What is the recommended DVT (Deep Vein Thrombosis) prophylaxis for patients with rhabdomyolysis?

DVT Prophylaxis in Patients with Rhabdomyolysis

For patients with rhabdomyolysis, mechanical thromboprophylaxis with graduated compression stockings (GCS) or intermittent pneumatic compression (IPC) is recommended until the risk of bleeding decreases, at which point pharmacologic prophylaxis should be initiated. 1

Risk Assessment in Rhabdomyolysis Patients

Patients with rhabdomyolysis are at increased risk for venous thromboembolism (VTE) due to:

• Immobilization associated with the underlying condition 1
• Inflammatory state that promotes hypercoagulability 1
• Potential hospitalization and critical illness 1

However, these patients also present unique challenges for DVT prophylaxis:

• Increased risk of bleeding due to potential coagulopathy 1
• Renal impairment affecting medication clearance 1
• Muscle damage potentially exacerbated by injections 1

Recommended Approach to DVT Prophylaxis

Initial Management (Acute Phase)

• For patients who are actively bleeding or at high risk for bleeding (common in acute rhabdomyolysis):
  • Use mechanical thromboprophylaxis with GCS or IPC rather than pharmacologic agents 1
  • Closely monitor for signs of VTE while using mechanical methods 1

When Bleeding Risk Decreases

• When the bleeding risk diminishes and renal function stabilizes:
  • Transition to pharmacologic thromboprophylaxis 1
  • For patients with normal renal function: LMWH (enoxaparin 40 mg subcutaneously daily) is preferred 2
  • For patients with renal impairment: Consider reduced dose of LMWH or unfractionated heparin 5000 units subcutaneously every 8-12 hours 1

Pharmacologic Options When Appropriate

• Low Molecular Weight Heparin (LMWH):

  • Preferred option for most patients once bleeding risk decreases 1
  • Enoxaparin 40 mg subcutaneously once daily for patients with normal renal function 2
  • Dose adjustment required for renal impairment (CrCl <30 ml/min) 1

• Unfractionated Heparin (UFH):

  • Alternative when LMWH is contraindicated 1
  • Dosing: 5000 units subcutaneously every 8 hours for high-risk patients 1
  • Advantage in renal impairment as it doesn't require dose adjustment 1

• Fondaparinux:

  • Consider in patients with history of heparin-induced thrombocytopenia 3
  • Low dose (1.5 mg once daily) may be used in patients with renal insufficiency 3

Special Considerations

• Weight-based dosing of LMWH should be considered for patients with obesity (>150 kg) 1, 4
• For critically ill patients with rhabdomyolysis in the ICU, more aggressive prophylaxis may be warranted once bleeding risk decreases 1
• Duration of prophylaxis should typically continue throughout the period of immobilization or acute hospital stay 1
• Monitor renal function closely as it may fluctuate in patients with rhabdomyolysis 1

Common Pitfalls to Avoid

• Initiating pharmacologic prophylaxis too early when bleeding risk is still high 1
• Failing to transition from mechanical to pharmacologic prophylaxis when bleeding risk decreases 1
• Not adjusting LMWH dosing in patients with renal impairment, which is common in rhabdomyolysis 1
• Overlooking the need for extended prophylaxis in patients who remain immobilized 1