Key: # Fondaparinux for orthopaedic surgery only
Based on Prevention of Venous Thromboembolism: Best Practice
Guidelines for ustralia and !e" #ealand $
th
%dition& 'ecember ())*+
Abbreviations: ,-./ ,o" molecular "eight heparin
,'0/ ,o" dose unfractionated heparin
G12 Graduated compression stoc3ings
4P1 4ntermittent pneumatic compression
5!/-61 ())7
Surgical VTE Risk
Tick Recommended VTE prophylaxis
!"
/ip arthroplasty ,-./ or Fondaparinux
#
A#$ 4P1
8"ith or "ithout G129
:nee arthroplasty
-a;or trauma
/ip fracture surgery
,-./ or ,'0/ or Fondaparinux
#
A#$ G12 8"ith or "ithout 4P19
<ther surgery "ith prior VT% =>or active cancer
-a;or surgery and age ?$) yrs
8-a;or surgery refers to intra@abdominal surgery and all other operations ?$A mins9
,-./ or ,'0/
A#$ G12 8"ith or "ithout 4P19
<ther ris3 8please state9:
%&'ER
ll other surgery 1onsider G12
ll other surgery "ith additional VT% ris3 factors
B 8see over9
1onsider ,-./ or ,'0/ = G12
(edical VTE Risk
)see over*
Tick
,-./ or ,'0/
&R
G12 =>or 4P1
4f heparin contraindicated
!"
4schaemic stro3e
/istory of VT%
ctive cancer
'ecompensated heart failure
cute on chronic lung disease
cute inflammatory disease
ge ? C) years
<ther ris3 8please state9:
%&' !one of the above ris3 factors !o prophylaxis recommended
Are there any contraindications to chemical or mechanical prophylaxis+ )indicate belo,*
-hemical Tick (echanical Tick
ctive bleeding 2evere peripheral arterial disease
/igh ris3 of bleeding
e+g+ /aemophilia& thrombocytopenia 8platelet count DA) x E)
F
>,9&
history of G4 bleeding
2evere peripheral neuropathy
2evere hepatic disease 84!6 ?E+G9 2evere leg deformity
dverse reaction to heparin 6ecent s3in graft
<n current anticoagulation <ther 8please state9:
<ther 8please state9: !o contraindications to mechanical prophylaxis
!o contraindications to chemical prophylaxis
.atient risk status .rophylaxis re/uired+
igh 0 'ocument ris3 status as per hospital policy
1es 0 ll drugs and orders for G12>4P1 must be documented as per
hospital policy
%o,er2 0 'ocument ris3 status as per hospital policy
%o,
#o 0 6eason:
.atient assessed by
#ame ).R!#T*: .osition:
Signature: $ate:
A33!4 .AT!E#T %A5E%
#!-S Venous Thromboembolism
Risk Assessment 3orm Version 6 6778
E+ Treating doctor or nurse to determine and document
highest VT% ris3 category
(+ 1hec3 for contraindications to VT% prophylaxis
G+ 6ecord drugs and orders for G12>4P1
as per hospital
policy
$+ Print name& sign and date on completion
$etails o9 risk strati9ication and recommended prophylaxis
Surgical Risk Strati9ication Recommended VTE .rophylaxis $uration
/4G/ /ip arthroplasty ,-./8%noxaparin $)mg>day <6
'alteparin A))) units>day9 <6
Fondaparinux# (+Amg>day
!' 4P1 8"ith or "ithout G129
A@E) days
(7@GA days for hip
arthroplasty
:nee arthroplasty
-a;or trauma
/ip fracture surgery ,-./8%noxaparin $)mg>day or
'alteparin A))) units>day9
<6 Fondaparinux# (+Amg>day <6 ,'0/
A))) units>T'2
!' G12 8"ith or "ithout 4P19
A@E) days
(7@GA days for hip
fracture surgery
<ther surgery "ith prior VT% =>or
active cancer
-a;or surgery = age ?$) years
8-a;or surgery refers to intra@
abdominal surgery and all other
operations ?$A mins9
,-./ 8%noxaparin ()mg>day <6
'alteparin (A)) units>day9 <6 ,'0/
A))) units B' or T'2
!' G12 8"ith or "ithout 4P19
A@E) days
,<.%6 ll other surgery 1onsider G12
4f additional VT% ris3 factors
B
consider
,-./8%noxaparin ()mg>day or
'alteparin (A)) units>day9 or ,'0/ A)))
units B' or T'2
0ntil hospital discharge
(edical Risk Strati9ication
/4G/ 4schaemic stro3e ,-./8%noxaparin $)mg>day <6
'alteparin A))) units>day9
<6 ,'0/ A))) units B' or T'2
<6
G12 8"ith or "ithout 4P19 if heparin
contraindicated
0ntil resolution of acute
medical illness or
hospital discharge
/istory of VT%
ctive cancer
'ecompensated heart failure
cute on chronic lung disease
cute inflammatory disease
ge ?C) years
<ther ris3
,<. !one of the above !o prophylaxis recommended
#otes 9or (edical Risk Strati9ication
Please note: This is a guide only. If unsure please consult the treating doctor.
