Prevalence of deep vein thrombosis in acutely admitted ambulatory non-surgical intensive care unit patients

Prevalence and factors related with venous thromboembolism in patients admitted to the critical care units: A systematic review and meta-analysis

OBJECTIVE

Venous thromboembolism is one of the most common cardiovascular disorders in the any intensive care units (ICUs), which annually leads to death and imposes great costs on patients and society worldwide. The present study was conducted with the aim of determining the prevalence and factors related to venous thromboembolism in the ICUs as a systematic review and meta-analysis.

METHODS

The current study was conducted in international databases, on all descriptive and analytical studies and clinical and semi-experimental trial studies, without time limit until November 2, 2021. The present study was designed and implemented based on PRISMA guideline. The quality of the studies was checked using STROBE checklist and meta-analysis was performed using CMA software.

RESULTS

Among the 3204 articles found, after the evaluations, 189 articles entered the full text review phase, and as a result, 38 articles were included in the study. The reported prevalence of thromboembolism was 1-45%. The prevalence of venous thromboembolism was 12% in overall. The chance of venous thromboembolism was higher in ICUs patients >57 years old and ICUs patients with a history of venous thromboembolism.

CONCLUSION

The results of this study showed that venous thromboembolism has a higher prevalence in ICUs patients in comparison to non-ICUs patients. It is recommended to nurses and healthcare staffs to provide accurate decision and care for prevention of venous thromboembolism and paying attention to the patient's warning signs, timely administration of anticoagulants, and monitor coagulation factors.

The risk factors for deep venous thrombosis in critically ill older adult patients: a subgroup analysis of a prospective, multicenter, observational study

BACKGROUND

Older adult patients mainly suffer from multiple comorbidities and are at a higher risk of deep venous thrombosis (DVT) during their stay in the intensive care unit (ICU) than younger adult patients. This study aimed to analyze the risk factors for DVT in critically ill older adult patients.

METHODS

This was a subgroup analysis of a prospective, multicenter, observational study of patients who were admitted to the ICU of 54 hospitals in Zhejiang Province from September 2019 to January 2020 (ChiCTR1900024956). Patients aged > 60 years old on ICU admission were included. The primary outcome was DVT during the ICU stay. The secondary outcomes were the 28- and 60-day survival rates, duration of stay in ICU, length of hospitalization, pulmonary embolism, incidence of bleeding events, and 60-day coagulopathy.

RESULTS

A total of 650 patients were finally included. DVT occurred in 44 (2.3%) patients. The multivariable logistic regression analysis showed that age (≥75 vs 60-74 years old, odds ratio (OR) = 2.091, 95% confidence interval (CI): 1.308-2.846, P = 0.001), the use of analgesic/sedative/muscarinic drugs (OR = 2.451, 95%CI: 1.814-7.385, P = 0.011), D-dimer level (OR = 1.937, 95%CI: 1.511-3.063, P = 0.006), high Caprini risk score (OR = 2.862, 95%CI: 1.321-2.318, P = 0.039), basic prophylaxis (OR = 0.111, 95%CI: 0.029-0.430, P = 0.001), and physical prophylaxis (OR = 0.322, 95%CI: 0.109-0.954, P = 0.041) were independently associated with DVT. There were no significant differences in 28- and 60-day survival rates, duration of stay in ICU, total length of hospitalization, 60-day pulmonary embolism, and coagulation dysfunction between the two groups, while the DVT group had a higher incidence of bleeding events (2.6% vs. 8.9%, P < 0.001).

CONCLUSION

In critically ill older adult patients, basic prophylaxis and physical prophylaxis were found as independent protective factors for DVT. Age (≥75 years old), the use of analgesic/sedative/muscarinic drugs, D-dimer level, and high Caprini risk score were noted as independent risk factors for DVT.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR1900024956).URL: http://www.chictr.org.cn/listbycreater.aspx .

Thromboembolic Events in Patients with Influenza: A Scoping Review

INTRODUCTION

Influenza is an acute respiratory infection that usually causes a short-term and self-limiting illness. However, in high-risk populations, this can lead to several complications, with an increase in mortality. Aside from the well-known extrapulmonary complications, several studies have investigated the relationship between influenza and acute cardio and cerebrovascular events. Reviews of the thromboembolic complications associated with influenza are lacking.

OBJECTIVES

the study aims to conduct a scoping review to analyze the epidemiological and clinical characteristics of patients suffering from influenza and thromboembolic complications.

MATERIALS AND METHODS

A computerized search of historical published cases using PubMed and the terms "influenza" or "flu" and "thrombosis", "embolism", "thromboembolism", "stroke", or "infarct" for the last twenty-five years was conducted. Only articles reporting detailed data on patients with thromboembolic complications of laboratory-confirmed influenza were considered eligible for inclusion in the scoping review.

RESULTS

Fifty-eight cases with laboratory documented influenza A or B and a related intravascular thrombosis were retrieved. Their characteristics were analyzed along with those of a patient who motivated our search. The localizations of thromboembolic events were pulmonary embolism 21/58 (36.2%), DVT 12/58 (20.6%), DVT and pulmonary embolism 3/58 (5.1%), acute ischemic stroke 11/58 (18.9%), arterial thrombosis 4/58 (6.8%), and acute myocardial infarction 5/58 (8.6%).

DISCUSSION

Our findings are important in clarifying which thromboembolic complications are more frequent in adults and children with influenza. Symptoms of pulmonary embolism and influenza can be very similar, so a careful clinical evaluation is required for proper patient management, possible instrumental deepening, and appropriate pharmacological interventions, especially for patients with respiratory failure.

Venous thrombosis, thromboembolism, biomarkers of inflammation, and coagulation in coronavirus disease 2019

OBJECTIVE

Coronavirus disease 2019 (COVID-19) is associated with abnormal inflammatory and coagulation markers, potentially mediating thrombotic events. Our objective was to investigate the incidence, time course, laboratory features, and in-hospital outcomes of COVID-19 patients with suspected venous thromboembolism (VTE).

METHODS

A retrospective observational cohort study was conducted of patients hospitalized with COVID-19 who had undergone ultrasound imaging for suspected VTE from March 13 to May 18, 2020. The medical records of the included patients were reviewed for D-dimer, fibrinogen, prothrombin time, partial thromboplastin time, platelet count, C-reactive protein (CRP), and high-sensitivity troponin T at admission and at up to seven time points before and after ultrasound examination. The clinical outcomes included superficial venous thrombosis, deep vein thrombosis, pulmonary embolism, intubation, and death. Mixed effects logistic, linear, and Cox proportional hazards methods were used to evaluate the relationships between the laboratory markers and VTE and other in-hospital outcomes.

RESULTS

Of 138 patients who had undergone imaging studies, 44 (31.9%) had evidence of VTE. On univariable analysis, an elevated admission CRP (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.09; P = .02; per 10-U increase in CRP), platelet count (OR, 1.48; 95% CI, 1.04-2.12; P = .03; per 1000-U increase in platelet count), and male sex (OR, 2.64; 95% CI, 1.19-5.84; P = .02), were associated with VTE. However only male sex remained significant on multivariable analysis (OR, 2.37; 95% CI, 1.01-5.56; P = .048). The independent predictors of death included older age (hazard ratio [HR], 1.04; 95% CI, 1.00-1.07; P = .04), active malignancy (HR, 4.39; 95% CI, 1.39-13.91; P = .01), elevated admission D-dimer (HR, 1.016; 95% CI, 1.003-1.029; P = .02), and evidence of disseminated intravascular coagulation (HR, 4.81; 95% CI, 1.76-13.10; P = .002).

CONCLUSIONS

Male sex, elevated CRP, and elevated platelet count at admission were associated with VTE on univariable analysis. However, only male sex remained significant on multivariable analysis. Older age, active malignancy, disseminated intravascular coagulation, and elevated D-dimer at admission were independently associated with death for patients hospitalized with COVID-19.

Utility of coagulation analyses to assess thromboprophylaxis with dalteparin in intensive care unit patients

BACKGROUND

The aim of this study was to evaluate the utility of coagulation analyses to assess thromboprophylaxis with dalteparin in intensive care unit (ICU) patients.

METHODS

Prospective observational study of ICU patients receiving dalteparin prophylaxis at Oslo University Hospital in Norway. Trough and peak antithrombin, protein C, anti-factor Xa activity (aFXa), d-dimer, thromboelastography, calibrated automated thrombogram and microparticles were analysed. Levels were compared in patients with and without venous thromboembolism (VTE), major bleeding, acute kidney injury (AKI) with use of renal replacement therapy (RRT) and variable dalteparin dose.

RESULTS

Among 50 included patients (76% male, mean age 62 years) five (10%) developed VTE and eight (16%) major bleeding. Median through aFXa level was 0.03 (0.02-0.05) IU/mL, and 48 (96%) of patients were within and two (4%) above target range. Peak aFXa level was 0.21 (0.13-0.29) IU/mL, the number of patients below, within and above prophylactic range were 21 (42%), 25 (50%) and four (8%). Peak aFXa levels were similar in patients with and without VTE (0.18 vs 0.21 IU/L, P = .72), major bleeding (0.22 vs 0.21 IU/mL, P = .38) and AKI with RRT (0.18 vs 0.24, P = .13), but lower in patients receiving dalteparin 5000 IU od compared to 7500 IU od (0.19 vs 0.30 IU/mL, P < .01).

CONCLUSIONS

Intensive care unit patients receiving dalteparin prophylaxis had half of patients within prophylactic peak aFXa target range. Peak aFXa levels was affected by administered dalteparin dose, but not presence of VTE, major bleeding or AKI with RRT.

The role of thrombophilia genes in the clinical implementation of arterial and venous thrombosis in newborns

The article considers the analysis results of the occurrence frequency of genotypes and alleles of plasma, platelet and fibrinolytic hemostasis in full-term newborns with arterial and venous thrombosis of various localization. Gene polymorphisms were studied by real-time PCR in human DNA samples obtained from buccal epithelium and venous blood lymphocytes. The control group was a group of healthy full-term newborns from families without a thrombophilic history. Predictors of arterial and venous thrombosis in children are such as polymorphism of the plasminogen activator inhibitor gene PAI-1-675 4G/4G (OR=5,6 [2,3-13,8]), combinations of polymorphisms PAI-1-675 4G/4G + factor VII G10976A G/G (OR=5,8 [1,7-19,1]), combinations of polymorphisms PAI-1 -675 4G/4G + factor VII G10976A G/G + factor XIII Val34Leu G/G (% AR=61), fibrinogen FGB -455 G/A (OR=3,75 [1,4-9,4]) and integrin alpha 2 ITGA2 807 T/T (OR=15,56 [1,9-126,7]). Thus, the study of polymorphisms of the plasminogen activator inhibitor, fibrinogen, integrin alpha 2 can serve as one of the criteria for identifying a high-risk group for the development of arterial and venous thrombosis in newborns and should be taken into account when evaluating individual thrombophilia risk.

Proximal deep vein thrombosis among hospitalised medical and obstetric patients in Rwandan university teaching hospitals: prevalence and associated risk factors: a cross-sectional study

OBJECTIVES

To determine the prevalence of proximal deep vein thrombosis (DVT) by ultrasound scanning, as well as associated clinical features and known risk factors, among medical and obstetrics-gynaecology inpatients in two Rwandan tertiary hospitals.

DESIGN

Cross-sectional study.

SETTINGS

Rwanda teaching hospitals: Kigali and Butare University Teaching Hospitals.

PARTICIPANTS

901 adult patients admitted to the Departments of Internal Medicine and Obstetrics-Gynecology (O&G) who were at least 21 years of age and willing to provide a consent.

OUTCOMES

Prevalence of proximal DVT, clinical features and known risk factors associated with DVT.

METHODS

Between August 2015 and August 2016, participants were screened for DVT by compressive ultrasound of femoral and popliteal veins, conducted as a monthly cross-sectional survey of all consenting eligible inpatients. Patients completed a self-report survey on DVT risk factors. Prevalence of proximal DVT by compression ultrasonography was the primary endpoint, with univariate and multivariate regression analyses performed to assess associated clinical features and risk factors.

RESULTS

Proximal DVT was found in 5.5% of the study population, with similar rates in medical and O&G inpatients. The mean age was 41±16 SD (range, 21-91), 70% were female and 7% were pregnant. Univariate analysis showed active malignancy, immobilisation, prolonged recent travel and history of DVT to be significant risk factors for proximal DVT (all p values <0.05); while only active malignancy was an independent risk factor on multivariate regression (OR 5.2; 95% CI 2.0 to 13). Leg pain or tenderness, increased calf circumference, unilateral limb swelling or pitting oedema were predictive clinical features of DVT on both univariate analysis and multivariate regression (all p values <0.05).

CONCLUSION

Proximal DVT prevalence is high among hospitalised medical and O&G patients in two tertiary hospitals in Rwanda. For reducing morbidity and mortality, research to develop Africa-specific clinical prediction tools for DVT and interventions to increase thromboprophylaxis use in the region are urgently needed.

The cumulative venous thromboembolism incidence and risk factors in intensive care patients receiving the guideline-recommended thromboprophylaxis

Few prospective studies have reported the cumulative incidence of venous thromboembolism (VTE) in the intensive care unit (ICU), especially for patients receiving guideline-recommended VTE prophylaxis. We aimed to design a prospective observational study to investigate the cumulative incidence and risk factors of ICU-acquired VTE for those populations.We prospectively studied 281 consecutively included patients in the ICU at a single center. All patients provided informed consent. Patients received ultrasound evaluation and were followed for VTE before ICU discharge or within 28 days of ICU stay. The type of VTE thromboprophylaxis was also recorded for all patients. Variables from univariate analyses that were associated with VTE were included in the binary logistic regression analysis to determine VTE predictors. The cumulative VTE incidence with 95% confidence interval (CI) was estimated using Kaplan-Meier methods.Patients had a median age of 60 years (range, 18-89) and an acute physiology and chronic health evaluation II score of 17 (range, 4-36). Despite all patients receiving guideline-recommended thromboprophylaxis, the cumulative incidence of VTE at 7, 14, 21, and 28 days was 4.45% (95% CI 2.55-7.71), 7.14% (95% CI 4.61-10.97), 7.53% (95% CI 4.92-11.43), and 9.55% (95% CI 6.55-13.81), respectively. Central venous catheter use (P = .002, odds ratio [OR] = 4.50), Caprini score (P = .012, OR = 1.20), and ICU length of stay (P = .006, OR = 1.08) were independent risk factors related to the incidence of VTE for patients admitted to the ICU.Our prospective observational study found that the 28-day cumulative incidence of VTE was relatively high for patients admitted to the ICU, despite the use of guideline-recommended thromboprophylaxis. Patients with femoral central venous catheter, prolonged ICU length of stay, or a high Caprini score may have an increased risk of developing VTE.

Prevalence and Predictors of Deep Vein Thrombosis in Critically Ill Medical Patients Who Underwent Diagnostic Duplex Ultrasonography

INTRODUCTION

Deep vein thrombosis (DVT) is a recognized but preventable cause of morbidity and mortality in the medical intensive care unit (MICU). We examined the prevalence and risk factors for DVT in MICU patients who underwent diagnostic venous duplex ultrasonography (DUS) and the potential effect on clinical outcomes.

METHODS

This is a retrospective study examining prevalence of DVT in 678 consecutive patients admitted to a tertiary care level academic MICU from July 2014 to 2015. Patients who underwent diagnostic DUS were included. Potential conditions of interest were mechanical ventilation, hemodialysis, sepsis, Sequential Organ Failure Assessment (SOFA) scores, central venous catheters, prior DVT, and malignancy. Primary outcomes were pulmonary embolism, ICU length of stay, and mortality. Additionally, means of thromboprophylaxis was compared between the groups. Multivariable logistic regression analysis was utilized to determine predictors of DVT occurrence.

RESULTS

Of the 678 patients, 243 (36%) patients underwent DUS to evaluate for DVT. The prevalence of DVT was 16% (38) among tested patients, and a prior history of DVT was associated with DVT prevalence (P < .01). Between cases and controls, there were no significant differences in central venous catheters, mechanical ventilation, hemodialysis, sepsis, SOFA scores, malignancy, and recent surgery. Patients receiving chemical prophylaxis had fewer DVTs compared to persons with no prophylaxis (14% vs 29%; P = .01) and persons with dual chemical and mechanical prophylaxis (P = 0.1). Fourteen percent of patients tested had documented DVT while on chemoprophylaxis. There were no significant differences in ICU length of stay (P = .35) or mortality (P = .34).

CONCLUSIONS

Despite the appropriate use of universal thromboprophylaxis, critically ill nonsurgical patients still demonstrated high rates of DVT. A history of DVT was the sole predictor for development of proximal DVT on DUS testing. Dual chemical and mechanical prophylaxis does not appear to be superior to single-chemical prophylaxis in DVT prevention in this population.

Thrombophilia testing in children: What and when should be tested?

Venous thrombosis (VTE) in children is gaining increased awareness and apart from underlying medical conditions, recently reported systematic reviews on pediatric VTE (70% provoked) have shown significant associations between thrombosis and presence of inherited thrombophilic risk factors (IT), such as protein C-, protein S- and antithrombin deficiency, mutations of factor 5 (F5: rs6025) and factor 2 (F2: rs1799963), even more pronounced when combined IT were involved. Although we have learned more about the pathophysiology of VTE with the increased discovery of IT evidence is still lacking as to whether IT influence the clinical outcome in pediatric VTE. It still remains controversial as to whether children with VTE or offspring from thrombosis-prone families benefit from IT screening. Thus, IT testing in children should be individualized. If the decision "pro screening" is discussed as an appropriate option in adolescents with unprovoked VTE and in children with a positive family history for VTE screening should be performed in a specialized coagulation unit for acquired or inherited and prothrombotic defects based on the individual population background. Apart from the laboratory assessment for the presence/absence of lupus anticoagulants and antiphospholipid antibodies screening should be performed beyond the acute VTE onset and after withdrawal of anticoagulant medication possibly influencing laboratory results.

Deep venous thrombosis in elderly patients as a surgical emergency at King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Background

Deep venous thrombosis (DVT) is a condition that occurs frequently among surgical, as well as acutely ill hospitalized medical patients, and is responsible for significant morbidity and mortality in hospitalized patients. Risk factors include older age, surgery and immobilization (as with bed rest, orthopedic casts, and sitting on long flights.

Objective

This study was conducted to identify the frequency and factors associated with occurrence of DVT among elderly patients referred to King Abdulaziz University (KAU) Hospital, Jeddah, Kingdom of Saudi Arabia.

Methods

The current study is a hospital based cross sectional study. The emergency, inpatients and outpatients' departments at KAU hospital were reviewed. We studied all the referred elderly subjects during the study period. All elderly patients (540) referred to or admitted to the hospital departments and who were clinically suspected to have DVT and subjected to Doppler examination were included in the study. Data were analyzed using descriptive statistics and Chi square test.

Results

Based on the results of Doppler examination, DVT was detected in 97 (18.0%) of the studied elderly population. There were no significant differences in gender between patients who developed DVT and those who were negative by Doppler examination (p=0.018). Other comorbidities as diabetes, IHD and hypertension were significantly associated with the occurrence of DVT among the participants (p=0.05, 0.05 and 0.04 respectively). Furthermore, the other investigated factors such as being bed ridden, cancer, orthopedic cast and previous DVT were not significantly associated with the development of DVT among the studied elderly patients (p=0.42, 0.16, 0.45 and 0.75 respectively).

Conclusion

DVT has high prevalence in Jeddah; KSA. Thrombophilia screening should be regular for elderly patients with diabetes, hypertension and bed-ridden patients with recurrent DVT or patients with other risk factors. Knowing the most common risk factors and their significance in developing DVT is essential for early detection of DVT to prevent unwanted complications for elderlies.

Risk factors for symptomatic venous and arterial thromboembolism in newborns, children and adolescents - What did we learn within the last 20years?

