Thromboprophylaxis is the most important patient safety strategy in patients admitted to hospital. Pulmonary embolism remains the leading cause of preventable in-hospital death.
The risk of venous thrombosis in patients admitted to hospital depends on medical versus surgical admission and, among surgical patients, the type of surgery.
Evaluating venous thromboembolic risk factors within these patient groups helps further stratify the thrombotic risk.
Bleeding risk and possible contraindication to anti-thrombotic agents must be assessed before instituting thromboprophylaxis.
Although national and international thromboprophylaxis guidelines have repeatedly recommended thromboprophylaxis of patients admitted to hospital, only 40% to 50% of medical patients and 60% to 75% of surgical patients receive adequate thromboprophylaxis.
Computer-based decision systems and pre-printed orders are most effective in optimising physician adherence to thromboprophylaxis guidelines. Periodic audits by pharmacists or other health professionals reinforce the consistent use of venous thromboembolism prophylaxis.
Venous thromboembolism (VTE) prophylaxis consists of pharmacological and non-pharmacological measures to diminish the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE).
DVT of the leg is the development of a blood clot in one of the major deep veins in the leg or thigh, which leads to impaired venous blood flow, usually causing leg swelling and pain.
PE is a consequence of thrombus formation in distal veins, most commonly those of the deep venous system of the lower extremities. Thrombus formation in the venous system occurs as a result of venous stasis, trauma, and hypercoagulability. About 51% of deep venous thrombi will embolise to the pulmonary vasculature, resulting in a PE.
History and exam
Key diagnostic factors
- previous VTE, thrombophilia, malignancy, postoperative setting, trauma, and indwelling central catheter
- chronic medical conditions, paresis, increasing age, obesity, oestrogen-containing contraceptive pills and hormone replacement therapy, varicose veins, pregnancy and up to 6 week postnatal, first-degree relative with a history of VTE, extended travel, and admission to intensive care
- previous VTE (deep vein thrombosis [DVT] and/or pulmonary embolism [PE])
- postoperative setting
- indwelling central catheter (upper or lower extremity)
- myeloproliferative diseases
- congestive heart failure
- chronic obstructive pulmonary disease
- inflammatory bowel disease
- neurological disease with extremity paresis
- increasing age
- oestrogen-containing contraceptive pills, hormone replacement therapy (HRT), and androgen deprivation therapy
- history of varicose veins
- extended travel
- lower leg immobility
- first-degree relative with a history of VTE
- admission to intensive care
1st investigations to order
- serum creatinine
Investigations to consider
- serum antiplatelet factor 4 antibodies
all at-risk patients
- Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update
- Call to action to prevent venous thromboembolism in hospitalized patients: a policy statement from the American Heart Association
Deep vein thrombosis
DVT and long-distance travelMore Patient leaflets
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer