Does a patient with acute bilateral cellulitis of the lower extremities and sepsis require Venous Thromboembolism (VTE) prophylaxis?

From the Guidelines

Yes, a patient with acute bilateral cellulitis of the lower extremities and sepsis requires Venous Thromboembolism (VTE) prophylaxis. Pharmacological prophylaxis should be initiated promptly using either low molecular weight heparin (LMWH) such as enoxaparin 40mg subcutaneously once daily, or unfractionated heparin (UFH) 5000 units subcutaneously every 8-12 hours, as recommended by the Surviving Sepsis Campaign guidelines 1. For patients with renal impairment, dose adjustments may be necessary, with dalteparin or another form of LMWH that has a low degree of renal metabolism being preferred options 1. Prophylaxis should continue throughout hospitalization and potentially for a short period after discharge depending on ongoing risk factors. Mechanical prophylaxis with intermittent pneumatic compression devices should be added if there are no contraindications to their use, especially if pharmacological prophylaxis is contraindicated due to bleeding risk, as suggested by the American Society of Hematology 2018 guidelines 1. These patients are at particularly high risk for VTE due to multiple factors: the inflammatory state from infection increases coagulability, sepsis activates the coagulation cascade, immobility during hospitalization reduces venous return, and the lower extremity involvement further compromises circulation. The combination of these factors creates a perfect environment for thrombus formation, making prophylaxis essential to prevent potentially life-threatening complications like deep vein thrombosis or pulmonary embolism. The patient's Chadvasc score of 1 and atrial fibrillation with RVR, well controlled with diltiazem, do not directly influence the decision to initiate VTE prophylaxis, which is primarily driven by the presence of sepsis and acute bilateral cellulitis of the lower extremities. However, it is essential to consider the patient's overall clinical condition and potential bleeding risks when selecting the type and duration of VTE prophylaxis, as emphasized by the Surviving Sepsis Campaign guidelines 1 and the American Society of Hematology 2018 guidelines 1.

Some key points to consider in the management of VTE prophylaxis in this patient include:

• The use of LMWH is preferred over UFH in the absence of contraindications, due to its ease of administration and lower risk of bleeding complications 1.
• The addition of mechanical prophylaxis with intermittent pneumatic compression devices can provide additional protection against VTE, especially in patients at high risk of bleeding or with contraindications to pharmacological prophylaxis 1.
• Regular assessment of the patient's VTE and bleeding risk is essential to guide the selection and duration of VTE prophylaxis, as recommended by the American Society of Hematology 2018 guidelines 1.
• Education of patients and caregivers on VTE and VTE prevention is an essential component of care, as emphasized by the American Society of Hematology 2018 guidelines 1.

Overall, the initiation of VTE prophylaxis in a patient with acute bilateral cellulitis of the lower extremities and sepsis is a critical component of care, and should be guided by the latest evidence-based guidelines and the patient's individual clinical condition.

From the FDA Drug Label

Indications and Usage Heparin Sodium Injection is indicated for: ... Low-dose regimen for prevention of postoperative deep venous thrombosis and pulmonary embolism in patients undergoing major abdominothoracic surgery or who, for other reasons, are at risk of developing thromboembolic disease

The patient has sepsis and acute bilateral cellulitis of the lower extremities, which puts them at risk of developing thromboembolic disease.

• VTE prophylaxis is recommended for patients at risk of developing thromboembolic disease.
• The patient's Chadvasc score of 1 and atrial fibrillation with RVR also suggest a need for VTE prophylaxis. Therefore, yes, the patient requires VTE prophylaxis 2.

From the Research

Patient Assessment

• The patient has acute bilateral cellulitis of the lower extremities and sepsis, which are risk factors for Venous Thromboembolism (VTE) 3, 4, 5.
• The patient has a Chadvasc score of 1, but the relevance of this score to VTE risk is not clear from the provided information.
• The patient has atrial fibrillation with rapid ventricular response (RVR), which is well controlled with diltiazem, but this condition may also increase the risk of VTE 6.

VTE Prophylaxis

• The American College of Chest Physicians guidelines recommend prophylactic anticoagulation for patients with acute medical illness, including sepsis, using fondaparinux, low-molecular weight heparin, or low-dose unfractionated heparin 3, 5.
• Studies have shown that VTE prophylaxis is often underused in patients hospitalized with acute medical illness, despite the presence of risk factors 3, 5.
• One study found that VTE prophylaxis did not confer a significant benefit in terms of mortality in acutely ill inpatients with sepsis, but was associated with higher rates of bleeding 4.

Decision Making

• The decision to initiate VTE prophylaxis should be based on a careful assessment of the patient's individual risk factors and the potential benefits and risks of prophylaxis 6, 3, 4, 5, 7.
• The use of decision-making tools and risk assessment scores, such as the Padua score, may help to identify patients at high risk of VTE and guide the use of prophylaxis 4.