Venous thrombosis (VTE) in children is increasingly diagnosed, as advanced medical care has increased treatment intensity of hospitalized pediatric patients. The aim of this review was to summarize the data available and to discuss the controversial issue of thrombophilia screening in the light of the pediatric data available. Follow-up data for VTE recurrence in children suggest a recurrence rate between 3% (neonates) and 21% in individuals with unprovoked VTE. Apart from underlying medical conditions, recently reported systematic reviews on pediatric VTE (70% provoked) have shown significant associations between thrombosis and presence of protein C-, protein S- and antithrombin deficiency, factor 5 (F5: rs6025), factor 2 (F2: rs1799963), even more pronounced when combined inherited thrombophilias [IT] were involved. The F2 mutation, protein C-, protein S-, and antithrombin deficiency did also play a significant role at VTE recurrence. Although we have learned more about the pathophysiology of VTE with the increased discovery of IT evidence is still lacking as to whether IT influence the clinical outcome in pediatric VTE. It still remains controversial as to whether children with VTE or offspring from thrombosis-prone families benefit from IT screening. Thus, IT testing in children should be individualized.

Impact of high risk thrombophilia status on recurrence among children and adults with VTE: An observational multicenter cohort study

BACKGROUND

Antithrombin [AT]-, protein C [PC]- or protein S [PS]-deficiency [D] constitutes a major risk factor for venous thromboembolism [VTE]. Primary study objective was to evaluate if the clinical presentation at first VTE onset differs between children and adults and to compare the individual recurrence risk among patients with respect to age at onset and their thrombophilia status ATD, PCD or PSD.

METHODS/PATIENTS/RESULTS

In 137 of 688 consecutively enrolled pediatric and adult VTE patients we calculated the absolute risk of VTE recurrence and event-free-survival adjusted for thrombophilia and positive family VTE history. At first VTE children manifested i) with a lower rate of pulmonary embolism, ii) a higher rate of cerebral vascular events or multiple VTEs, and iii) showed a higher proportion of unprovoked VTE compared to adolescents and adults. Adult patients reported more often a positive VTE history compared to younger study participants. The adjusted odds of recurrence in adults was 2.05 compared to children.

CONCLUSION

At disease manifestation children and adults differ with respect to i) thrombotic locations, ii) percentage of unprovoked versus provoked VTE, and iii) different rates of positive VTE family histories. Furthermore, adults showed a two-fold increase risk of VTE recurrence compared to children.

H1N1-Induced Venous Thromboembolic Events? Results of a Single-Institution Case Series

We describe the clinical and imaging characteristics of 7 cases with polymerase chain reaction-confirmed novel influenza A H1N1 virus (pH1N1) infection who developed venous thromboembolic events (VTEs) while being hospitalized for influenza pneumonia. Pulmonary embolism (PE) without deep vein thrombosis (DVT) was observed in 6 of 7 cases (85.7%); PE with underlying DVT was found in 1 patient (14.3%).

Thrombotic events as incidental finding on computed tomography in intensive care unit patients

INTRODUCTION

Intensive care unit (ICU) patients are a risk group to develop thrombosis and/or thromboembolism. The purpose of this study was to analyze the frequency and localization of clinically silent thrombotic events (TE) detected on CT.

MATERIALS AND METHODS

From 2006 to 2013 a total of 370 patients from the ICU of our university clinic were investigated by postcontrast CT. In all cases CT was performed for detecting septic foci. There were 135 women and 235 men. CT scans included cervical, thoracic, abdominal, and pelvic regions. CT images of all patients were re-interpreted by 2 radiologists by consensus. Only thromboses detected for the first time on CT were included into the analysis. Collected data were evaluated by means of descriptive statistics. Frequencies and localizations of TE in surgical and non surgical patients were analyzed by Chi-square test. Significance level was p<0.05.

RESULTS

In 31.9% several TE were diagnosed. There were venous thrombosis (89.8%), cardiac thrombus (2.6%), and pulmonary embolism (7.6%). More often jugular veins were affected followed by brachiocephalic veins, and iliac veins. The frequency of TE in surgical patients was 31.1%, and 32.1% in non surgical patients. Patients after surgery had more often thrombosis of extremities veins in comparison to non surgical patients. In 61.9% of all TE the identified thrombotic complications were not diagnosed at the time of CT investigations.

CONCLUSION

TE can be identified in 31.9% of ICU patients as incidental finding on CT. There were venous thromboses, pulmonary embolism, and cardiac thrombus. Most frequently neck and thoracic veins were affected. 61.9% of all TE were not diagnosed at the time of CT investigations. Radiologists should check carefully CT scans for presence of different TE.