DVT Prophylaxis in Hospitalized Patients: Master the High-Stakes Balance of VTE and Bleeding Risk in Hospital Medicine

In this episode of Hospital Medicine Unplugged, we sprint through inpatient VTE prevention—screen fast, prophylax right, and use system nudges so clots don’t slip through.

We open with the do-firsts: risk-stratify at admission and again daily. Use Padua/IMPROVE for medical patients, Caprini for surgical; pair with a bleeding check (IMPROVE-Bleed or clinical gestalt). If high VTE risk and bleeding risk is acceptable, start chemoprophylaxis now; if bleeding risk is high or there’s active bleeding, go mechanical and reassess q24h. Don’t let missed doses happen.

Prophylaxis decisions—match risk to modality: • Low VTE risk (Padua <4): Early ambulation, no routine anticoagulant. • High VTE risk + low bleed risk: Heparin-based prophylaxis (default). • High VTE risk + high bleed risk/contraindication: Intermittent pneumatic compression (IPC) until safe to switch to heparin. • Very high surgical risk (major ortho/onc): Plan extended duration per pathway.

Pharmacologic playbook (in-hospital defaults): • UFH: 5,000 units SC q8–12h (handy for CrCl <30 mL/min, procedures expected). • LMWH (enoxaparin): 40 mg SC daily; 30 mg daily if CrCl <30.  – Obesity: many centers use 40 mg BID or weight-based; follow local protocol. • Fondaparinux: 2.5 mg SC daily (avoid if CrCl <30, very low body weight, or neuraxial catheters). • Cancer inpatients/ICU: LMWH convenient; UFH if renal failure or frequent procedures. • Neuraxial anesthesia: time doses around catheter placement/removal; when in doubt, hold and ask anesthesia.

When to hold anticoagulation (hit the brakes): active bleeding, platelets <50k, recent high-bleed-risk procedure, intracranial bleed/lesion, known/suspected HIT, severe coagulopathy (e.g., INR >2 not on warfarin), uncontrolled bleeding diathesis, or true heparin allergy. Use IPC and recheck daily to flip to heparin as soon as safe.

Mechanical prophylaxis (when drugs are out—or as add-on): • IPC/SCDs fit to size, run ≥18 h/day, check skin each shift. • GCS only if IPC not tolerated and no PAD/skin risk. • Early ambulation helps but is not a standalone prophylaxis.

Special situations: • Renal failure: Prefer UFH; if LMWH, renal-dose and monitor. • Obesity (BMI ≥40): Consider higher-intensity LMWH per protocol; add IPC in very high risk. • Orthopedic/major surgery: 10–35 days total prophylaxis depending on procedure/risk (LMWH/DOAC/aspirin per pathway). • Cancer surgery/inpatients: LMWH/UFH in hospital; consider extended prophylaxis post-op in high risk. • Stroke: Ischemic—usually prophylax unless tPA/bleed risk; hemorrhagic—mechanical first, then reassess.

Monitoring and safety (make it boring-safe): daily VTE/bleed risk reassessment; don’t miss doses; trend hemoglobin/platelets (watch for HIT days 4–14 on heparin); watch renal function for dosing; confirm IPC adherence and skin integrity. Avoid routine DVT screening; investigate symptoms fast.

Discharge and extended prophylaxis: not routine. Consider in select high-risk, low-bleed-risk medical patients (e.g., high IMPROVE/Padua with persistent immobility or elevated D-dimer) after weighing renal function, drug interactions, adherence, and cost. Set a clear stop date and follow-up plan.

We close with the system moves: a VTE bundle that (1) auto-calculates Padua/IMPROVE/Caprini and proposes an order set; (2) defaults to LMWH with built-in renal/weight adjustments (UFH if CrCl <30); (3) hard-stops for major contraindications and fires IPC orders automatically; (4) pings teams on missed doses and day-4 platelet checks (HIT window); (5) prompts daily flip from IPC → heparin when safe; (6) runs surgical pathways for 10–35 day prophylaxis where indicated; (7) offers a discharge checker for truly high-risk, low-bleed candidates; (8) standardizes patient education to reduce refusals.

Fast, risk-adapted, and system-supported—everything your team needs to prevent clots, avoid bleeds, and keep patients off the PE tightrope.