragmin [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2007.
Incomplete SCI associated with Mechanical methods instead of anticoagulant at least for urologic procedures
Hip replacement surgery 30 mg SC every 12 h or 40 mg SC once daily (initial dose 12 h prior to surgery) (CrCl < 30 mL/min): 7. Lovenox [package insert]. Bridgewater, NJ: sanofi-aventis US LLC; 2007.
spinal hematoma on CT or MRI first few days Major open procedures LDUH bid or tid, GCS and/or IPC just before surgery Group Specific Thromboprophylaxis
Knee replacement surgery 30 mg SC every 12 h 30 mg SC once daily 8. Fraxiparine [package insert]. Mississauga, Ontario: GlaxoSmithKline Inc; 2008.
For patients with SCI Recommend against the use of IVC filter as primary and used continuously while not ambulating, LMWH, Medical patients 40 mg SC once daily 9. Innohep [package insert]. Thornhill, Ontario: Leo Pharma Inc; 2008.
fondaparinux, or combination pharmacologic (ie, LMWH, Manufacturer Prescribing Information
prophylaxis 10. Sintrom [package insert]. Montreal, Quebec: Squire Pharmaceuticals Inc; 2007.
LDUH, or fondaparinux) with mechanical method (ie, nadroparin (Fraxiparine®)8 General surgery 2850 IU SC once daily, initial dose 2 - 4 h before surgery Severe renal dysfunction
Rehabilitation following acute Continuation of LMWH or conversion to oral VKA GCS and/or IPC) (CrCl < 30 mL/min): 11. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2007.
SCI (INR target, 2.5; INR range 2.0 to 3.0) 38 IU/kg SC 12 h before surgery, then 38 IU/kg SC 12 h after surgery, then
Hip replacement surgery Reduce dose by 25 - 33%
For patients actively bleeding or Optimal use of mechanical method with GCS and/or 38 IU/kg SC once daily up to and including Day 3, then 57 IU/kg as of Day 4
Disclaimer
at very high-risk for bleeding IPC until bleeding risk decreases; then pharmacologic tinzaparin (Innohep®)9 General surgery 3500 IU SC 2 h before surgery, then 3500 IU once daily This Guideline attempts to define principles of practice that should produce high-quality patient
prophylaxis substituted for or added to mechanical method Severe renal dysfunction care. It is applicable to specialists, primary care, and providers at all levels. This Guideline should
50 IU/kg SC 2 h before surgery followed by 50 IU/kg once daily (CrCl < 30 mL/min): not be considered exclusive of other methods of care reasonably directed at obtaining the same
Vascular Surgery Thromboprophylaxis Hip surgery or results. The ultimate judgement concerning the propriety of any course of conduct must be made
Consider dosage by the clinician after consideration of each individual patient situation.
75 IU/kg SC given post-operatively once daily
No additional risk factors Early and frequent ambulation reduction
Knee surgery 75 IU/kg SC given post-operatively once daily 5740 Executive Drive Suite 220 • Baltimore, MD 21228
Undergoing major procedure LMWH, LDUH, or fondaparinux
TEL: 410-869-3332 • FAX: 410-744-2150
with additional risk factors Vitamin K Antagonist (VKA)
Orders and inquiries: guidelines@MyGuidelinesCenter.com
Acenocoumarol (Sintrom®)10 Venous thrombosis and its extension Individualized; dose adjusted by INR response INR target of 2.5 Copyright © 2009 All rights reserved
For additional copies: www.myguidelinescenter.com For additional copies: guidelines@myguidelinescenter.com
Warfarin (Coumadin )® 11
Venous thrombosis and its extension Individualized; dose adjusted by INR response (INR range, 2.0 to 3.0)
Fold

Fold

Fold

Fold
13662S R3 VTE Prevention.indd 1 3/19/09 10:10:56 AM
Fold

Fold

Fold

Fold
Group Specific Thromboprophylaxis Table 4. Manufacturer Prescribing Information for Thromboprophylaxis Options

