SUGGESTIONS FOR SUBSTITUTION OF DVT PROPHYLAXIS RECOMMENDATIONS
ON ORDER SETS (as of June 7th, 2010)
1. ACUTE PAIN SERVICE (APS) ORDER FORM CONTINUOUS EPIDURAL INFUSION: PR 37006
Notify APS before administering any of the following medications: ASA, clopidogrel, ticlopidine,
enoxaparin (dose > 40 mg/day), IV heparin or warfarin.
2. ACUTE PAIN SERVICE (APS) ORDER FORM PERIPHERAL NERVE BLOCK: PR 37012
Notify APS before administering any of the following medications: ASA, clopidogrel, ticlopidine,
enoxaparin (dose > 40 mg/day), IV heparin or warfarin.
3. ROSS TILLEY BURN CENTRE (RTBC) ADMISSION ORDERS: PR 09021
Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:
o enoxaparin (Lovenox®) 40 mg sc QHS
o enoxaparin (Lovenox®) 30 mg sc QHS for patients weighing less than 40 kg or with
CrCl less than 30mL/min
o enoxaparin (Lovenox®) 40 mg sc BID for patients weighing greater than 100 kg
o For high risk bleeding ONLY, properly measured, bilateral, below-the-knee TED
stockings. Reassess daily for conversion to enoxaparin
o NO prophylaxis – REASON: _____________________________________________.
Reassess daily for conversion to enoxaparin.
4. STANDARD CARDIOLOGY WARD ADMISSION ORDERS: PR 69026
Venous Thromboembolism (VTE) Prophylaxis (see guidelines on back)
Patient must NOT be receiving any CONCURRENT therapeutic anticoagulant
Choose ONE of the following:
o enoxaparin 40 mg sc QHS
Order Set Changes
June 7th , 2010
AD
o enoxaparin 30 mg sc QHS for patients weighing less than 40 kg or with CrCl less than
30 mL/min
o if enoxaparin not ordered, give REASON:___________________________________.
Reassess daily for conversion to enoxaparin.
Note: back of order sheet has addition info on prevention of VTE. Proposed change:
STEP 3: PROVIDE THROMBOPROPHYLAXIS

For almost all patients, the recommended thromboprophylaxis is enoxaparin 40 mg sc
QHS

Reduce the dose to 30 mg sc QHS for patients with CrCl less than 30mL / min or weight
less than 40 kg
5. POST-OPERATIVE ORDERS FOR CARDIOVASCULAR SURGERY PATIENTS: PR 36000
ANTIPLATELET/ANTICOAGULANT THERAPY:
52. Do not start warfarin until patient extubated and chest tubes, central lines, IABP
removed.
53. •Hold treatment dose of enoxaparin at least 12h before removal of chest tubes, central
lines, IABP, epicardial pacemaker wires or surgical procedures.
•Delay next dose of enoxaparin until at least 2h after line/tube removal and at least 12h
after surgical procedures.
•Do NOT hold prophylactic enoxaparin (30 mg or 40 mg) for procedures.
Refer to Abbreviation Legend on back of page 2
Physician ordering instructions: Check one of the following regimens (Orders 54-57). If patient
has undergone more than 1 surgical procedure, select the surgical procedure requiring more
intensive anticoagulation.
* Chest tube drainage criteria: less than 300 mL in previous 6h
2
54. • Isolated, on-pump CABG • tissue AVR without an indication for therapeutic anticoagulation
o enoxaparin 30 mg sc QHS#. Start if chest tube drainage criteria met*
o EC ASA 81 mg po daily. Start when chest tube drainage criteria met*
55. Isolated CABG and coronary patch arterioplasty, coronary endarterectomy, or off-pump bypass
o enoxaparin 30 mg sc QHS#. Start if chest tube drainage criteria met*
o EC ASA 81 mg po daily. Start when chest tube drainage criteria met*.