!schaemic stroke: acute& confirmed by 1T or -64 and unable to "al3 unassisted because of motor impairment "ith a
score of ( or more 8!4/229 for motor function of the leg+
istory o9 VTE: Previous P% or 'VT+
Active cancer: prophylaxis is recommended for hospitalised or bed@ridden patients and ambulatory patients receiving
thalidomide or lenalidomide "ith chemotherapy or dexamethasone+
$ecompensated heart 9ailure: symptoms of heart failure that occur "ith minimal activity or at rest 8!H/ 1lass 444 or 4V9+
Acute on chronic lung disease: respiratory failure or exacerbation of respiratory disease "ith or "ithout ventilation+
Acute in9lammatory disease: eg rheumatoid arthritis& systemic lupus erythematosus+
B Additional Risk 3actors
4mmobility: patients "ith permanent immobility or significant period of past immobilisation
Thrombophilia: evidence of a disorder of the haemostatic system "hich increases ris3 of thrombosis eg: antithrombin G&
protein 1& or protein 2 deficiencies+
<estrogen therapy
Pregnancy: current or puerperium+
ctive inflammation
2trong family history of VT% and>or obesity
Re9erences
E+ !icolaides !& et al+ Prevention and treatment of venous thromboembolism+ 4nternational 1onsensus 2tatement
8Guidelines according to scientific evidence9+International Angiology+ ())CI (A8(9:E)E@CE+
(+ 2herman 'G& et al+ P6%V4, 2tudy& Lancet+ ())*I GCF:EG$*@AA+
G+ ,yman G& et al+ merican 2ociety of 1linical <ncology guideline: 6ecommendations for venous thromboembolism
prophylaxis and treatment in patients "ith cancer+ Journal of Clinical Oncology+ ())*I (A8G$9:A$F)@A)A+
#&TE: ll hospitals should have a venous thromboembolism 8VT%9 prophylaxis policy for assessment of VT% ris3 in admitted
patients+ The policy should include information about appropriate prophylactic measures to minimise the ris3 of deep vein
thrombosis and pulmonary embolism in every admitted patient based on best practice recommendations+ This sample ris3
assessment form "as developed by the !ational 4nstitute of 1linical 2tudies in collaboration "ith the Private /ospital VT%
Prevention Program dvisory 1ommittee+ The recommendations used in this form are based on Prevention of Venous
Thromboembolism: Best Practice Guidelines for ustralia and !e" #ealand& $
th
%dition& 'ecember ())*& by the !# .or3ing
Party on the -anagement and Prevention of Venous Thromboembolism+
This "or3 "as developed by !412>!/-61 as part of the Private /ospital VT% Prevention Program+ 4t may be reproduced in
"hole or part sub;ect to inclusion of an ac3no"ledgement of the source+ 4t may not be reproduced for commercial use or sale+