Long-Distance Travel Thromboprophylaxis Spine Surgery Thromboprophylaxis Drug Prophylaxis Indication Dosage and Administration Comments
Flights > 8 h Avoidance of constrictive clothing around lower No additional VTE risk factors Early and frequent ambulation Low Dose Unfractionated
Low-dose regimen for major abdominothoracic surgery 5000 U SC 1 - 2 h before surgery, then 5000 U SC every 8 - 12 h
extremities or waist, maintenance of adequate hydration, Heparin2 (LDUH)
Additional VTE risk Postoperative LDUH, postoperative LMWH, or
and frequent calf muscle contraction Oral Direct Thrombin Inhibitor
perioperative IPC (Alternative: GCS)
Additional VTE risk factors General measures listed above; consider below-knee GCS > VTE risk factors: advanced age, malignancy, presence of dabigatran
(15 to 30 mmHg pressure at ankle), or single LMWH neurologic deficit, previous VTE, or anterior surgical approach (Pradax®, Pradaxa®)3 Hip replacement surgery 110 mg PO 1-4 h after surgery, then 220 mg PO once daily Severe renal dysfunction This Pocketcard edition is intended for the European and Canadian healthcare
dose prior to departure For patients older than 75 years or with moderate renal impairment (creatinine (CrCl < 30 mL/min): communities and contains only the European Medicines Agency (EMEA) and the
Multiple risk factors for VTE Pharmacologic prophylaxis (LDUH or LMWH) combined clearance 30-50 mL/min) 75 mg PO 1-4 h after surgery, then 150 mg PO once daily contraindicated
with mechanical method (GCS and/or IPC)
Knee replacement surgery Canadian Agency for Drugs and Technologies in Health (CADTH) approved drugs.
Long-distance travelers Recommend against the use of aspirin for VTE prevention

Prevention
Medical Conditions Thromboprophylaxis Thoracic Surgery Thromboprophylaxis Indirect Factor Xa Inhibitor
Major thoracic surgery LMWH, LDUH, or fondaparinux fondaparinux (Arixtra®)4 Abdominal surgery Abbreviations
Acutely ill medical patients with LMWH, LDUH, or fondaparinux Severe renal dysfunction
> Risk factors: active cancer, previous VTE, sepsis, acute Hip fracture surgery

of Venous
CHF, severe respiratory disease, High risk of bleeding GCS and/or IPC 2.5 mg SC once daily with initial dose 6 - 8 h after surgery (CrCl < 30 mL/min): bid, twice daily; CADTH, Canadian Agency for Drugs and Technologies in Health; CHF,
confined to bed, or ≥ 1 risk neurologic disease, or inflammatory bowel disease Hip replacement surgery congestive heart failure; CrCl, creatinine clearance; CT, computerized tomography; DUS,
contraindicated
factors Trauma Thromboprophylaxis Knee replacement surgery Doppler ultrasonography; DVT, deep vein thrombosis; EMEA, European Medicines
Agency; GCS, graduated compression stockings; h, hour(s); HFS, hip fracture surgery;
Thromboembolism
VTE risk factors and GCS or IPC Major trauma LMWH (starting when considered safe to do so) Oral Direct Factor Xa Inhibitor
> Continuation until hospital discharge INR, international normalized ratio; IPC, intermittent pneumatic compression; IU,
contraindication to anticoagulant rivaroxaban (Xarelto®)5 Hip replacement surgery Severe renal dysfunction
> For impaired mobility during inpatient rehabilitation, international units; IVC, inferior vena cava; kg, kilogram; LDUH, low-dose unfractionated
Neurosurgery Thromboprophylaxis continue LMWH or VKA 10 mg PO once daily with initial dose 6 - 10 h after surgery (CrCl < 30 mL/min): heparin; LMWH, low-molecular-weight heparin; mg, milligram; min, minute(s); mL, (for use in Europe and Canada)
Knee replacement surgery
(INR target, 2.5; INR range, 2.0 to 3.0) not recommended milliliter, MRI, magnetic resonance imaging; PE, pulmonary embolism; PO, oral; PT,
Major neurosurgery IPC Alternative: Low-Molecular-Weight Heparins (LMWH) prothrombin time; SC, subcutaneous; SCI, spinal cord injury; THR, total hip replacement;
Alternatives: > Combination LMWH and mechanical method
> Postoperative LMWH or LDUH tid, three times daily; TKR, total knee replacement; U, units; VFP, venous foot pump;
Major trauma if LMWH IPC or possibly GCS; when high bleeding risk decreases, dalteparin (Fragmin®)6 Abdominal surgery 2500 IU SC once daily, starting 1 - 2 h prior to surgery and repeated once daily VKA, vitamin K antagonist; VTE, venous thromboembolism Expert Reviewer:
High thrombosis risk GCS and/or IPC combined with postoperative contraindicated then pharmacologic prophylaxis substituted for or added to High risk of thromboembolic complications 5000 IU SC evening before surgery, then once daily William Geerts, MD, FRCPC
LMWH or LDUH mechanical method 2500 IU SC 1 to 2 h before surgery, then 2500 IU SC 12 h later, Thromboembolism Program
Alternative in malignancy Severe renal dysfunction References
Spinal Cord Injury (SCI) Thromboprophylaxis then 5000 IU SC once daily Sunnybrook Health Sciences Centre
Trauma > Recommend against routine DUS screening for (CrCl < 30 mL/min):
asymptomatic DVT 5000 IU SC 10 - 14 h before surgery, then 5000 IU SC 4 - 8 h after surgery, monitor anti-Xa levels to 1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: University of Toronto
For acute SCI LMWH (commenced once primary hemostasis evident) Hip replacement surgery: Preoperative start - evening before surgery American College of Chest Physicians evidence-based clinical practice guidelines (8th
> Recommend DUS screening in high VTE risk (eg, SCI, then 5000 IU SC once daily determine the appropriate
Alternatives: 2500 IU SC within 2 h before surgery, then 2500 IU SC 4 - 8 h after surgery, edition). Chest. 2008;133:381S-453S.
> Combined use of IPC and either LDUH or LMWH lower-extremity or pelvic fracture, or major head injury) Preoperative start - day of surgery dose
and suboptimal or no thromboprophylaxis then 5000 IU SC once daily 2. Heparin [package insert]. Schaumburg, IL: APP Pharmaceuticals LLC; 2008.
> If anticoagulant contraindicated because of high
bleeding risk, use IPC and/or GCS; when bleeding risk > Recommend against use of IVC filter as primary prophylaxis Postoperative start 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 3. Pradax [package insert]. Burlington, Ontario: Boehringer Ingelheim Canada Ltd; 2008.
decreases, pharmacologic prophylaxis substituted for or Urologic Surgery Thromboprophylaxis Medical patients 5000 IU SC once daily 4. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2008. Rationale for Thromboprophylaxis
added to mechanical method enoxaparin 5. Xarelto [package insert]. Toronto, Ontario: Bayer Inc; 2008.
Transurethral or other low-risk Early and frequent ambulation Abdominal surgery 40 mg SC once daily with initial dose 2 h prior to surgery General Risk Groups and Recommendations
(Lovenox®, Clexane®)7 Severe renal dysfunction 6. Fragmin [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2007.
Incomplete SCI associated with Mechanical methods instead of anticoagulant at least for urologic procedures
Hip replacement surgery 30 mg SC every 12 h or 40 mg SC once daily (initial dose 12 h prior to surgery) (CrCl < 30 mL/min): 7. Lovenox [package insert]. Bridgewater, NJ: sanofi-aventis US LLC; 2007.
spinal hematoma on CT or MRI first few days Major open procedures LDUH bid or tid, GCS and/or IPC just before surgery Group Specific Thromboprophylaxis
Knee replacement surgery 30 mg SC every 12 h 30 mg SC once daily 8. Fraxiparine [package insert]. Mississauga, Ontario: GlaxoSmithKline Inc; 2008.
For patients with SCI Recommend against the use of IVC filter as primary and used continuously while not ambulating, LMWH, Medical patients 40 mg SC once daily 9. Innohep [package insert]. Thornhill, Ontario: Leo Pharma Inc; 2008.
fondaparinux, or combination pharmacologic (ie, LMWH, Manufacturer Prescribing Information
prophylaxis 10. Sintrom [package insert]. Montreal, Quebec: Squire Pharmaceuticals Inc; 2007.
LDUH, or fondaparinux) with mechanical method (ie, nadroparin (Fraxiparine®)8 General surgery 2850 IU SC once daily, initial dose 2 - 4 h before surgery Severe renal dysfunction
Rehabilitation following acute Continuation of LMWH or conversion to oral VKA GCS and/or IPC) (CrCl < 30 mL/min): 11. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2007.
SCI (INR target, 2.5; INR range 2.0 to 3.0) 38 IU/kg SC 12 h before surgery, then 38 IU/kg SC 12 h after surgery, then
Hip replacement surgery Reduce dose by 25 - 33%
For patients actively bleeding or Optimal use of mechanical method with GCS and/or 38 IU/kg SC once daily up to and including Day 3, then 57 IU/kg as of Day 4
Disclaimer
at very high-risk for bleeding IPC until bleeding risk decreases; then pharmacologic tinzaparin (Innohep®)9 General surgery 3500 IU SC 2 h before surgery, then 3500 IU once daily This Guideline attempts to define principles of practice that should produce high-quality patient
prophylaxis substituted for or added to mechanical method Severe renal dysfunction care. It is applicable to specialists, primary care, and providers at all levels. This Guideline should
50 IU/kg SC 2 h before surgery followed by 50 IU/kg once daily (CrCl < 30 mL/min): not be considered exclusive of other methods of care reasonably directed at obtaining the same
Vascular Surgery Thromboprophylaxis Hip surgery or results. The ultimate judgement concerning the propriety of any course of conduct must be made
Consider dosage by the clinician after consideration of each individual patient situation.
75 IU/kg SC given post-operatively once daily
No additional risk factors Early and frequent ambulation reduction
Knee surgery 75 IU/kg SC given post-operatively once daily 5740 Executive Drive Suite 220 • Baltimore, MD 21228
Undergoing major procedure LMWH, LDUH, or fondaparinux
TEL: 410-869-3332 • FAX: 410-744-2150
with additional risk factors Vitamin K Antagonist (VKA)
Orders and inquiries: guidelines@MyGuidelinesCenter.com
Acenocoumarol (Sintrom®)10 Venous thrombosis and its extension Individualized; dose adjusted by INR response INR target of 2.5 Copyright © 2009 All rights reserved
For additional copies: www.myguidelinescenter.com For additional copies: guidelines@myguidelinescenter.com
Warfarin (Coumadin )® 11
Venous thrombosis and its extension Individualized; dose adjusted by INR response (INR range, 2.0 to 3.0)
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13662S R3 VTE Prevention.indd 1 3/19/09 10:10:56 AM
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Group Specific Thromboprophylaxis Table 4. Manufacturer Prescribing Information for Thromboprophylaxis Options

