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Sahle BW, Pilcher D, Peter K, McFadyen JD, Litton E, Bucknall T. Mortality data from omission of early thromboprophylaxis in critically ill patients highlights the importance of an individualised diagnosis-related approach. Thromb J 2023; 21:59. [PMID: 37221578 DOI: 10.1186/s12959-023-00499-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/03/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) prophylaxis is effective in reducing VTE events, however, its impact on mortality is unclear. We examined the association between omission of VTE prophylaxis within the first 24 h after intensive care unit (ICU) admission and hospital mortality. METHODS Retrospective analysis of prospectively collected data from the Australian New Zealand Intensive Care Society Adult Patient Database. Data were obtained for adult admissions between 2009 and 2020. Mixed effects logistic regression models were used to evaluate the association between omission of early VTE prophylaxis and hospital mortality. RESULTS Of the 1,465,020 ICU admissions, 107,486 (7.3%) did not receive any form of VTE prophylaxis within the first 24 h after ICU admission without documented contraindication. Omission of early VTE prophylaxis was independently associated with 35% increased odds of in-hospital mortality (odds ratios (OR): 1.35; 95% CI: 1.31-1.41). The associations between omission of early VTE prophylaxis and mortality varied by admission diagnosis. In patients diagnosed with stroke (OR: 1.26, 95% CI: 1.05-1.52), cardiac arrest (OR: 1.85, 95% CI: 1.65-2.07) or intracerebral haemorrhage (OR: 1.48, 95% CI: 1.19-1.84), omission of VTE prophylaxis was associated with increased risk of mortality, but not in patients diagnosed with subarachnoid haemorrhage or head injury. CONCLUSIONS Omission of VTE prophylaxis within the first 24 h after ICU admission was independently associated with increased risk of mortality that varied by admission diagnosis. Consideration of early thromboprophylaxis may be required for patients with stroke, cardiac arrest and intracerebral haemorrhage but not in those with subarachnoid haemorrhage or head injury. The findings highlight the importance of individualised diagnosis-related thromboprophylaxis benefit-harm assessments.
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Affiliation(s)
- Berhe W Sahle
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Melbourne, VIC, Australia.
- Centre for Quality and Patient Safety Research, Alfred Health Partnership, Institute for Health Transformation, Melbourne, VIC, Australia.
| | - David Pilcher
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
| | - James D McFadyen
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Clinical Hematology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Edward Litton
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
- Fiona Stanley Hospital, Perth, WA, Australia
- The University of Western Australia, Perth, WA, Australia
| | - Tracey Bucknall
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Melbourne, VIC, Australia
- Centre for Quality and Patient Safety Research, Alfred Health Partnership, Institute for Health Transformation, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Ushio N, Wada T, Ono Y, Yamakawa K. Sepsis-induced disseminated intravascular coagulation: an international estrangement of disease concept. Acute Med Surg 2023; 10:e00843. [PMID: 37153869 PMCID: PMC10157372 DOI: 10.1002/ams2.843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 04/05/2023] [Indexed: 05/10/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by widespread intravascular activation of coagulation, which can be caused by infectious and noninfectious insults, such as trauma, postcardiac arrest syndrome, and malignant diseases. At present, diagnosis and treatment of DIC clearly differ between Japan and Western countries; in Japan, DIC has long been considered a therapeutic target, and much evidence on DIC has been published. However, there has recently been no international consensus on whether DIC should be a therapeutic target with anticoagulant therapy. This review describes the coagulofibrinolytic system abnormalities associated with sepsis and discusses related management strategies. It also explores the reasons why DIC is perceived differently in different regions. There is a major discrepancy between diagnostic and treatment options in Japan, which are based on holistic assessments of trials, as well as the results of post hoc subgroup analyses and observational studies, and those in Western countries, which are based mainly on the results of sepsis mega trials, especially randomized controlled trials. The differences might also be due to various patient factors in each region, especially racial characteristics in thrombolytic mechanisms, and differences in interpretation of evidence for candidate drugs. Hence, Japanese researchers need to distribute their high-quality clinical research data not only to Japan but also to the rest of the world.
