VTE Prophylaxis & Treatment — LMWH, IPC, Thrombolysis & the ICU Default

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• ALL ICU patients are HIGH VTE risk by default — prophylaxis is the standard of care, not optional; LMWH (enoxaparin 40 mg SC daily) unless contraindicated
• LMWH accumulates in severe renal impairment — switch to UFH (5000 U two or three times daily) or dose-reduce and monitor anti-Xa
• Heparin-induced thrombocytopenia (HIT) — falling platelets with new thrombosis on heparin: STOP all heparin (PROTECT: HIT HR 0.27 with dalteparin vs UFH); switch to a non-heparin anticoagulant. Item-level 4Ts timing is not in this topic abstracts
• Neuraxial anaesthesia and LMWH — spinal haematoma is catastrophic; Highlow: ≥12 h after low-dose and ≥24 h after intermediate-dose LMWH before a neuraxial procedure
• Anticoagulation contraindicated (active bleeding) — use mechanical IPC and consider a (temporary) IVC filter; do NOT leave the patient unprotected
• Cancer-associated thrombosis — LMWH historically preferred; DOACs (apixaban, rivaroxaban, edoxaban) now non-inferior (Caravaggio, Hokusai-VTE Cancer) with a CRNMB trade-off in SELECT-D (13% vs 4%); GI/GU-site bleed caution is **not in this topic abstracts**
• Massive PE (hypotension, shock) — thrombolysis alteplase 100 mg IV over 2 h, or embolectomy if thrombolysis contraindicated; UFH infusion over LMWH for rapid reversibility
• Duration: CHEST 2016 did not change who should stop anticoagulation at 3 months versus receive extended therapy; cancer-associated VTE is treated while cancer is active (CLOT 6 months in-trial)