10. What are the indications for, risks, and benefits of empiric anticoagulation for suspected VTE?

a. HOMERuN institutions

Institutional guidelines on this subject varied greatly. Six institutions (28%) did not address this issue. Fifteen (71%) institutions said they “recommended,” “suggested,” or said to “consider” empiric therapeutic anticoagulation for patients at high risk for VTE or in whom there was high suspicion of VTE with low bleeding risk when confirmatory testing could not be obtained. The definition of “high risk for VTE” or “high suspicion for VTE” varied, including high risk Wells score, refractory hypoxemia, increased dead space, organ failure, physical findings consistent with thrombosis, elevated D-dimer or elevated fibrinogen (varying thresholds), TEG consistent with hypercoagulability, clotting of CRRT, peripheral ischemia, or based on hematology/multidisciplinary consultation. Two protocols (9.5%) said they “do not recommend” or “discourage” the use of empiric anticoagulation in the absence of confirmed VTE, one of which used the rationale that anticoagulation for DIC has not shown a benefit in the past, though one protocol also left this open in the case of “strongly suspected thrombosis.” Two protocols (9.5%) suggested consideration of thrombolysis either as part of a clinical trial or empirically for severely ill patients without confirmed thrombosis but with high suspicion for PE, MI, or ischemic stroke.