o clopidogrel 75 mg po daily, starting the day after chest tubes removed
56. • Isolated CABG and Maze procedure or chronic atrial fibrillation
• tissue MVR • mitral annuloplasty •mechanical AVR or
•tissue AVR with indication for therapeutic anticoagulation:
Check indication(s) for therapeutic anticoagulation for tissue AVR
□
Sustained or intermittent atrial fibrillation for longer than 48 h
□
Maze procedure
□
Grade IV left ventricle
□
Other (Specify): _________________
o enoxaparin 30 mg sc QHS#. Start if chest tube drainage criteria met*
o warfarin po daily. Start when chest tube drainage criteria met*. Target INR range =
2.0-3.0
o If INR less than 2.0 at 96h post-operative, obtain order to increase enoxaparin to
treatment** dose
57. Mechanical MVR
o enoxaparin 40 mg sc QHS#. Start if chest tube drainage criteria met*
o warfarin po daily. Start when chest tube drainage criteria met*. Target INR range =
2.5-3.5
o If INR less than 2.0 at 96h post-operative, obtain order to increase enoxaparin to
treatment** dose
3
Table 1. Daily Treatment Doses of Enoxaparin According to Weight and Renal Function. Refer
to Abbreviation Legend on back of page 2.**
Patient weight
(kg)
Less than 36 kg
36 – 40
41 - 45
46 – 50
51 – 55
56 – 60
61 – 65
66 – 70
71 – 75
76 – 80
81 – 85
86 – 90
91 – 95
96 – 100
101 – 105
106 – 110
111 – 115
116 – 120
121 – 125
126 – 130
Greater than 130
Treatment dose enoxaparin for
CrCl* greater than 30 mL/min
(dose: 1mg/kg sc BID)
Treatment dose enoxaparin
for CrCl* less than or equal to
30 mL/min
(dose: 1mg/kg sc once daily)
Consult Thromboembolism
40 mg sc BID
40 mg sc BID
40 mg sc BID
60 mg sc BID
60 mg sc BID
60 mg sc BID
60 mg sc BID
80 mg sc BID
80 mg sc BID
80 mg sc BID
80 mg sc BID
100 mg sc BID
100 mg sc BID
100 mg sc BID
100 mg sc BID
120 mg sc BID
120 mg sc BID
120 mg sc BID
120 mg sc BID
Consult Thromboembolism
Consult Thromboembolism
40 mg sc once daily
40 mg sc once daily
40 mg sc once daily
60 mg sc once daily
60 mg sc once daily
60 mg sc once daily
60 mg sc once daily
80 mg sc once daily
80 mg sc once daily
80 mg sc once daily
80 mg sc once daily
100 mg sc once daily
100 mg sc once daily
100 mg sc once daily
100 mg sc once daily
120 mg sc once daily
120 mg sc once daily
120 mg sc once daily
120 mg sc once daily
Consult Thromboembolism
* Creatinine Clearance can be estimated using the following formula:
CrCl (mL/min) = (140-age)(actual body weight in kg) x 1.2 [x 0.85 if female]
Serum creatinine (mmol/L)
An on-line calculator for creatinine clearance is available on the Sunnybrook intranet under:
Quick Links – Pharmacy – Alphabetical Index – letter C – Creatinine clearance calculator
or at: http://sunnynet.ca/datapharmacy/htdocs/misc/Ext_Creatinine_Clearance.html
# Dosing Considerations for prophylactic enoxaparin:
 For weight greater than 100 kg, double enoxaparin prophylaxis dose
 If CrCl less than 30mL/min AND weight less than 40 kg, give enoxaparin 20 mg sc QHS
 If CrCl less than 30mL/min AND weight greater than 100 kg, give enoxaparin 40 mg sc QHS
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6. WARD TRANSFER ORDERS FOR CARDIOVASCULAR SURGERY PATIENTS: PR 36001
Table 1. Daily Treatment Doses of Enoxaparin According to Weight and Renal Function.
Patient weight
(kg)
Less than 36 kg
36 – 40
41 – 45
46 – 50
51 – 55
56 – 60
61 – 65
66 – 70
71 – 75
76 – 80
81 – 85
86 – 90
91 – 95
96 – 100
101 – 105
106 – 110
111 – 115
116 – 120
121 – 125
126 – 130
Greater than
130
Treatment dose enoxaparin for
CrCl* greater than 30 mL/min
Treatment dose enoxaparin for CrCl*
less than or equal to 30 mL/min
(dose: 1 mg/kg sc BID)
(dose: 1 mg/kg sc once daily)
Consult Thromboembolism
40 mg sc BID
40 mg sc BID
40 mg sc BID
60 mg sc BID
60 mg sc BID
60 mg sc BID
60 mg sc BID
80 mg sc BID
80 mg sc BID
80 mg sc BID
80 mg sc BID
100 mg sc BID
100 mg sc BID
100 mg sc BID
100 mg sc BID
120 mg sc BID
120 mg sc BID
120 mg sc BID
120 mg sc BID
Consult Thromboembolism
Consult Thromboembolism
40 mg sc once daily
40 mg sc once daily
40 mg sc once daily
60 mg sc once daily
60 mg sc once daily
60 mg sc once daily
60 mg sc once daily
80 mg sc once daily
80 mg sc once daily
80 mg sc once daily
80 mg sc once daily
100 mg sc once daily
100 mg sc once daily
100 mg sc once daily
100 mg sc once daily
120 mg sc once daily
120 mg sc once daily
120 mg sc once daily
120 mg sc once daily
Consult Thromboembolism
* Creatinine Clearance can be estimated using the following formula:
CrCl (mL/min) = (140-age)(actual body weight in kg) x 1.2 [x 0.85 if female]
Serum creatinine (mmol/L)
An on-line calculator for creatinine clearance is available on the Sunnybrook intranet under:
Quick Links – Pharmacy – Alphabetical Index – letter C – Creatinine clearance calculator
or at: http://sunnynet.ca/datapharmacy/htdocs/misc/Ext_Creatinine_Clearance.html
5
Physician ordering instructions: Select only one of the following regimens (a-d). If patient has
undergone more than 1 surgical procedure, select the regimen (a-d) for the surgical procedure
requiring more intensive anticoagulation.