Long-Distance Travel Thromboprophylaxis Spine Surgery Thromboprophylaxis Drug Prophylaxis Indication Dosage and Administration Comments
Flights > 8 h Avoidance of constrictive clothing around lower No additional VTE risk factors Early and frequent ambulation Low Dose Unfractionated
Low-dose regimen for major abdominothoracic surgery 5000 U SC 1 - 2 h before surgery, then 5000 U SC every 8 - 12 h
extremities or waist, maintenance of adequate hydration, Heparin2 (LDUH)
Additional VTE risk Postoperative LDUH, postoperative LMWH, or
and frequent calf muscle contraction Oral Direct Thrombin Inhibitor
perioperative IPC (Alternative: GCS)
Additional VTE risk factors General measures listed above; consider below-knee GCS > VTE risk factors: advanced age, malignancy, presence of dabigatran
(15 to 30 mmHg pressure at ankle), or single LMWH neurologic deficit, previous VTE, or anterior surgical approach (Pradax®, Pradaxa®)3 Hip replacement surgery 110 mg PO 1-4 h after surgery, then 220 mg PO once daily Severe renal dysfunction This Pocketcard edition is intended for the European and Canadian healthcare
dose prior to departure For patients older than 75 years or with moderate renal impairment (creatinine (CrCl < 30 mL/min): communities and contains only the European Medicines Agency (EMEA) and the
Multiple risk factors for VTE Pharmacologic prophylaxis (LDUH or LMWH) combined clearance 30-50 mL/min) 75 mg PO 1-4 h after surgery, then 150 mg PO once daily contraindicated
with mechanical method (GCS and/or IPC)
Knee replacement surgery Canadian Agency for Drugs and Technologies in Health (CADTH) approved drugs.
Long-distance travelers Recommend against the use of aspirin for VTE prevention

Prevention
Medical Conditions Thromboprophylaxis Thoracic Surgery Thromboprophylaxis Indirect Factor Xa Inhibitor
Major thoracic surgery LMWH, LDUH, or fondaparinux fondaparinux (Arixtra®)4 Abdominal surgery Abbreviations
Acutely ill medical patients with LMWH, LDUH, or fondaparinux Severe renal dysfunction
> Risk factors: active cancer, previous VTE, sepsis, acute Hip fracture surgery

of Venous
CHF, severe respiratory disease, High risk of bleeding GCS and/or IPC 2.5 mg SC once daily with initial dose 6 - 8 h after surgery (CrCl < 30 mL/min): bid, twice daily; CADTH, Canadian Agency for Drugs and Technologies in Health; CHF,
confined to bed, or ≥ 1 risk neurologic disease, or inflammatory bowel disease Hip replacement surgery congestive heart failure; CrCl, creatinine clearance; CT, computerized tomography; DUS,
contraindicated
factors Trauma Thromboprophylaxis Knee replacement surgery Doppler ultrasonography; DVT, deep vein thrombosis; EMEA, European Medicines
Agency; GCS, graduated compression stockings; h, hour(s); HFS, hip fracture surgery;
Thromboembolism
VTE risk factors and GCS or IPC Major trauma LMWH (starting when considered safe to do so) Oral Direct Factor Xa Inhibitor
> Continuation until hospital discharge INR, international normalized ratio; IPC, intermittent pneumatic compression; IU,
contraindication to anticoagulant rivaroxaban (Xarelto®)5 Hip replacement surgery Severe renal dysfunction
> For impaired mobility during inpatient rehabilitation, international units; IVC, inferior vena cava; kg, kilogram; LDUH, low-dose unfractionated
Neurosurgery Thromboprophylaxis continue LMWH or VKA 10 mg PO once daily with initial dose 6 - 10 h after surgery (CrCl < 30 mL/min): heparin; LMWH, low-molecular-weight heparin; mg, milligram; min, minute(s); mL, (for use in Europe and Canada)
Knee replacement surgery
(INR target, 2.5; INR range, 2.0 to 3.0) not recommended milliliter, MRI, magnetic resonance imaging; PE, pulmonary embolism; PO, oral; PT,
Major neurosurgery IPC Alternative: Low-Molecular-Weight Heparins (LMWH) prothrombin time; SC, subcutaneous; SCI, spinal cord injury; THR, total hip replacement;
Alternatives: > Combination LMWH and mechanical method
> Postoperative LMWH or LDUH tid, three times daily; TKR, total knee replacement; U, units; VFP, venous foot pump;
Major trauma if LMWH IPC or possibly GCS; when high bleeding risk decreases, dalteparin (Fragmin®)6 Abdominal surgery 2500 IU SC once daily, starting 1 - 2 h prior to surgery and repeated once daily VKA, vitamin K antagonist; VTE, venous thromboembolism Expert Reviewer:
High thrombosis risk GCS and/or IPC combined with postoperative contraindicated then pharmacologic prophylaxis substituted for or added to High risk of thromboembolic complications 5000 IU SC evening before surgery, then once daily William Geerts, MD, FRCPC
LMWH or LDUH mechanical method 2500 IU SC 1 to 2 h before surgery, then 2500 IU SC 12 h later, Thromboembolism Program
Alternative in malignancy Severe renal dysfunction References
Spinal Cord Injury (SCI) Thromboprophylaxis then 5000 IU SC once daily Sunnybrook Health Sciences Centre
Trauma > Recommend against routine DUS screening for (CrCl < 30 mL/min):
asymptomatic DVT 5000 IU SC 10 - 14 h before surgery, then 5000 IU SC 4 - 8 h after surgery, monitor anti-Xa levels to 1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: University of Toronto
For acute SCI LMWH (commenced once primary hemostasis evident) Hip replacement surgery: Preoperative start - evening before surgery American College of Chest Physicians evidence-based clinical practice guidelines (8th
> Recommend DUS screening in high VTE risk (eg, SCI, then 5000 IU SC once daily determine the appropriate
Alternatives: 2500 IU SC within 2 h before surgery, then 2500 IU SC 4 - 8 h after surgery, edition). Chest. 2008;133:381S-453S.
> Combined use of IPC and either LDUH or LMWH lower-extremity or pelvic fracture, or major head injury) Preoperative start - day of surgery dose
and suboptimal or no thromboprophylaxis then 5000 IU SC once daily 2. Heparin [package insert]. Schaumburg, IL: APP Pharmaceuticals LLC; 2008.
> If anticoagulant contraindicated because of high
bleeding risk, use IPC and/or GCS; when bleeding risk > Recommend against use of IVC filter as primary prophylaxis Postoperative start 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 3. Pradax [package insert]. Burlington, Ontario: Boehringer Ingelheim Canada Ltd; 2008.
decreases, pharmacologic prophylaxis substituted for or Urologic Surgery Thromboprophylaxis Medical patients 5000 IU SC once daily 4. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2008. Rationale for Thromboprophylaxis
added to mechanical method enoxaparin 5. Xarelto [package insert]. Toronto, Ontario: Bayer Inc; 2008.
Transurethral or other low-risk Early and frequent ambulation Abdominal surgery 40 mg SC once daily with initial dose 2 h prior to surgery General Risk Groups and Recommendations
(Lovenox®, Clexane®)7 Severe renal dysfunction 6. Fragmin [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2007.
Incomplete SCI associated with Mechanical methods instead of anticoagulant at least for urologic procedures
Hip replacement surgery 30 mg SC every 12 h or 40 mg SC once daily (initial dose 12 h prior to surgery) (CrCl < 30 mL/min): 7. Lovenox [package insert]. Bridgewater, NJ: sanofi-aventis US LLC; 2007.
spinal hematoma on CT or MRI first few days Major open procedures LDUH bid or tid, GCS and/or IPC just before surgery Group Specific Thromboprophylaxis
Knee replacement surgery 30 mg SC every 12 h 30 mg SC once daily 8. Fraxiparine [package insert]. Mississauga, Ontario: GlaxoSmithKline Inc; 2008.
For patients with SCI Recommend against the use of IVC filter as primary and used continuously while not ambulating, LMWH, Medical patients 40 mg SC once daily 9. Innohep [package insert]. Thornhill, Ontario: Leo Pharma Inc; 2008.
fondaparinux, or combination pharmacologic (ie, LMWH, Manufacturer Prescribing Information
prophylaxis 10. Sintrom [package insert]. Montreal, Quebec: Squire Pharmaceuticals Inc; 2007.
LDUH, or fondaparinux) with mechanical method (ie, nadroparin (Fraxiparine®)8 General surgery 2850 IU SC once daily, initial dose 2 - 4 h before surgery Severe renal dysfunction
Rehabilitation following acute Continuation of LMWH or conversion to oral VKA GCS and/or IPC) (CrCl < 30 mL/min): 11. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2007.
SCI (INR target, 2.5; INR range 2.0 to 3.0) 38 IU/kg SC 12 h before surgery, then 38 IU/kg SC 12 h after surgery, then
Hip replacement surgery Reduce dose by 25 - 33%
For patients actively bleeding or Optimal use of mechanical method with GCS and/or 38 IU/kg SC once daily up to and including Day 3, then 57 IU/kg as of Day 4
Disclaimer
at very high-risk for bleeding IPC until bleeding risk decreases; then pharmacologic tinzaparin (Innohep®)9 General surgery 3500 IU SC 2 h before surgery, then 3500 IU once daily This Guideline attempts to define principles of practice that should produce high-quality patient
prophylaxis substituted for or added to mechanical method Severe renal dysfunction care. It is applicable to specialists, primary care, and providers at all levels. This Guideline should
50 IU/kg SC 2 h before surgery followed by 50 IU/kg once daily (CrCl < 30 mL/min): not be considered exclusive of other methods of care reasonably directed at obtaining the same
Vascular Surgery Thromboprophylaxis Hip surgery or results. The ultimate judgement concerning the propriety of any course of conduct must be made
Consider dosage by the clinician after consideration of each individual patient situation.
75 IU/kg SC given post-operatively once daily
No additional risk factors Early and frequent ambulation reduction
Knee surgery 75 IU/kg SC given post-operatively once daily 5740 Executive Drive Suite 220 • Baltimore, MD 21228
Undergoing major procedure LMWH, LDUH, or fondaparinux
TEL: 410-869-3332 • FAX: 410-744-2150
with additional risk factors Vitamin K Antagonist (VKA)
Orders and inquiries: guidelines@MyGuidelinesCenter.com
Acenocoumarol (Sintrom®)10 Venous thrombosis and its extension Individualized; dose adjusted by INR response INR target of 2.5 Copyright © 2009 All rights reserved
For additional copies: www.myguidelinescenter.com For additional copies: guidelines@myguidelinescenter.com
Warfarin (Coumadin )® 11
Venous thrombosis and its extension Individualized; dose adjusted by INR response (INR range, 2.0 to 3.0)
Fold

Fold

Fold

Fold
13662S R3 VTE Prevention.indd 1 3/19/09 10:10:56 AM
Fold

Fold

Fold

Fold
Group Specific Thromboprophylaxis Table 4. Manufacturer Prescribing Information for Thromboprophylaxis Options

Long-Distance Travel Thromboprophylaxis Spine Surgery Thromboprophylaxis Drug Prophylaxis Indication Dosage and Administration Comments
Flights > 8 h Avoidance of constrictive clothing around lower No additional VTE risk factors Early and frequent ambulation Low Dose Unfractionated
Low-dose regimen for major abdominothoracic surgery 5000 U SC 1 - 2 h before surgery, then 5000 U SC every 8 - 12 h
extremities or waist, maintenance of adequate hydration, Heparin2 (LDUH)
Additional VTE risk Postoperative LDUH, postoperative LMWH, or
and frequent calf muscle contraction Oral Direct Thrombin Inhibitor
perioperative IPC (Alternative: GCS)
Additional VTE risk factors General measures listed above; consider below-knee GCS > VTE risk factors: advanced age, malignancy, presence of dabigatran
(15 to 30 mmHg pressure at ankle), or single LMWH neurologic deficit, previous VTE, or anterior surgical approach (Pradax®, Pradaxa®)3 Hip replacement surgery 110 mg PO 1-4 h after surgery, then 220 mg PO once daily Severe renal dysfunction This Pocketcard edition is intended for the European and Canadian healthcare
dose prior to departure For patients older than 75 years or with moderate renal impairment (creatinine (CrCl < 30 mL/min): communities and contains only the European Medicines Agency (EMEA) and the
Multiple risk factors for VTE Pharmacologic prophylaxis (LDUH or LMWH) combined clearance 30-50 mL/min) 75 mg PO 1-4 h after surgery, then 150 mg PO once daily contraindicated
with mechanical method (GCS and/or IPC)
Knee replacement surgery Canadian Agency for Drugs and Technologies in Health (CADTH) approved drugs.
Long-distance travelers Recommend against the use of aspirin for VTE prevention