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Affiliation(s)
- Noritaka Ushio
- Department of Emergency and Critical Care MedicineOsaka Medical and Pharmaceutical UniversityTakatsukiJapan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care MedicineHokkaido University Faculty of MedicineSapporoJapan
| | - Yuichiro Ono
- Kakogawa Acute Care Medical CenterHyogo Prefectural Kakogawa Medical CenterKakogawaJapan
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care MedicineOsaka Medical and Pharmaceutical UniversityTakatsukiJapan
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McMahon MAJMJ, Holley COLAB. To Generalize or Not to Generalize? Chest 2022; 161:305-306. [DOI: 10.1016/j.chest.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 10/19/2022] Open
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Fernando SM, Tran A, Cheng W, Sadeghirad B, Arabi YM, Cook DJ, Møller MH, Mehta S, Fowler RA, Burns KEA, Wells PS, Carrier M, Crowther MA, Scales DC, English SW, Kyeremanteng K, Kanji S, Kho ME, Rochwerg B. Venous Thromboembolism Prophylaxis in Critically Ill Adults: A Systematic Review and Network Meta-analysis. Chest 2021; 161:418-428. [PMID: 34419428 DOI: 10.1016/j.chest.2021.08.050] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Critically ill adults are at increased risk of VTE, including DVT, and pulmonary embolism. Various agents exist for venous thromboprophylaxis in this population. RESEARCH QUESTION What is the comparative efficacy and safety of prophylaxis agents for prevention of VTE in critically ill adults? STUDY DESIGN AND METHODS Systematic review and network meta-analysis of randomized clinical trials (RCTs) evaluating efficacy of thromboprophylaxis agents among critically ill patients. We searched six databases (including PubMed, EMBASE, and Medline) from inception through January 2021 for RCTs of patients in the ICU receiving pharmacologic, mechanical, or combination therapy (pharmacologic agents and mechanical devices) for thromboprophylaxis. Two reviewers performed screening, full-text review, and extraction. We used the Grading of Recommendations Assessment, Development, and Evaluation to rate certainty of effect estimates. RESULTS We included 13 RCTs (9,619 patients). Compared with control treatment (a composite of no prophylaxis, placebo, or compression stockings only), low-molecular-weight heparin (LMWH) reduced the incidence of DVT (OR, 0.59 [95% credible interval [CrI], 0.33-0.90]; high certainty) and unfractionated heparin (UFH) may reduce the incidence of DVT (OR, 0.82 [95% CrI, 0.47-1.37]; low certainty). LMWH probably reduces DVT compared with UFH (OR, 0.72 [95% CrI, 0.46-0.98]; moderate certainty). Compressive devices may reduce risk of DVT compared with control treatments; however, this is based on low-certainty evidence (OR, 0.85 [95% CrI, 0.50-1.50]). Combination therapy showed unclear effect on DVT compared with either therapy alone (very low certainty). INTERPRETATION Among critically ill adults, compared with control treatment, LMWH reduces incidence of DVT, whereas UFH and mechanical compressive devices may reduce the risk of DVT. LMWH is probably more effective than UFH in reducing incidence of DVT and should be considered the primary pharmacologic agent for thromboprophylaxis. The efficacy and safety of combination pharmacologic therapy and mechanical compressive devices were unclear. TRIAL REGISTRY Open Science Framework; URL: https://osf.io/694aj.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Alexandre Tran
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Wei Cheng
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Yaseen M Arabi
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Deborah J Cook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Righospitalet, Copenhagen, Denmark
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Karen E A Burns
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Philip S Wells
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marc Carrier
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mark A Crowther
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Shane W English
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Salmaan Kanji
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Michelle E Kho
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Schizodimos T, Soulountsi V, Iasonidou C, Kapravelos N. Thromboprophylaxis in critically ill patients: balancing on a tightrope. Minerva Anestesiol 2021; 87:1239-1254. [PMID: 34337918 DOI: 10.23736/s0375-9393.21.15755-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is a common and potentially fatal complication in the intensive care unit (ICU). Critically ill patients have some special characteristics that increase the risk for VTE and complicate risk stratification and diagnosis. Given the positive effect of thromboprophylaxis on main outcomes, its use is mandatory in these patients, which is documented by various studies and recommended by all published guidelines. However, anticoagulation management is not an easy issue in clinical practice, as the critical patient may be at high risk for thrombosis or, conversely, at increased risk of bleeding or may balance between thrombotic and bleeding risk. Thrombotic and bleeding risk scoring should be evaluated daily in order to select the appropriate form of thromboprophylaxis. The selection depends on the degree of bleeding risk and the subgroup of ICU patients involved, such as patients with sepsis, acute brain injury, major trauma or coronavirus disease-2019. If there is no bleeding risk or other contraindication, the patient should receive pharmacologic thromboprophylaxis with unfractionated heparin or low molecular weight heparins, weighing the advantages of each agent. If the patient is at high risk of bleeding or there is a contraindication to pharmacologic prophylaxis, he should receive mechanical thromboprophylaxis mainly with intermittent pneumatic compression or graduated compression stockings. Thromboprophylaxis compliance with the guidelines is a prerequisite for moving from theory to practice. Direct oral anticoagulants have been studied in ICU patients and have no place at present in VTE prophylaxis requiring further research.
