Venous Thromboembolism (VTE) Prevention Clinical Pathway — Inpatient

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Provider Resources

Related Pathway

Pulmonary Embolism, Acute, ED, ICU and Inpatient

Child on Inpatient Unit
Exclusions: COVID-19, MIS-C

History of Central Venous Catheter (CVC) Clot with Current CVC

Consider therapeutic enoxaparin dosing
- Review contraindications
- Goal anti-Xa 0.5-1.0 IU/mL
Monitor for Signs/Symptoms of Bleeding

< 12 yrs

≥ 12 yrs

Does not meet criteria for VTE risk assessment or routine prophylaxis.
Contact Hematology if concerned
for VTE risk

Assess and document current
VTE risk level in EHR
- RN: Admission and daily
- Provider: Admission and transfer

Low Risk

Baseline mobility
and
No VTE risk factors

Moderate Risk

Altered mobility and no VTE Risk factors
or
Baseline mobility and ≥ 1 VTE risk factor

High Risk

Altered mobility
and
≥ 1 VTE risk factor

All children ≥ 12 yrs, regardless of risk, should ambulate ≥ 50 ft at least 3xday

For children confined to room, view Get Up and Move for strategies to meet ambulation goal

Mechanical Prophylaxis

With Pneumatic Sequential Compression Device (SCD) while in bed
Review Contraindications

Pharmacologic Prophylaxis

Review Contraindications
Recommend for ≥ 18 yrs
Strongly consider for 12-17 yrs

Enoxaparin
- < 60 kg
  - 0.5 mg/kg q12hr
- ≥ 60 kg
  - High-risk ortho surgery 30 mg q12hr
- All Other Medical
  - 40 mg q24hr
Dose adjustment is required for
renal insufficiency
Hold Enoxaparin for procedures

Monitor for Signs and Symptoms of Bleeding

Ongoing monitoring for signs and symptoms of VTE

Risk assessment continues until discharge

Mobility Status

Baseline Mobility
Ambulatory at baseline and meeting goals of ≥ 50 ft, 3x/day
Altered Mobility
Ambulatory at baseline and unable to meet goal of ≥ 50 ft, 3x/day
Examples of 50 ft distance:
- Length of semi-truck trailer
- 5 story building

VTE Risk Factors

Acute Conditions
- Active cancer
- Burns:
  50% total body surface area
- Critically ill (currently in an ICU)
- Major trauma
- Pregnancy
- Severe dehydration
- Severe systemic infection
- Spinal cord injury
- Surgery within past 30 days

Chronic Medical Conditions
- Estrogen containing medications
- Inflammatory disorders
  - IBD, SLE, chronic extensive GVHD
- Known acquired or inherited thrombophilia
- Obesity
  - < 18 yrs: BMI ≥ 95 percentile
  - ≥ 18 yrs: BMI ≥ 30
- Protein-losing disorders
  - Nephrotic syndrome, PLE, draining chylous effusion
- Sickle Cell Disease

Historical Factors
- Previous history of clots (DVT/PE)
- Family history of VTE in 1st-degree relative
  < 40 yrs old

Posted: February 2017
Revised: April 2024

Authors:
- C. Witmer, MD;
- L. Raffini, MD;

Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

Inpatient Clinical Pathway for VTE Prevention in Children

Evidence