What are the guidelines for writing compression orders for patients at risk of deep vein thrombosis (DVT) or pulmonary embolism (PE)?

Compression Orders for VTE Prophylaxis in Hospitalized Patients

Use intermittent pneumatic compression (IPC) devices as the mechanical prophylaxis method of choice, and do not order graduated compression stockings as they are ineffective and cause harm. 1

Mechanical Prophylaxis: What to Order

Intermittent Pneumatic Compression (IPC) - RECOMMENDED

• Order IPC devices for all nonambulatory patients at risk for VTE 1, 2
• Start IPC on the day of hospital admission or diagnosis for medical patients 1
• Start IPC on the day of surgery for surgical patients 1
• Continue until the patient is fully mobile 2
• IPC reduces DVT by 62% compared to no prophylaxis and by 47% compared to compression stockings 3, 4
• IPC is particularly effective in high-risk populations including neurosurgery, major orthopedic surgery, trauma, and ICU patients 5, 3

Graduated Compression Stockings (GCS) - NOT RECOMMENDED

• Do not order graduated compression stockings (knee-high or thigh-high) for VTE prophylaxis 1
• GCS are ineffective at preventing DVT and cause skin breakdown, ulceration, and other complications 1
• The CLOTS trials definitively showed GCS provide no benefit and cause harm in hospitalized patients 1
• This is a strong recommendation against their use 1

Combined Mechanical and Pharmacologic Prophylaxis

When to Combine IPC with Anticoagulation

• Order combined IPC plus pharmacologic prophylaxis within 24 hours after bleeding risk is controlled 1
• Combined therapy reduces PE by 54% and DVT by 62% compared to pharmacologic prophylaxis alone 6
• Combined therapy reduces PE by 49% and DVT by 49% compared to IPC alone 6
• Continue combined prophylaxis until the patient is fully mobile 1, 2

Specific Clinical Scenarios

Patients with Active Bleeding or High Bleeding Risk

• Order IPC alone until bleeding risk resolves 1, 2
• Do not use any pharmacologic prophylaxis during active bleeding 1
• Reassess bleeding risk daily and add pharmacologic prophylaxis when safe 1

Intracerebral Hemorrhage (ICH) Patients

• Order IPC starting on day of diagnosis 1
• Add low-dose UFH or LMWH at 24-48 hours after ICH onset if no hematoma expansion 1
• Delay pharmacologic prophylaxis 1-2 weeks for proximal DVT or PE in ICH patients 1
• Consider retrievable IVC filter as bridge if proximal DVT develops before anticoagulation can be safely initiated 1

Trauma Patients

• Order IPC immediately upon admission 1
• Add LMWH within 24 hours after bleeding is controlled 1
• Do not use IVC filters routinely 1

Surgical Patients

• Order IPC plus LMWH for all major surgery patients 2, 6
• Start both modalities preoperatively or on day of surgery 2
• Continue for minimum 7-10 days postoperatively 2
• Extend to 4 weeks for major abdominal, pelvic, or cancer surgery 2

Medical Patients

• Order IPC for all acutely ill, nonambulatory medical patients 1, 2
• Add LMWH (enoxaparin 40 mg subcutaneously once daily) unless contraindicated 2
• Continue for minimum 7 days and until fully mobile 2
• Do NOT order extended prophylaxis beyond hospital discharge for medical patients 2

Pharmacologic Prophylaxis Specifics

First-Line Agent

• LMWH (enoxaparin 40 mg subcutaneously once daily) is preferred over UFH or DOACs 2
• LMWH has once-daily dosing and lower risk of heparin-induced thrombocytopenia compared to UFH 1, 2

Renal Impairment Adjustments

• CrCl <30 mL/min: Use UFH instead of LMWH, or reduce enoxaparin to 30 mg once daily 2

Monitoring

• No routine laboratory monitoring required for LMWH prophylaxis 2
• Monitor platelet count if using UFH due to heparin-induced thrombocytopenia risk 1

Common Pitfalls to Avoid

• Do not order compression stockings alone or in combination with IPC - they add no benefit and cause harm 1
• Do not delay IPC initiation - start immediately upon admission or diagnosis 1
• Do not use IVC filters routinely - reserve only for patients with contraindication to anticoagulation who develop proximal DVT 1
• Do not prescribe extended outpatient prophylaxis for medical patients - this increases bleeding without reducing VTE 2
• Do not forget to reassess bleeding risk daily - add pharmacologic prophylaxis as soon as safe 1

Sample Order Sets

For Medical Patients (Low Bleeding Risk):

• Intermittent pneumatic compression devices to bilateral lower extremities, continuous use while in bed
• Enoxaparin 40 mg subcutaneously once daily
• Continue until patient fully ambulatory

For Surgical Patients:

• Intermittent pneumatic compression devices to bilateral lower extremities, start in OR, continuous use while in bed
• Enoxaparin 40 mg subcutaneously once daily, start preoperatively
• Continue both for minimum 7-10 days (4 weeks for major abdominal/pelvic/cancer surgery)

For Patients with Active Bleeding:

• Intermittent pneumatic compression devices to bilateral lower extremities, continuous use while in bed
• Hold pharmacologic prophylaxis until bleeding controlled
• Reassess bleeding risk daily