Background
Venous thromboembolism management
The Sheffield venous thromboembolism management pathway: deep vein thrombosis
Step 1: Patient presentation
Step 2: Diagnosis in the thrombosis clinic (or by emergency department physician)
Criteria | Points |
---|---|
Active cancer | +1 |
Paralysis, paresis or recent plaster cast of the lower limb | +1 |
Bedridden for 3+ days or major surgery within 12 weeks | +1 |
Pain/tenderness along deep vein system | +1 |
Swollen leg | +1 |
Calf swelling >3 cm more than asymptomatic leg | +1 |
Pitting oedema in symptomatic leg only | +1 |
Collateral superficial veins | +1 |
History of DVT | +1 |
Alternative cause is considered at least as likely as DVT | −2 |
Outcome: | |
DVT unlikely: | Score ≤1 (consider trauma, cellulitis) |
DVT likely: | Score ≥2 |
Step 3: Risk stratification
Step 4: Treatment strategy
Step 5: Follow-up
The Sheffield venous thromboembolism management pathway: pulmonary embolism
Step 1: Patient presentation
Step 2: Diagnosis in the thrombosis clinic (or by emergency department physician)
Clinical feature | Original score | Simplified score |
---|---|---|
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) | 3 | 1 |
An alternative diagnosis is less likely than PE | 3 | 1 |
Heart rate ≥100 beats per minute | 1.5 | 1 |
Immobilisation (for >3 days) or surgery in the previous 4 weeks | 1.5 | 1 |
Previous DVT/PE | 1.5 | 1 |
Haemoptysis | 1 | 1 |
Active cancer | 1 | 1 |
Outcome | ||
PE unlikely: | Score ≤4 | Score 0 or 1 |
PE likely: | Score >4 | Score ≥2 |
Step 3: Risk stratification
Prediction factors | PESI | sPESI |
---|---|---|
Age >80 years | Age in years | 1 |
Male gender | +10 | - |
Cancer | +30 | 1 |
Heart failure | +10 | 1a
|
Chronic lung disease | +10 | |
Pulse ≥110 beats/minute | +20 | 1 |
Systolic blood pressure <100 mmHg | +30 | 1 |
Respiratory rate ≥30 breaths/minute | +20 | - |
Temperature <36 °C | +20 | - |
Altered mental status | +60 | - |
Arterial oxyhaemoglobin saturation <90% | +20 | 1 |
Outcome | ||
Low risk: | Class I: ≤65 Class II: 66–85 | PESI = 0 |
Intermediate risk: | Class III: 86–105 | |
High risk: | Class IV: 106–125 Class V: >125 | PESI = ≥1 |
HESTIA criteria: Zondag [3] | Exclusion criteria: Aujesky [2] |
---|---|
Is the patient haemodynamically unstable? | SBP <100 mmHg |
Is thrombolysis or embolectomy necessary? | |
>24 h oxygen to maintain sats >90% | Oxygen saturation <90% |
Active bleeding or high risk of bleeding | Active bleeding High risk of bleeding (stroke within the preceding 10 days, GI bleed within the last 14 days or platelet count <75,000/mm3) |
PE diagnosed on anticoagulation? | Therapeutic anticoagulation (INR ≥2.0) at diagnosis |
Severe pain needing IV pain medication for >24 h | Chest pain needing opiates |
Medical or social reason for treatment in hospital (infection, malignancy, no support system) | Barriers to treatment adherence or follow-up |
CrCl <30 mL/min | Severe renal failure (CrCl <30 mL/min) |
Severe liver impairment | |
Documented history of HIT | HIT |
Is the patient pregnant? | |
Obesity (weight >150 kg) |