* Chest tube drainage criteria: less than 300 mL in previous 6h
**Treatment dose enoxaparin dosing chart on Table 1 above.
a) • Isolated, on-pump CABG • tissue AVR without an indication for therapeutic anticoagulation
o enoxaparin 30 mg sc QHS#. Start if chest tube drainage criteria met*
o EC ASA 81 mg po daily. Start when chest tube drainage criteria met*
b) Isolated CABG and coronary patch arterioplasty, coronary endarterectomy, or off-pump bypass
o enoxaparin 30 mg sc QHS#. Start if chest tube drainage criteria met*
o EC ASA 81 mg po daily. Start when chest tube drainage criteria met*.
o clopidogrel 75 mg po daily, starting the day after chest tubes removed
c) • Isolated CABG and Maze procedure or chronic atrial fibrillation
• tissue MVR
• mitral annuloplasty •mechanical AVR or
•tissue AVR with indication for therapeutic anticoagulation:
Check indication(s) for therapeutic anticoagulation for tissue AVR
□
Sustained or intermittent atrial fibrillation for longer than 48 h
□
Maze procedure
□
Grade IV left ventricle
□
Other (Specify): _______________
6
o enoxaparin 30 mg sc QHS#. Start if chest tube drainage criteria met*
o warfarin po daily. Start when chest tube drainage criteria met*. Target INR range =
2.0-3.0
o If INR less than 2.0 at 96h post-operative, obtain order to increase enoxaparin to
treatment** dose
d) Mechanical MVR
o enoxaparin 40 mg sc QHS#. Start if chest tube drainage criteria met*
o warfarin po daily. Start when chest tube drainage criteria met*. Target INR range =
2.5-3.5
o If INR less than 2.0 at 96h post-operative, obtain order to increase enoxaparin to
treatment** dose
# Dosing Considerations for prophylactic enoxaparin:
 For weight greater than 100 kg, double enoxaparin prophylaxis dose
 If CrCl less than 30mL/min AND weight less than 40 kg, give enoxaparin 20 mg sc QHS
 If CrCl less than 30mL/min AND weight greater than 100 kg, give enoxaparin 40 mg sc QHS
ANTIPLATELETS/ANTICOAGULANTS:
(Physician to reference regimens on the back of page 3 AND confirm with CVICU orders and
kardex for most recent therapy)
40. EC ASA 81 mg po daily
41. clopidogrel 75 mg po daily, start day after chest tubes removed
42. enoxaparin _____________ mg sc ___________ (frequency)
43. warfarin po daily

Daily CBC and INR
7

Do not start warfarin until all chest tubes and epicardial pacemaker wires
are removed
44. If patient is receiving warfarin and INR less than 2.0 at 96h postoperative, obtain
physician order to increase enoxaparin to treatment dose. Physician to use enoxaparin
dosing table on back of page 3.
45. When treatment dose enoxaparin is ordered:
 Hold AM dose for removal of chest tubes or epicardial wires or surgical
procedures
 Give same dose 2h post line removals or 12h post surgical procedure
 Bloodwork: CBC, INR daily and urea/creatinine every other day
7. GENERAL INTERNAL MEDICINE STANDARD ADMISSION ORDERS: PR 99979
Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:
o enoxaparin (Lovenox®) 40 mg sc QHS
o enoxaparin (Lovenox®) 30 mg sc QHS for patients weighing less than 40 kg or with
CrCl less than 30mL/min
o properly measured, bilateral, below-the-knee TED stockings because of:
o active bleeding
o hemorrhagic stroke in past 7 days
Reassess daily for conversion to enoxaparin
o NO prophylaxis – REASON: _____________________________________________.
Reassess daily for conversion to enoxaparin.
