What is the recommended DVT (Deep Vein Thrombosis) prophylaxis for immobile patients after a stroke?

DVT Prophylaxis for Immobile Stroke Patients

For immobile stroke patients, intermittent pneumatic compression (IPC) devices should be started immediately as first-line DVT prophylaxis, with pharmacological prophylaxis using low-molecular-weight heparin (LMWH) as an alternative when IPC is contraindicated. 1

Risk Assessment

All stroke patients should be assessed for their risk of developing venous thromboembolism. High-risk factors include:

• Inability to move one or both lower limbs
• Inability to mobilize independently
• Previous history of venous thromboembolism
• Dehydration
• Comorbidities such as cancer 1

Prophylaxis Algorithm for Ischemic Stroke

First-line: Mechanical Prophylaxis

• Apply thigh-high intermittent pneumatic compression (IPC) devices as soon as possible and within the first 24 hours after admission 1
• Continue IPC until:
  • Patient becomes independently mobile
  • Discharge from hospital
  • Development of adverse effects
  • 30 days have elapsed (whichever comes first) 1
• Monitor skin integrity daily when using IPC devices 1
• If skin breakdown occurs, consult a wound care specialist 1

Alternative: Pharmacological Prophylaxis

• If IPC is contraindicated, use low-molecular-weight heparin (enoxaparin 40mg subcutaneously once daily) 1, 2
• For patients with renal failure, unfractionated heparin may be used instead 1
• Start pharmacological prophylaxis between days 2-4 for patients with restricted mobility 3

Prophylaxis Algorithm for Hemorrhagic Stroke

• For patients with intracerebral hemorrhage, delay pharmacological prophylaxis for at least 48 hours after stroke onset 1
• Consider pharmacological prophylaxis after 48 hours only after:
  • Careful risk assessment
  • Repeat brain imaging confirming stability of the hematoma 1
• Use IPC devices as first-line therapy for these patients 1

Extended Prophylaxis

• For patients remaining immobile for longer than 30 days, continue venous thromboembolism prophylaxis with pharmacological agents 1

Important Cautions

• Anti-embolism stockings alone are NOT recommended for post-stroke venous thromboembolism prophylaxis 1
• The CLOTS-3 trial demonstrated that IPC reduced the risk of proximal DVT within 30 days (8.5% vs. 12.1%) compared to no IPC 1
• The PREVAIL study showed that enoxaparin reduced the risk of venous thromboembolism by 43% compared with unfractionated heparin in immobile ischemic stroke patients 2

Additional Measures

• Early mobilization (between 24-48 hours after stroke onset) should be encouraged when there are no contraindications 1
• Maintain adequate hydration to help prevent venous thromboembolism 1
• If IPC is considered after the first 24 hours of admission, venous leg Doppler studies should be considered 1

Contraindications

• Contraindications to IPC include: dermatitis, gangrene, severe edema, venous stasis, severe peripheral vascular disease, postoperative vein ligation or grafting, and existing DVT 1
• Contraindications to heparins include: history of heparin-induced thrombocytopenia and bleeding diathesis 1

Early implementation of appropriate DVT prophylaxis is critical, as complications from immobility account for up to 51% of deaths in the first 30 days after ischemic stroke 1.