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Documentation that an order was given for venous thromboembolism (VTE) prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time (PERI 2)

CPT4 code

Name of the Procedure:

Venous Thromboembolism (VTE) Prophylaxis within 24 Hours Prior to Incision or 24 Hours After Surgery (PERI 2)


This procedure involves administering measures to prevent venous thromboembolism (VTE), a condition where blood clots form in the veins. It ensures VTE prophylaxis is given within 24 hours before the surgical incision or within 24 hours after the surgery ends.


The purpose of VTE prophylaxis is to prevent blood clots, which can lead to serious complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE). The goal is to minimize the risk of clot formation during the perioperative period, enhancing patient safety.


Patients undergoing surgery who are at risk for VTE, particularly those with factors such as prolonged immobility, existing cardiovascular issues, obesity, or a history of blood clots, warrant this procedure.


  • Patients may be advised to fast if required by the type of surgery.
  • Medication adjustments might be necessary, particularly with anticoagulants.
  • Diagnostic tests such as blood work or coagulation profiles may be needed.

Procedure Description

  1. Pre-Procedure: Assess patient risk factors and history; ensure patient is informed.
  2. Administration: VTE prophylaxis may involve mechanical methods (e.g., compression stockings or pneumatic compression devices) or pharmacological agents (e.g., anticoagulants like heparin or low molecular weight heparin).
  3. Timing: Ensure prophylaxis is administered within the designated time window (24 hours prior to incision or 24 hours post-surgery).
  4. Monitoring: Continuous monitoring for signs of bleeding or adverse reactions.


The administration of VTE prophylaxis typically takes a few minutes, but monitoring continues throughout the perioperative period.


This procedure is usually performed in a hospital setting, including surgical units or recovery rooms.


  • Surgeon: Oversees the surgical procedure and VTE prophylaxis plan.
  • Nurse: Administers prophylaxis and monitors patient.
  • Anesthesiologist: Manages anesthesia and ensures patient stability.

Risks and Complications

  • Common Risks: Minor bleeding or bruising at injection sites.
  • Rare Risks: Severe bleeding, allergic reactions, and complications from mechanical devices.
  • Management: Immediate medical intervention for any complications, adherence to standardized protocols.


  • Primary Benefit: Reduction in the risk of developing life-threatening conditions like DVT and PE.
  • Timeline: The protective effects start soon after administration and continue through the critical perioperative period.


  • Post-Procedure Care: Regular monitoring for signs of VTE, continued use of prophylactic measures if needed.
  • Recovery Time: Varies depending on the surgical procedure, typically immediate monitoring with follow-up during recovery period.
  • Restrictions: Follow personalized advice on mobility and activity levels.


  • Non-Pharmacological Methods: Includes mechanical prophylaxis alone for patients who cannot receive anticoagulants.
  • Pros and Cons: Mechanical methods may be less effective alone; pharmacological methods carry a risk of bleeding.

Patient Experience

  • During Procedure: Minimal discomfort from mechanical devices or injections.
  • After Procedure: Patients should report any pain, swelling, or signs of bleeding. Pain management strategies and comfort measures will be provided as necessary.

By following this protocol, healthcare providers aim to enhance postoperative outcomes and minimize the risk of thromboembolic events.

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