8
On back of page of GIM order sheet, table:
Excerpt from:
Guidelines for Prevention and Treatment of Venous Thromboembolism
Indication
Recommendations for Prophylaxis
Medical patients (e.g. congestive heart failure,
severe respiratory disease, confined to bed
with active cancer, previous venous
thromboembolism, sepsis, acute neurologic
disease, inflammatory bowel disease, etc.)
 Enoxaparin 40 mg SC daily at bedtime* OR
Stroke, hemorrhagic
 Enoxaparin 30 mg SC daily at bedtime for patients
with CrCl < 30mL/min** or weighing less than 40 kg
For patients at high risk of bleeding only, properly
measured, bilateral, below-the-knee TED
stockings. Reassess daily for conversion to
enoxaparin.
 Properly measured, bilateral, below-the-knee TED
stockings initially; reassess daily for conversion to
enoxaparin. When “safe”:
 Enoxaparin 40 mg SC daily at bedtime* OR
 Enoxaparin 30 mg SC daily at bedtime for patients
with CrCl < 30mL/min** or weighing less than 40 kg
Stroke, non-hemorrhagic
 Enoxaparin 40 mg SC daily* at bedtime
 Enoxaparin 30 mg SC daily at bedtime for patients
with CrCl < 30mL/min** or weighing < 40 kg
For patients at high risk of bleeding only, properly
measured, bilateral, below-the-knee TED stockings.
Reassess daily for conversion to enoxaparin.
* Consider increasing the dose of enoxaparin to 40 mg SC BID for patients weighing more than 100 kg
** Consider giving enoxaparin 40 mg SC daily for patients with CrCl < 30mL/min and weighing > 100 kg
9
8. Standard Admission Orders for Acute Stroke: PR 74021
Venous Thromobembolism (VTE) Prophylaxis. Choose ONE of the following:
o enoxaparin 40 mg sc QHS
o enoxaparin 30 mg sc QHS for patients weighing less than 40 kg or with CrCl less
than 30mL/min
o For high risk bleeding ONLY, properly measured, bilateral, below-the-knee TED
stockings. Reassess daily for conversion to enoxaparin
o NO prophylaxis – REASON: _____________________________________________.
Reassess daily for conversion to enoxaparin.
9. PRE-OPERATIVE ORDERS FOR HEPATOBILIARY, PANCREATIC & GASTRIC SURGERY – DAY OF
SURGERY: PR 14086
Venous Thromboembolism (VTE) Prophylaxis – choose ONE of the following:
o enoxaparin 40 mg sc to be sent with the patient to the operating room for
administration
o enoxaparin 30 mg sc (if weight less than 40 kg or CrCl less than 30mL/min) to be sent
with the patient to the operating room for administration
o no pre-op anticoagulant prophylaxis (e.g. for liver resection)
10. PREOPERATIVE ORDERS FOR GYNAECOLOGIC ONCOLOGY PROCEDURES: PR 80021 (no
anticoagulant order)
11. POSTOPERATIVE ORDERS FOR GYNAECOLOGIC ONCOLOGY PROCEDURES: PR 46002
Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:
o enoxaparin (Lovenox®):
□
40mg sc QHS starting tonight (2200 hours)
□
40mg sc daily starting tomorrow morning (1000 hours)
10
o enoxaparin (Lovenox®) (for patients weighing less than 40 kg or with CrCl less than
30 mL/min):
□
30 mg sc QHS starting tonight (2200 hours)
□
30 mg sc daily starting tomorrow morning (1000 hours)
o If enoxparin not odered, give REASON:____________________________________.
Reassess daily for conversion to enoxaparin
12. ADMISSION ORDERS FOR PATIENTS WITH HIP FRACTURE: PR 68053
Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:
o enoxaparin (Lovenox®) 30 mg sc QHS. Do not hold enoxaparin if patient is
scheduled for surgery tomorrow morning.
o If enoxaparin not ordered, give REASON:__________________________
13. POST OPERATIVE ORDERS FOR PATIENTS WITH HIP FRACTURE: PR 68054
Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:
o enoxaparin (Lovenox®):
□
40mg sc QHS starting tonight (2200 hours)
□
40mg sc daily starting tomorrow morning (1000 hours)
o enoxaparin (Lovenox®) (for patients weighing less than 40 kg or with CrCl less than
30 mL/min):
□
30 mg sc QHS starting tonight (2200 hours)
□
30 mg sc daily starting tomorrow morning (1000 hours)
o If enoxparin not odered, give REASON:____________________________________.
