VTE Prophylaxis Protocol for Surgery Trauma/Burn (STB) Patients

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Trauma patients

  1. Inpatient: All trauma admissions will have a Caprini score calculated on admission. Patients with a score of 2 or greater will receive thromboprophylaxis with LMWH (enoxaparin 30 mg SQ twice daily administered at 0600 and 1800) and SCD’s while admitted to the hospital unless contraindicated.
  2. Contraindications to immediate use of LMWH:
    1. Traumatic brain injury with any of the following findings:
      • Intracerebral contusion or hematoma >2 cm in diameter
      • Multiple smaller contusions within one region of the brain
      • Subdural or epidural hematoma >8 mm in thickness
      • Persistent intracranial pressure greater than 20 mm Hg
      • Increased size or number of brain lesions on follow-up CT scan performed 24 hours after admission
    2. Ongoing bleeding, transfusion requirement, coagulopathy, or unstable hematocrit
    3. Allergy
  3. Contraindications to SCDs:
    1. Trauma or burn Injury that does not allow device to be placed on lower extremity.
    2. Known lower extremity acute or subacute DVT
  4. Operation: Administer nighttime LMWH dose at 1800 prior to operations the next day and hold LMWH dose on the morning of operations unless directed otherwise by the operating service.. Resume LMWH with nighttime dose the day of operation unless contraindicated due to excessive bleeding.
  5. Special situations:
    1. Patients undergoing pelvis, acetabular or spine surgery will receive SCD’s for the first 12 hours after operation. If their hematocrit remains stable, they will then proceed to with LMWH (enoxaparin 30 mg SQ twice daily) and SCD’s. If an alternative plan is desired, the Orthopedic surgery attending
    2. Patients requiring a ventriculostomy, craniotomy, or who have a traumatic brain injury with a stable head CT scan for 24 hours, will receive LMWH (enoxaparin 30 mg twice daily). If an alternative plan is desired, the Neurosurgery surgery attending will bring it to the attention of the Trauma surgery attending.
    3. Trauma patients who receive an epidural catheter will receive LMWH (enoxaparin 40 mg SQ once daily). Special dose holding instructions apply:
      • In patients with an epidural catheter you must wait 4 hours before starting

        LMWH. The second dose may be given no sooner than 24 hours after the first dose.

      • LMWH must be suspended 12 hours prior to removing the epidural catheter
      • May resume LMWH 4 hours after epidural catheter has been removed and change dose to enoxaparin 40mg SQ once daily
    4. If VTE chemoprophylaxis is unable to be initiated following admission due to a contraindication; patients will receive a lower and upper extremity DVT scan every 48 hours until VTE chemoprophylaxis is initiated.
  6. Dosing considerations: In cases of renal failure or pregnancy use UMHS LMWH dosing guidelin For renal failure or pregnant patients follow monitoring recommendations for anti- factor Xa level and dose adjustment.
    1. Renal Failure

      • If CrCl <10 mL/min use Heparin 5000 units TID.

        If CrCl = 10-29 mL/min use LMWH (enoxaparin 30 mg SQ once daily).

    2. Pregnant patients: Per institutional guidelines for VTE prophylaxis in pregnant patients (http://www.med.umich.edu/i/vte/pdfs/OB%20Guidelines_2017.pdf).

  7. Vena Cava Filter: Consider temporary vena cava filter placement in patients at very high risk for VTE whom are unable to receive chemoprophylaxis and are likely to have a prolonged ICU stay (> 4 days). Reassess daily for chemoprophylaxis.

Burn patients

  1. Inpatient: All burn admissions will have a Caprini score calculated on admission. Patients with a score of 2 or greater will receive thromboprophylaxis with LMWH (enoxaparin 40mg SQ once daily) and SCD’s while admitted to the hospital unless contraindicated.

  2. Operation: Administer nighttime LMWH dose prior to burn operation the next day unless specified by attending burn surgeon.. Resume LMWH with nighttime dose the day of operation unless contra indicated due to excessive bleeding.
  3. Dosing considerations: Use dosing considerations listed above for trauma patients.

General Surgery patients

  1. Inpatient or ADP: Perform Caprini score DVT risk assessment. Follow UMHS guidelines for VTE prophylaxis regimen based on risk factor score (0-1 low risk, 2 moderate risk, 3-4 higher risk, 5 or more highest risk).

  2. Operation: Administer nighttime LMWH dose prior to surgery the next day. Resume LMWH with nighttime dose the day of operation unless contraindicated due to excessive bleeding.
  3. Special situations: General Surgery patients who receive an epidural catheter will receive LMWH (enoxaparin 40 mg SQ once daily). Special dose holding instructions apply:
    1. In patients with an epidural catheter you must wait 4 hours before starting LMWH. The second dose may be given no sooner than 24 hours after the first d
    2. LMWH must be suspended 12 hours prior to removing the epidural cathet
    3. May resume LMWH 4 hours after epidural catheter has been removed.
  4. Dosing considerations: Use dosing considerations listed above for trauma patients.

Special Thanks

Attribution

If reusing this content please use the following information to provide credit to the content authors:  

  1. Title: VTE Prophylaxis Protocol for Surgery Trauma/Burn (STB) Patients
  2. Author:  Michigan Medicine
  3. Source: https://ecosystem.tactuum.com/
  4. License: “CC BY-NC 4.0”

VTE Prophylaxis Protocol for Surgery Trauma/Burn (STB) Patients,  Michigan Medicine, Dept of Surgery,  “CC BY-NC 4.0”

Last reviewed: 09 June 2021