| Category 1 D-dimer < 3,000 ng/mL FEU Standard prophylaxis | Category 2 D-dimer > 3,000 ng/mL FEU High-intensity prophylaxis | Category 3 Confirmed VTE | |
|---|---|---|---|
| Standard dose | Enoxaparin 40 mg SC q24h | Enoxaparin 40 mg SC q12h | IV Heparin DVT/PE nomogram or Enoxaparin 1 mg/kgSC q12h |
| Renal failure ‡AKI definition: Doubling of creatinine in 48h or anuria | CrCI > 10-30mL/min: Enoxaparin 30 mg SC q24h | CrCI < 30 mL/min or AKI: Enoxaparin 40 mg SC q24h | IV heparin DVT/VTE nomogram |
| CrCI < 10 mL/min or AKI‡: UFH 5,000 USCq12h | CrCI < 10 mL/min or AKI‡: UFH 7500 U SC ql2h | ||
| CRRT: 500 U/h through circuit Circuit clotting: IV ACS nomogram | CRRT: 500 U/h through circuit Circuit clotting: IV ACS nomogram | ||
| Obesity | |||
| Standard | > 100 kg: Enoxaparin 40 mg SC q12h > 120 kg: Enoxaparin 60 mg SC q12h | > 100 kg: Enoxaparin 60 mg SC q12h > 120 kg: Enoxaparin 80 mg SC q12h | IV Heparin DVT/PE nomogram or Enoxaparin 1 mg/kgSC q12h - up to 150 mg Above 150 kg use UFH |
| Renal failure 30mL/min or AKI‡ ‡AKI definition: Doubling of creatinine in 48h or anuria | ≤ 120 kg: 7,500 U q12h > 120kg: 10,000U q12h | ≤ 120 kg: 7,500 U q8h > 120kg: 10,000U q8h | IV heparin DVT/PE nomogram |
| CRRT: 500 U/h through circuit Circuit clotting: IV Heparin ACS‡ nomogram | CRRT: 500 U/h through circuit Circuit clotting: IV Heparin ACS‡ nomogram | ||
| IV Heparin ACS nomogram: initial dose 60-U/kg bolus, 12 U/kg/h - Target =aPTT49 – 67 seconds - Target heparin anti-Xa. 0.2 - 0.5 until/ml | |||
ACS = acute coronary syndrome; AKI = acute kidney injury; aPTT = activated partial thromboplastin time; CrCl = creatinine clearance; CRRT = continuous renal replacement therapy; DVT = deep vein thrombosis; FEU = fibrinogen equivalent units; IV = intravenous; PE = pulmonary embolism; SC = subcutaneously; UFH = unfractionated heparin