VTE Prophylaxis in Hospitalized Medical Patients

Algorithm Steps

1. ▶

   Start

   Hospitalized Medical Patient

   Admitted for acute medical illness

   1. ◆

      Decision

      Assess VTE Risk

      Use Padua Score or clinical judgment

      • Padua Score ≥4 = high risk
      • Risk factors: immobility, cancer, prior VTE
      • Age >70, obesity, HF, COPD, sepsis
      • Thrombophilia, stroke, acute MI
      1. ✓

         Outcome

         Low VTE Risk (Padua <4)

         Pharmacologic prophylaxis not recommended

         • Early mobilization encouraged
         • No routine pharmacologic or mechanical prophylaxis
         • Reassess if clinical status changes
      2. ●

         Action

         High VTE Risk (Padua ≥4)

         Prophylaxis recommended

         1. ◆

            Decision

            Assess Bleeding Risk

            IMPROVE score or clinical factors

            • Active bleeding or recent major bleed
            • Severe thrombocytopenia (<50K)
            • Recent stroke, surgery
            • Concurrent anticoagulation
            • Severe hepatic disease
            1. ●

               Action

               Low Bleeding Risk

               Pharmacologic prophylaxis preferred

               • Enoxaparin 40mg SC daily, OR
               • Heparin 5000 units SC q8-12h, OR
               • Fondaparinux 2.5mg SC daily
               • Continue for duration of immobility
               1. ●

                  Action

                  Renal Dose Adjustment

                  CrCl <30 mL/min

                  • Enoxaparin: reduce to 30mg daily
                  • Heparin: preferred in severe CKD
                  • Fondaparinux: avoid if CrCl <30
                  1. ◆

                     Decision

                     Duration of Prophylaxis

                     During hospitalization minimum

                     • Standard: duration of acute illness/immobility
                     • No routine extended prophylaxis post-discharge
                     • Extended may be considered: high VTE risk, low bleed risk
                     1. ✓

                        Outcome

                        At Discharge

                        Assess need for extended prophylaxis

                        • Discontinue in most patients
                        • Continue mobilization
                        • Consider extended for very high risk (cancer, prior VTE)
               2. ⚠

                  Warning

                  HIT Monitoring

                  Heparin-induced thrombocytopenia

                  • Platelets at baseline
                  • Recheck if >4 days on heparin/LMWH
                  • Higher risk with UFH vs LMWH
                  • 4Ts score if HIT suspected
            2. ●

               Action

               High Bleeding Risk

               Mechanical prophylaxis only

               • Sequential compression devices (SCDs)
               • Graduated compression stockings (GCS)
               • Reassess daily for pharmacologic option
               • Add pharmacologic when bleeding risk decreases
      3. ●

         Action

         Special Populations

         Consider specific needs

         • ICU: prophylaxis for most (LMWH or UFH)
         • Stroke: delayed start if hemorrhagic
         • Cancer: LMWH preferred
         • COVID-19: standard dose (not intensified)
         • Obesity: may need dose adjustment