1. Pharmacological prophylaxis such as unfractionated heparin or lower molecular weight heparin should be initiated within 24 hours for ICU patients to prevent venous thromboembolism, unless contraindicated due to bleeding risk. 2. Mechanical prophylaxis with intermittent pneumatic compression or graduated compression stockings is recommended when pharmacological prophylaxis cannot be used due to bleeding risk. 3. The risk of VTE and bleeding should be reassessed daily and prophylaxis adjusted or discontinued based on the patient's condition and mobility.

1. VTE PROPHYLAXIS

2. PRINCIPLES
1. Assess bleeding risk before initiating pharmacological prophylaxis.
2. Select a pharmocological agent based on its pharmocokinetics and
the risk of developing VTE.
3. Use mechanical prophylaxis when pharmacological prophylaxis is
contraindicated.
4. There is no role of routine screening for DVT

3. • 1. All patients admitted to ICU should receive pharmacological
prophylaxis, either unfractionated heparin (UFH) or lower molecular
heparin (LMWH) within 24 hours of admission unless contraindicated.
2. Contraindications to pharmacological prophylaxis:

4. • 3. Weigh the risk of VTE against bleeding before initiating prophylaxis

5. • 4. Use LMHW in patients with risk factors and UFH in those without the
above risk factors.
5. Dose adjustment of LMWH may be required in the following patients:
a. CrCl < 30 ml/min
b. BMI < 20 kg/m2
c. BMI > 30 kg/m2
d. Increased risk of bleeding
6. Reassess VTE and bleeding risk daily.
7. Discuss with surgeon before initiating pharmacological prophylaxis in
patients with traumatic brain injury or at high risk of post-operative
bleed.
8. Continue pharmacological prophylaxis until the patient is fully
ambulatory or discharged from hospital.

8. MECHANICAL PROPHYLAXIS
• 1. Provide mechanical prophylaxis with either intermittent penumatic compressor
(IPC) or graduated compression stockings (GCS) when pharmacological prophylaxis is
contraindicated.
2. IPC is preferred over GCS in patients at high risk of VTE.
3. Contraindications to mechanical prophylaxis:
a. Severe arterial insufciency or periphery arterial disease
b. Congestive heart failure
c. Recent or acute DVT/PE
d. Acute fractures of the lower limbs
e. Loss of skin integrity
f. Recent skin graft
g. Post-operative venous ligation
h. Morbid obesity which makes it difcult to correctly ft the stockings
i. Oedema or deformity of the lower limb
j. Diabetic neuropathy
4. Ensure proper fit and optimal compliance of mechanical devices.
5. Assess skin integrity of the lower limbs and pressure areas every nursing shift.
6. Initiate pharmacological prophylaxis once bleeding risk subsides.