ANUP INSTITUTE OF ORTHOPAEDICS & REHABILITATION
G 75- G 77, P.C. COLONY, KANKARBAGH, PATNA, BIHAR-800020
Thrombosis risk Factor Assessment
PATIENTS NAME: _______________________________ AGE: ________ SEX: ______WEIGHT:_______Kg
Choose All That Apply
Each Risk factors represents 2
Each Risk factors represents 1 point Each Risk factors represents 3 points
points
Age 41 - 60 years Age 60– 74years Age 75 years
Minor surgery planned Arthroscopic surgery History of DVT/PE
Malignancy(present or previous) Family history of thrombosis
History of prior Major surgery(<1 month)
Major surgery(>45 min) Positive factor V Leiden
varicose veins
Laparoscopic surgery(>45 min) Positive prothombin 20210A
History of Inflammatory bowel disease
Patient confined to bed(>72 Hours) Elevated serum homocysteine
Swollen legs
Immobilizing plaster cast (<1 Positive lupus anticoagulant
Obesity ( BMI> 25Kg/m2)
month) Elevated anticardiolipin antibodies
Acute myocardial infarction
central venous access Heparin-induced thrombocytopenia
Congestive Heart failure(CHF)
other congenital or acquired
Sepsis
thrombophillia
Serious lung disease including pneumonia
Abnormal pulmonary function(COPD)
If Yes:
Medical patient currently at bed rest
Type_____________________________
other risk factor______________________
__________________________________
*Most frequently missed risk factor
Each Risk factor represents 5 points For Women only (Each represents one points)
Elective major lower extremity arthroplasty Oral contraceptives or hormone replacement therapy
Hip, pelvis or leg fracture(<1 month) pregnancy or postpartum(<1 month)
Stroke(<1 month) History of unexplained stillborn infant, recurrent spontaneous
Multiple trauma(<1 month) abortion((>3),prebirth with toxemia, or growth restricted infant
Acute spinal cord injury(Paralysis) (<1 month)
TOTAL RISK FACTOR -SCORE
TOTAL RISK INCIDENCE RISK PROPHYLAXIS REGIMEN
FACTOR OF DVT LEVEL LEGEND
SCORE
0-1 <10% Low Risk No Specific measures: early ambulation ES-Elastic stockings
IPC-Intermittent
2 10-20% Moderate ES or IPS or LDUH or LWMH Pneumatic Compression
Risk
LDUH-Low Dose
3-4 20-40% High risk IPC or LDUH or LMWH alone or in Unfractionated Heparin
combination with ES or IPC
LMWH-Low molecular
5 OR MORE 40-80% Highest risk Pharmacological Weight Heparin
LDUH,LMWH,Warfarin,or Fac XA
Fac Xa-Factor Xa Inhibitor
alone or in combination with ES or IPC
Prophylaxis Safety Consideration: Check Box if answer is “YES”
Anticoagulant :Factors Associated with Increased Bleeding
Is patient Experiencing any Active Bleeding?
Does patient have (Or had a history of)HIT ?
Is patient’s platelet count <100,000/mm3 ?
Is patient taking oral anticoagulants, platelet inhibitors ?
Is patients creatinine clearance abnormal ?Please indicate value:
If any of the above boxes are cheked, the patient may not be a candidate for anticoagulant therapy and should be considered for
Alternative prophylactic measures.
Intermittent Pneumatic compression(IPC)
Does patient have severe peripheral arterial disease ?
Does patient have CHF ?
Does patient have an acute /superficial DVT ?
If any of the above boxes are checked, the patient may not be a candidate for IPC therapy and should be considered for
alternative prophylactic measures.
[Link] WH, Pineo GH Heit,et al .Prevention of venous thromboembolism: the seventh ACCP conference on a
Antithrombotic therapy. Chest 2004; 126(suppl):[Link] of venous [Link]
consensus statement guidelines compiled in accordance with the scientific evidence. J Vasc Br 2002; I: 133.170, 3. Caprini JA,Arcelus
JL . et al. State-of-the-art venous thromboembolism. Scope. [Link]-240. 5. Turpie AG, Bauer KA, Eriksson BI, Lassen MR.
Fondaparinunx vs enonaxaparin for the prevention of venous thromboembolism in major orthopedic surgery;a data-analysis of 4
randomized double-blind [Link] Intern Med 2002;162;1833-1840.6. Ringley CD, Johanning JM, Gruenberg JC, Veverka
[Link] KR. Evaluation of pulmonary arterial catheter parameters analyzing intermittent pneumatic compresion boots in congestive
heart failure. Am Surg. [Link]-[Link] RJ, Woodcock JP Effects of supine intermittent compression on arterial inflow to
the lower limb. Arch;2002;137:1269-I273.
Doctor’s Signature & Stamp
Date: Time:
