DVT Prophylaxis During Plasmapheresis
Patients undergoing plasmapheresis should receive DVT prophylaxis based on their underlying thrombotic risk factors and bleeding risk, not based on the plasmapheresis procedure itself, as plasmapheresis is not classified as a high-bleeding-risk procedure that mandates holding anticoagulation. 1
Risk-Stratified Approach to Prophylaxis
The decision to provide DVT prophylaxis during plasmapheresis follows standard hospitalized patient risk assessment rather than procedure-specific considerations:
High-risk patients (age >60 years, prior VTE history, cancer, reduced mobility, or multiple risk factors) should receive pharmacological prophylaxis with LMWH, low-dose unfractionated heparin, or fondaparinux throughout their hospitalization unless contraindicated by active bleeding or severe thrombocytopenia. 1
Moderate-risk patients (age 40-60 years with additional risk factors) should receive either pharmacological prophylaxis or mechanical methods such as intermittent pneumatic compression devices. 1
Low-risk patients (age <40 years without additional risk factors) can rely on early ambulation alone as sufficient prophylaxis. 1
Pharmacological Prophylaxis Regimens During Plasmapheresis
When pharmacological prophylaxis is indicated, standard dosing applies:
- Enoxaparin 40 mg subcutaneously once daily is the preferred agent for most patients. 1
- Dalteparin 5000 IU subcutaneously once daily is an alternative LMWH option. 1
- Unfractionated heparin 5000 units subcutaneously twice or thrice daily can be used, particularly in patients with renal impairment. 1, 2
- Fondaparinux 2.5 mg subcutaneously once daily is another option for patients without severe renal dysfunction. 1
Critical Dose Adjustments
Renal function must be assessed before initiating prophylaxis:
- For creatinine clearance <30 mL/min: Reduce enoxaparin to 30 mg once daily or use unfractionated heparin instead. 1
- For creatinine clearance 30-50 mL/min: Reduce fondaparinux to 1.5 mg once daily. 1
- For patients >150 kg: Consider increasing enoxaparin to 40 mg subcutaneously every 12 hours. 1
Contraindications to Pharmacological Prophylaxis
Absolute contraindications that would necessitate mechanical prophylaxis alone include:
- Active bleeding or coagulopathy with INR >1.5. 1
- Severe thrombocytopenia with platelet count <50,000/μL (some sources use <20,000/μL as the threshold for mechanical prophylaxis). 3, 1
- Recent major bleeding within 3 months. 1
- Recent neurosurgery or active intracranial bleeding. 1
Mechanical Prophylaxis as Alternative
When pharmacological prophylaxis is contraindicated during plasmapheresis:
- Intermittent pneumatic compression devices should be applied immediately and used continuously. 3, 1
- Graduated compression stockings (30-40 mm Hg knee-high) can be used, though they are less effective than IPC devices. 3, 1
- Mechanical methods alone reduce DVT risk but have not been proven to prevent fatal pulmonary embolism. 2
Special Considerations for Plasmapheresis Patients
The evidence base specifically addressing plasmapheresis is limited to case reports of heparin-induced thrombocytopenia with thrombosis (HITT) where plasmapheresis was used therapeutically rather than prophylactically. 4, 5 These cases demonstrate that:
- Plasmapheresis itself does not inherently increase bleeding risk to a degree that would contraindicate standard DVT prophylaxis. 4, 5
- In rare situations where anticoagulation is absolutely contraindicated (such as progressive intracerebral hemorrhage complicating HITT), plasmapheresis can serve as a salvage procedure to remove pathogenic antibodies while DVT risk is managed mechanically. 4, 5
Duration of Prophylaxis
- Prophylaxis should continue throughout the hospitalization or until the patient is fully ambulatory, whichever is longer. 1
- For patients remaining immobile longer than 30 days, ongoing pharmacological prophylaxis is recommended beyond the initial period. 1
- Extended prophylaxis up to 4 weeks is indicated for cancer patients undergoing major surgery or those with restricted mobility. 1
Common Pitfalls to Avoid
- Do not withhold prophylaxis based solely on the plasmapheresis procedure itself, as it is not a high-bleeding-risk intervention. 1
- Do not fail to assess renal function before dosing LMWH or fondaparinux, as this leads to over-anticoagulation and increased bleeding risk. 1
- Do not use mechanical prophylaxis alone in high-risk patients when pharmacological agents can be safely administered, as mechanical methods have not been shown to prevent fatal PE. 2
- Do not overlook the 58.5% underutilization rate of appropriate VTE prophylaxis in at-risk patients—ensure every hospitalized patient receives risk-stratified prophylaxis. 1