What is the recommended DVT (Deep Vein Thrombosis) prophylaxis for patients in inpatient rehab?

DVT Prophylaxis in Inpatient Rehabilitation

Patients with impaired mobility in inpatient rehabilitation should receive DVT prophylaxis with either intermittent pneumatic compression (IPC) or subcutaneous prophylactic doses of heparin (LMWH or UFH) until mobility is regained. 1

Risk Assessment and Indications

• DVT and pulmonary embolism are significant sources of morbidity and mortality in rehabilitation settings, particularly for patients with impaired mobility
• All patients with stroke or other conditions causing immobility should be assessed for DVT risk upon admission to inpatient rehabilitation
• Prophylaxis should be continued throughout the entire rehabilitation stay until mobility is regained

Recommended Prophylactic Options

First-line options:

1. Intermittent Pneumatic Compression (IPC)

   • Preferred mechanical option for patients with contraindications to anticoagulation
   • CLOTS 3 trial showed IPC reduced DVT risk (9.6% vs 14.0%) and improved 6-month survival 1
   • May cause skin breaks (3.1% vs 1.4% without IPC) 1

2. Low Molecular Weight Heparin (LMWH)

   • Suggested over UFH when pharmacological prophylaxis is chosen 1
   • Once-daily dosing (more convenient for nursing staff and patients) 1
   • Example: Enoxaparin 40mg subcutaneously once daily 2
   • Caution: Higher risk of major extracranial hemorrhages compared to UFH (OR 3.79) 1
   • Special considerations: Increased bleeding risk in elderly patients with renal impairment 1

3. Unfractionated Heparin (UFH)

   • Typically administered as 5000 IU subcutaneously three times daily 1
   • Alternative when LMWH is contraindicated or unavailable

Contraindications to Prophylaxis

Contraindications to pharmacological prophylaxis:

• Active bleeding
• History of heparin-induced thrombocytopenia
• Severe bleeding diathesis
• Recent intracranial hemorrhage
• Thrombocytopenia (platelets <50,000/mcL)
• Recent major surgery with high bleeding risk 1

Contraindications to IPC:

• Dermatitis
• Gangrene
• Severe edema
• Venous stasis
• Severe peripheral vascular disease
• Existing DVT or signs of DVT 1

Duration of Prophylaxis

• Continue DVT prophylaxis for each day the patient remains at risk (immobile) 1
• Discontinue when mobility is regained
• Note: No clear standards for "regained mobility" have been established (e.g., ambulation of specified minimal distances) 1

Monitoring and Documentation

• Document DVT prophylaxis use for each day during which immobility is present
• Assess and document mobility status regularly
• Monitor for signs of bleeding with pharmacological prophylaxis
• Monitor for skin complications with IPC

Special Considerations

1. Stroke patients:

   • Meta-analyses show LMWH/heparinoid significantly reduces DVT risk (OR 0.55) compared to UFH 1
   • Prophylactic anticoagulants reduce symptomatic pulmonary embolisms (OR 0.69) and DVTs (OR 0.21) 1
   • However, increased risk of symptomatic intracranial hemorrhage (OR 1.68) and extracranial hemorrhages (OR 1.65) 1

2. Patients with epidural/spinal anesthesia:

   • Increased risk of spinal/epidural hematoma with anticoagulants
   • Use extreme caution with timing of anticoagulant administration 3

3. Patients with renal impairment:

   • Consider dose adjustment or UFH instead of LMWH 1

Implementation Challenges

• Lack of clear documentation of mobility status
• No established standards for defining "regained mobility"
• Most DVT prophylaxis studies focused on acute populations rather than rehabilitation phase 1
• Need for consistent assessment and documentation of contraindications

Key Pitfalls to Avoid

1. Failing to reassess DVT risk and mobility status throughout the rehabilitation stay
2. Discontinuing prophylaxis prematurely before adequate mobility is achieved
3. Not recognizing contraindications to specific prophylactic methods
4. Overlooking the need for prophylaxis in patients who appear to be improving
5. Inadequate documentation of prophylaxis administration and mobility status