If the patient's weight exceeds the weight for their height in the table below the patient's BMI  is greater than 25.

BMI 25
Weight
(pounds)		 119 124 128 132 136 141 145 150 155 159 164 169 174 179 184 189 194 200 205
Height (inches) 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76

Select all current factors and add total.

Risk Factors Score Risk Factors Score Risk Factors Score
Age 40-60 1 Surgery/ anesthesia > 45 minutes 2 Documented pt history of DVT or PE 3
Leg swelling, ulcer, varicose vein 1 Patient confined to bed for longer than 72 hours 2 Thrombophilias*,myeloproliferative,  or hyperviscosity syndrome 3
Pregnancy or post partum (<1 month) 1 Central venous catheter 2 Family history of thrombosis 3
Estrogen therapy 1 Age over 60 years old 2 Stroke 5
History of unexplained stillbirth, recurrent SAB (> 3), premature birth with preeclampsia or IUGR infant. 1 Respiratory failure or COPD 2 Elective knee or hip arthroplasty 5
Inflammatory Bowel Disease 1 Malignancy and/or chemotherapy 2 Hip, pelvis or leg fracture 5
Body Mass Index (BMI) > 25 kg/m2 1 CHF or MI 3 Multiple trauma or spinal cord injury 5
Currently at bedrest 1 Sepsis 3    
Surgery/ anesthesia < 45 minutes 1        

*Antiphospholipid antibodies, lupus anticoagulant, dysfibrinogenemia, 20210A prothrombin mutation, Factor V Leiden mutation, protein C and protein S deficiency, heparin-induced thrombocytopenia, disorders of plasminogen and plasmin activation, and hyperhomocysteinemia.

Total Risk Factor Score:______

Repeat assessment if patient has been hospitalized longer than 24 hours, before going to surgery, or with any significant change in patient condition.

Treatment Recommendations

Score (Please check the treatment desired)
0 - 1 [  ] Early ambulation
2 [  ] Heparin 5,000 units subcutaneously every 12 hours OR
[  ] Enoxaparin 40 mg (if CrCl < 30 mls/min = 30 mg) subcutaneously every 24 hours OR
Mechanical Prophylaxis   
  [  ] Thigh High Graduated Compression Stockings
  [  ] Sequential Compression Devices (SCDs) AV Impulse Foot Pumps
 3 - 4

[  ] Heparin 5,000 units subcutaneously every 8 hours OR
[  ] Enoxaparin 40 mg (if CrCl < 30 mls/min = 30 mg) subcutaneously every 24 hours AND
Mechanical Prophylaxis   
  [  ]Thigh High Graduated Compression Stockings
  [  ] Sequential Compression Devices (SCDs) AV Impulse Foot Pumps

5 or more

[  ] Adjusted dose heparin  OR
[  ] Enoxaparin 40 mg subcutaneously every 12 hours (if CrCl < 30 mls/min = every 24 hours) OR
[  ] Warfarin_____mg today, Adjust dose daily in collaboration with Pharmacy AND
Mechanical Prophylaxis   
  [  ]Thigh High Graduated Compression Stockings
  [  ] Sequential Compression Devices (SCDs) AV Impulse Foot Pumps

Lab Orders for heparin or enoxaparin:Baseline CBC and Serum Creatinine if not done within last 24 hours .Check platelet count at the start of treatment, on day 4 of therapy, and then every 2 to 3 days for first two weeks and then at 3 weeks.
Pharmacy to adjust dose for weight greater than 100 kg
Renal disease - Pharmacy to adjust dose as follows if CrCl less than 30 mL/min

Lab Orders for warfarin: Baseline CBC, PT, PTT, and INR. Then obtain daily INR for patients on warfarin.

  Possible Exclusion Criteria for Pharmacological When Prophylaxis:
  • Bleeding (active)
  • Recent intraocular or intracranial surgery
  • Spinal tap or epidural anesthesia within 12 hours
  • Coagulopathy
  • Uncontrolled hypertension
  • Recent intraocular or intracranial surgery
  • Hypersensitivity to heparin or LMWH
  • Significant renal insufficiency
  • Heparin induced thrombocytopenia (consider fondaparinux)
  • Procedure placing patient at high risk of bleeding
  • Severe thrombocytopenia

*Consider insertion of IVC filter for excluded patients at high risk of DVT/PE
Reason for not giving pharmacological prophylaxis for patients at significant risk of DVT/PE (score > 2) should be documented on medical record.

  Possible Exclusion Criteria for Mechanical  Prophylaxis When Indicated:
  • Lower extremity dermatitis
  • Recent skin graft
  • Ischemic vascular disease
  • Massive edema of the legs
  • Pulmonary edema from CHF
  • Suspected pre-existing DVT
  • Absent pedal pulses
  • Diabetic conditions with compromised circulation.
  • Bilateral lower extremity trauma

Reason for not giving mechanical prophylaxis when indicated should be documented in the medical record

 
Adult Deep Vein Thrombosis (DVT) Risk Assessment and Orders  
Physician signature                                             Date/Time
 
RBTO by Signature                                             Date/ Time

REFERENCES:

1. Caprini JA, Arcelus JI, Reyna JJ.Effective risk stratification of surgical and nonsurgical patients for venous thromboembolic disease. Semin Hematol. 2001;38(2 Suppl 5):12-9. PMID:11449339
2. Motykie GD, Zebala LP, Caprini JA, Lee CE, Arcelus JI, Reyna JJ, Cohen EB. A guide to venous thromboembolism risk factor assessment. J Thromb Thrombolysis. 2000;9(3):253-62.PMID:10728025
3. Arcelus JI, Caprini JA, Motykie GD, Reyna JJ.Matching risk with treatment strategies in deep vein thrombosis management. Blood Coagul Fibrinolysis. 1999;10 Suppl 2:S37-43. PMID:10493229
4. Bahl V, et al. A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg. 2010 Feb;251(2):344-50. PMID:19779324
5. Abdollahi M, Obesity: risk of venous thrombosis and the interaction with coagulation factor levels and oral contraceptive use..Thromb Haemost. 2003 Mar;89(3):493-8. PMID:12624633

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