Prevention
Medical Conditions Thromboprophylaxis Thoracic Surgery Thromboprophylaxis Indirect Factor Xa Inhibitor
Major thoracic surgery LMWH, LDUH, or fondaparinux fondaparinux (Arixtra®)4 Abdominal surgery Abbreviations
Acutely ill medical patients with LMWH, LDUH, or fondaparinux Severe renal dysfunction
> Risk factors: active cancer, previous VTE, sepsis, acute Hip fracture surgery

of Venous
CHF, severe respiratory disease, High risk of bleeding GCS and/or IPC 2.5 mg SC once daily with initial dose 6 - 8 h after surgery (CrCl < 30 mL/min): bid, twice daily; CADTH, Canadian Agency for Drugs and Technologies in Health; CHF,
confined to bed, or ≥ 1 risk neurologic disease, or inflammatory bowel disease Hip replacement surgery congestive heart failure; CrCl, creatinine clearance; CT, computerized tomography; DUS,
contraindicated
factors Trauma Thromboprophylaxis Knee replacement surgery Doppler ultrasonography; DVT, deep vein thrombosis; EMEA, European Medicines
Agency; GCS, graduated compression stockings; h, hour(s); HFS, hip fracture surgery;
Thromboembolism
VTE risk factors and GCS or IPC Major trauma LMWH (starting when considered safe to do so) Oral Direct Factor Xa Inhibitor
> Continuation until hospital discharge INR, international normalized ratio; IPC, intermittent pneumatic compression; IU,
contraindication to anticoagulant rivaroxaban (Xarelto®)5 Hip replacement surgery Severe renal dysfunction
> For impaired mobility during inpatient rehabilitation, international units; IVC, inferior vena cava; kg, kilogram; LDUH, low-dose unfractionated
Neurosurgery Thromboprophylaxis continue LMWH or VKA 10 mg PO once daily with initial dose 6 - 10 h after surgery (CrCl < 30 mL/min): heparin; LMWH, low-molecular-weight heparin; mg, milligram; min, minute(s); mL, (for use in Europe and Canada)
Knee replacement surgery
(INR target, 2.5; INR range, 2.0 to 3.0) not recommended milliliter, MRI, magnetic resonance imaging; PE, pulmonary embolism; PO, oral; PT,
Major neurosurgery IPC Alternative: Low-Molecular-Weight Heparins (LMWH) prothrombin time; SC, subcutaneous; SCI, spinal cord injury; THR, total hip replacement;
Alternatives: > Combination LMWH and mechanical method
> Postoperative LMWH or LDUH tid, three times daily; TKR, total knee replacement; U, units; VFP, venous foot pump;
Major trauma if LMWH IPC or possibly GCS; when high bleeding risk decreases, dalteparin (Fragmin®)6 Abdominal surgery 2500 IU SC once daily, starting 1 - 2 h prior to surgery and repeated once daily VKA, vitamin K antagonist; VTE, venous thromboembolism Expert Reviewer:
High thrombosis risk GCS and/or IPC combined with postoperative contraindicated then pharmacologic prophylaxis substituted for or added to High risk of thromboembolic complications 5000 IU SC evening before surgery, then once daily William Geerts, MD, FRCPC
LMWH or LDUH mechanical method 2500 IU SC 1 to 2 h before surgery, then 2500 IU SC 12 h later, Thromboembolism Program
Alternative in malignancy Severe renal dysfunction References
Spinal Cord Injury (SCI) Thromboprophylaxis then 5000 IU SC once daily Sunnybrook Health Sciences Centre
Trauma > Recommend against routine DUS screening for (CrCl < 30 mL/min):
asymptomatic DVT 5000 IU SC 10 - 14 h before surgery, then 5000 IU SC 4 - 8 h after surgery, monitor anti-Xa levels to 1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: University of Toronto
For acute SCI LMWH (commenced once primary hemostasis evident) Hip replacement surgery: Preoperative start - evening before surgery American College of Chest Physicians evidence-based clinical practice guidelines (8th
> Recommend DUS screening in high VTE risk (eg, SCI, then 5000 IU SC once daily determine the appropriate
Alternatives: 2500 IU SC within 2 h before surgery, then 2500 IU SC 4 - 8 h after surgery, edition). Chest. 2008;133:381S-453S.
> Combined use of IPC and either LDUH or LMWH lower-extremity or pelvic fracture, or major head injury) Preoperative start - day of surgery dose
and suboptimal or no thromboprophylaxis then 5000 IU SC once daily 2. Heparin [package insert]. Schaumburg, IL: APP Pharmaceuticals LLC; 2008.
> If anticoagulant contraindicated because of high
