ICU care bundles and infection prevention

VTE and stress ulcer prophylaxis

Reviewed Nov 2026·7 references
New· views rounded down, updated weekly

Choosing pharmacological or mechanical thromboprophylaxis, renal and obesity dosing, and who needs stress ulcer prophylaxis after REVISE.

Definition
Critically ill patients are at high VTE risk. ASH 2018 recommends pharmacological prophylaxis (LMWH preferred over UFH) over none, and mechanical prophylaxis when anticoagulants are contraindicated. Stress-related mucosal bleeding risk is highest in ventilated patients and those with coagulopathy, shock or chronic liver disease.

At the bedside

  1. 1

    Assess bleeding risk

    Active bleeding, platelets < 50 × 10⁹/L, recent neurosurgery/intracranial haemorrhage, severe coagulopathy, planned neuraxial procedure.

  2. 2

    No contraindication

    LMWH: enoxaparin 40 mg SC daily (dalteparin 5,000 units daily is an alternative). CrCl < 30 mL/min: enoxaparin 30 mg daily or UFH 5,000 units SC every 8-12 h.

  3. 3

    Contraindication

    Intermittent pneumatic compression; start pharmacological prophylaxis as soon as bleeding risk allows. Adding IPC to pharmacological prophylaxis gives no extra benefit (PREVENT).

  4. 4

    Special cases

    Obesity: higher doses (see drug); trauma, burns, spinal cord injury: earlier and more intensive prophylaxis per trauma guidelines; HIT: non-heparin anticoagulant.

  5. 5

    SUP: who

    Invasive mechanical ventilation, coagulopathy, shock, chronic liver disease (high risk). Not routinely for low-risk patients.

  6. 6

    SUP: what

    Pantoprazole 40 mg IV/enteral daily (or H2RA); REVISE showed fewer clinically important UGI bleeds in ventilated patients with no mortality difference.

  7. 7

    Stop

    Stop SUP when the risk factor resolves (extubation, shock resolved); do not continue at discharge.

VTE prophylaxis

Enoxaparin

SC
Dose
40 mg once daily
Worked example
70 kg, CrCl 80 mL/min: enoxaparin 40 mg SC at 18:00 daily. If CrCl falls to 25 mL/min: 30 mg daily or switch to UFH 5,000 units SC every 12 h.

Range: 30 mg daily (CrCl < 30) to 40 mg every 12 h (BMI ≥ 40).

Open Creatinine clearance (Cockcroft-Gault)

VTE prophylaxis in severe renal impairment

Unfractionated heparin (subcutaneous)

SC
Dose
5,000 units every 8-12 h

Stress ulcer prophylaxis (high risk)

Pantoprazole

IV or enteral
Dose
40 mg once daily
Worked example
Ventilated 70 kg patient: pantoprazole 40 mg IV daily; stop after extubation if no other indication.

Stress ulcer prophylaxis (alternative)

Famotidine

IV or enteral
Dose
20 mg every 12 h

Once daily if CrCl < 50 mL/min.

Stress ulcer prophylaxis decision

Risk groupExamplesSUP
HighInvasive ventilation; coagulopathy (platelets < 50 × 10⁹/L, INR > 1.5); shock; chronic liver diseaseSuggest PPI or H2RA
LowNon-ventilated, haemodynamically stable, no coagulopathyNot routinely
Already on therapeutic indicationRecent peptic ulcer, Barrett's, dual antiplatelets with GI riskContinue home PPI

Based on the 2021 clinical practice guideline and REVISE 2024.

Red flag · call your senior now
Unilateral leg swelling, unexplained tachycardia or hypoxaemia despite prophylaxis: evaluate for DVT/PE.
Red flag
Platelet fall > 50% from day 5-10 of heparin: assess for HIT (4T score) and stop all heparin if likely.
Pitfall
Holding LMWH for days 'in case of procedures' without a plan to restart.
Pitfall
Graduated compression stockings alone in ICU - IPC is preferred when mechanical prophylaxis is needed.
Pearl
Give the evening dose of LMWH at a fixed time so that morning procedures can be timed 12 h after the dose.

Calculators for this topic

Creatinine clearance (Cockcroft-Gault)

(140 − age) × weight ÷ (72 × creatinine), × 0.85 if female. Not valid in unstable AKI.

Body mass index

Weight ÷ height². Asian cut-offs differ (overweight ≥ 23, obese ≥ 25 in Indian guidance).

References

  1. 1

    Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv 2018;2:3198-225.

  2. 2

    Arabi YM, Al-Hameed F, Burns KEA, et al. Adjunctive intermittent pneumatic compression for venous thromboprophylaxis (PREVENT). N Engl J Med 2019;380:1305-15.

  3. 3

    Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023;27:80.

  4. 4

    Cook D, Deane A, Lauzier F, et al. Stress ulcer prophylaxis during invasive mechanical ventilation (REVISE). N Engl J Med 2024;391:9-20.

  5. 5

    Krag M, Marker S, Perner A, et al. Pantoprazole in patients at risk for gastrointestinal bleeding in the ICU (SUP-ICU). N Engl J Med 2018;379:2199-208.

  6. 6

    Ye Z, Reintam Blaser A, Lytvyn L, et al. (Scandinavian/European) Clinical practice guideline on gastrointestinal bleeding prophylaxis for critically ill patients. Acta Anaesthesiol Scand 2021;65:681-94.

  7. 7

    Farkas J. The Internet Book of Critical Care (IBCC). EMCrit Project; continuously updated.

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