Reassess daily for conversion to enoxaparin
11
14. ADMISSION ORDERS FOR PATIENTS WITH LOWER EXTREMITY FRACTURE: PR 68055
Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:
o enoxaparin 40 mg sc QHS. Do not hold enoxaparin if surgery is scheduled for
tomorrow morning.
o enoxaparin 30 mg sc QHS (for patients weighing less than 40kg or with CrCl less than
30mL/min). Do not hold enoxaparin if surgery is scheduled for tomorrow morning.
o If enoxaparin not ordered, give REASON:___________________________________
15. POST OPERATIVE ORDERS for patients with LOWER EXTREMITY FRACTURE: PR 68056
Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:
o enoxaparin (Lovenox®):
□
40mg sc QHS starting tonight (2200 hours)
□
40mg sc daily starting tomorrow morning (1000 hours)
o enoxaparin (Lovenox®) (for patients weighing less than 40 kg or with CrCl less than
30 mL/min):
□
30 mg sc QHS starting tonight (2200 hours)
□
30 mg sc daily starting tomorrow morning (1000 hours)
o If enoxparin not odered, give REASON:____________________________________.
Reassess daily for conversion to enoxaparin
16. CRITICAL CARE UNIT ADMISSION ORDERS: PR 58045
Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:
o enoxaparin 40 mg sc daily at 22:00h
o enoxaparin 30 mg sc daily at 22:00h (for patients weighing less than 40 kg or with
CrCl less than 30mL/min
12
o enoxaparin 40 mg sc BID at 10:00h and 22:00h (for patients weighing greater than
100 kg)
o For high risk bleeding ONLY, properly measured, bilateral, below-the-knee TED
stockings. Reassess daily for conversion to enoxaparin
o NO prophylaxis – REASON: _____________________________________________.
Reassess daily for conversion to enoxaparin
17. LEVEL-II ICU ADMISSION ORDERS: PR 99823
Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:
o Without epidural, enoxaparin 40 mg sc daily at 22:00 h
o Without epidural, enoxaparin 30 mg sc daily at 22:00 h (for patients weighing
less than 40kg or with CrCl less than 30 mL/min)
o With epidural, enoxaparin 40 mg sc daily at 10:00 h
o With epidural, enoxaparin 30 mg sc daily at 10:00 h (for patients weighing
less than 40kg or with CrCl less than 30 mL/min)
o enoxaparin 40 mg sc bid at 10:00h and 22:00h (for patients weighing greater
than 100kg)
o For high risk bleeding ONLY, properly measured, bilateral, below-the-knee TED
stockings. Reassess daily for conversion to enoxaparin
o NO prophylaxis – REASON: _____________________________________________.
Reassess daily for conversion to enoxaparin
13
18. CRITICAL CARE TO WARD TRANSFER ORDERS: PR 14012
Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:
o enoxaparin 40 mg sc QHS
o enoxaparin 30 mg sc QHS (for patients weighing less than 40 kg or with CrCl less
than 30 mL/min)
o enoxaparin 40 mg sc bid at 10:00h and 22:00h (for patients weighing greater than
100 kg)
o For high risk bleeding ONLY, properly measured, bilateral, below-the-knee TED
stockings. Reassess daily for conversion to enoxaparin
o NO prophylaxis – REASON: _____________________________________________.
Reassess daily for conversion to enoxaparin
19. GYNECOLOGY POST-OPERATIVE ORDERS: PR 14003 (Women’s College)
ANTI-THROMBOTICS Refer to table on back of page for guidelines
Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:
o enoxaparin (Lovenox®):
□
40mg sc QHS starting tonight (2200 hours)
□
40mg sc daily starting tomorrow morning (1000 hours)
o enoxaparin (Lovenox®) (for patients weighing less than 40 kg or with CrCl less than
30 mL/min):
□
30 mg sc QHS starting tonight (2200 hours)
□
30 mg sc daily starting tomorrow morning (1000 hours)
o If enoxparin not odered, give REASON:____________________________________.
Reassess daily for conversion to enoxaparin
14
20. Post-Operative Orders for Open Aortic Vascular Surgery Patients: PR 74025
Under SCHEDULED MEDICATIONS:
Venous Thromboembolism (VTE) Prophylaxis. Choose ONE of the following:
o enoxaparin 40 mg sc daily starting POD #1. Hold dose if chest tube(s) in situ and
drainage > 300mL/6h
o enoxaparin 30 mg sc daily (for patients weighing less than 40kg or with CrCl less than
30mL/min). Hold dose if chest tube(s) in situ and drainage > 300mL/6h
o If enoxaparin not ordered, give REASON:___________________________________.
Reassess daily for conversion to enoxaparin.
15