bleeding risk, use IPC and/or GCS; when bleeding risk > Recommend against use of IVC filter as primary prophylaxis Postoperative start 2500 IU SC 4 - 8 h after surgery, then 5000 IU SC once daily 3. Pradax [package insert]. Burlington, Ontario: Boehringer Ingelheim Canada Ltd; 2008.
decreases, pharmacologic prophylaxis substituted for or Urologic Surgery Thromboprophylaxis Medical patients 5000 IU SC once daily 4. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2008. Rationale for Thromboprophylaxis
added to mechanical method enoxaparin 5. Xarelto [package insert]. Toronto, Ontario: Bayer Inc; 2008.
Transurethral or other low-risk Early and frequent ambulation Abdominal surgery 40 mg SC once daily with initial dose 2 h prior to surgery General Risk Groups and Recommendations
(Lovenox®, Clexane®)7 Severe renal dysfunction 6. Fragmin [package insert]. Woodcliff Lake, NJ: Eisai Inc; 2007.
Incomplete SCI associated with Mechanical methods instead of anticoagulant at least for urologic procedures
Hip replacement surgery 30 mg SC every 12 h or 40 mg SC once daily (initial dose 12 h prior to surgery) (CrCl < 30 mL/min): 7. Lovenox [package insert]. Bridgewater, NJ: sanofi-aventis US LLC; 2007.
spinal hematoma on CT or MRI first few days Major open procedures LDUH bid or tid, GCS and/or IPC just before surgery Group Specific Thromboprophylaxis
Knee replacement surgery 30 mg SC every 12 h 30 mg SC once daily 8. Fraxiparine [package insert]. Mississauga, Ontario: GlaxoSmithKline Inc; 2008.
For patients with SCI Recommend against the use of IVC filter as primary and used continuously while not ambulating, LMWH, Medical patients 40 mg SC once daily 9. Innohep [package insert]. Thornhill, Ontario: Leo Pharma Inc; 2008.
fondaparinux, or combination pharmacologic (ie, LMWH, Manufacturer Prescribing Information
prophylaxis 10. Sintrom [package insert]. Montreal, Quebec: Squire Pharmaceuticals Inc; 2007.
LDUH, or fondaparinux) with mechanical method (ie, nadroparin (Fraxiparine®)8 General surgery 2850 IU SC once daily, initial dose 2 - 4 h before surgery Severe renal dysfunction
Rehabilitation following acute Continuation of LMWH or conversion to oral VKA GCS and/or IPC) (CrCl < 30 mL/min): 11. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2007.
SCI (INR target, 2.5; INR range 2.0 to 3.0) 38 IU/kg SC 12 h before surgery, then 38 IU/kg SC 12 h after surgery, then
Hip replacement surgery Reduce dose by 25 - 33%
For patients actively bleeding or Optimal use of mechanical method with GCS and/or 38 IU/kg SC once daily up to and including Day 3, then 57 IU/kg as of Day 4
Disclaimer
at very high-risk for bleeding IPC until bleeding risk decreases; then pharmacologic tinzaparin (Innohep®)9 General surgery 3500 IU SC 2 h before surgery, then 3500 IU once daily This Guideline attempts to define principles of practice that should produce high-quality patient
prophylaxis substituted for or added to mechanical method Severe renal dysfunction care. It is applicable to specialists, primary care, and providers at all levels. This Guideline should
50 IU/kg SC 2 h before surgery followed by 50 IU/kg once daily (CrCl < 30 mL/min): not be considered exclusive of other methods of care reasonably directed at obtaining the same
Vascular Surgery Thromboprophylaxis Hip surgery or results. The ultimate judgement concerning the propriety of any course of conduct must be made
Consider dosage by the clinician after consideration of each individual patient situation.
75 IU/kg SC given post-operatively once daily
No additional risk factors Early and frequent ambulation reduction
Knee surgery 75 IU/kg SC given post-operatively once daily 5740 Executive Drive Suite 220 • Baltimore, MD 21228
Undergoing major procedure LMWH, LDUH, or fondaparinux
TEL: 410-869-3332 • FAX: 410-744-2150
with additional risk factors Vitamin K Antagonist (VKA)
Orders and inquiries: guidelines@MyGuidelinesCenter.com
Acenocoumarol (Sintrom®)10 Venous thrombosis and its extension Individualized; dose adjusted by INR response INR target of 2.5 Copyright © 2009 All rights reserved
For additional copies: www.myguidelinescenter.com For additional copies: guidelines@myguidelinescenter.com
Warfarin (Coumadin )® 11
Venous thrombosis and its extension Individualized; dose adjusted by INR response (INR range, 2.0 to 3.0)
Fold

Fold

Fold

Fold
13662S R3 VTE Prevention.indd 1 3/19/09 10:10:56 AM