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Affiliation(s)
- Theodoros Schizodimos
- Second Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece -
| | - Vasiliki Soulountsi
- First Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece
| | - Christina Iasonidou
- Second Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece
| | - Nikos Kapravelos
- Second Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece
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What Do We Know about Thromboprophylaxis and Its Monitoring in Critically Ill Patients? Biomedicines 2021; 9:biomedicines9080864. [PMID: 34440068 PMCID: PMC8389559 DOI: 10.3390/biomedicines9080864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 01/19/2023] Open
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is an important complication in patients hospitalized in intensive care units (ICU). Thromboprophylaxis is mainly performed with Low Molecular Weight Heparin (LMWH) and, in some specific patients, with Unfractionated Heparin (UFH). These intensive units are an environment where individual patient variability is extreme and where traditional antithrombotic protocols are frequently ineffective. This was known for a long time, but the hospitalization of many patients with COVID-19 inflammatory storms suddenly highlighted this knowledge. It is therefore reasonable to propose variable antithrombotic prevention protocols based initially on a series of individual criteria (weight, BMI, and thrombotic risks). Secondly, they should be adjusted by the monitoring of anticoagulant activity, preferably by measuring the anti-Xa activity. However, we still face unresolved questions, such as once- or twice-daily LMWH injections, monitoring at the peak and/or trough, and poorly defined therapeutic targets. Equally surprisingly, we observed a lack of standardization of the anti-Xa activity kits.
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Eck RJ, Hulshof L, Wiersema R, Thio CHL, Hiemstra B, van den Oever NCG, Gans ROB, van der Horst ICC, Meijer K, Keus F. Incidence, prognostic factors, and outcomes of venous thromboembolism in critically ill patients: data from two prospective cohort studies. Crit Care 2021; 25:27. [PMID: 33436012 PMCID: PMC7801861 DOI: 10.1186/s13054-021-03457-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/01/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The objective of this study was to describe the prevalence, incidence, prognostic factors, and outcomes of venous thromboembolism in critically ill patients receiving contemporary thrombosis prophylaxis. METHODS We conducted a pooled analysis of two prospective cohort studies. The outcomes of interest were in-hospital pulmonary embolism or lower extremity deep vein thrombosis (PE-LDVT), in-hospital nonleg deep vein thrombosis (NLDVT), and 90-day mortality. Multivariable logistic regression analysis was used to evaluate the association between predefined baseline prognostic factors and PE-LDVT or NLDVT. Cox regression analysis was used to evaluate the association between PE-LDVT or NLDVT and 90-day mortality. RESULTS A total of 2208 patients were included. The prevalence of any venous thromboembolism during 3 months before ICU admission was 3.6% (95% CI 2.8-4.4%). Out of 2166 patients, 47 (2.2%; 95% CI 1.6-2.9%) developed PE-LDVT and 38 patients (1.8%; 95% CI 1.2-2.4%) developed NLDVT. Renal replacement therapy (OR 3.5 95% CI 1.4-8.6), respiratory failure (OR 2.0; 95% CI 1.1-3.8), and previous VTE (OR 3.6; 95% CI 1.7-7.7) were associated with PE-LDVT. Central venous catheters (OR 5.4; 95% CI 1.7-17.8) and infection (OR 2.2; 95% CI 1.1-4.3) were associated with NLDVT. Occurrence of PE-LDVT but not NLDVT was associated with increased 90-day mortality (HR 2.7; 95% CI 1.6-4.6, respectively, 0.92; 95% CI 0.41-2.1). CONCLUSION Thrombotic events are common in critically ill patients, both before and after ICU admittance. Development of PE-LDVT but not NLDVT was associated with increased mortality. Prognostic factors for developing PE-LDVT or NLDVT despite prophylaxis can be identified at ICU admission and may be used to select patients at higher risk in future randomized clinical trials. TRIAL REGISTRATION NCT03773939.
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Affiliation(s)
- Ruben J Eck
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Lisa Hulshof
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Critical Care, Treant Zorggroep Emmen, Emmen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Chris H L Thio
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Reinold O B Gans
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Lauzier F, Douketis JD, Cook DJ. A Device on Trial - Intermittent Pneumatic Compression in Critical Care. N Engl J Med 2019; 380:1367-1368. [PMID: 30943342 DOI: 10.1056/nejme1902334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- François Lauzier
- From the Population Health and Optimal Health Practices Research Unit, Centre de Recherche du Centre Hospitalier Universitaire de Québec-Université Laval, and the Departments of Medicine and Anesthesiology and Critical Care Medicine, Université Laval, Quebec, QC (F.L.), and the Departments of Medicine (J.D.D., D.J.C.) and Health Research Methods, Evidence, and Impact (D.J.C.), McMaster University, and the Department of Medicine (J.D.D., D.J.C.) and the Division of Critical Care (D.J.C.), St. Joseph's Healthcare, Hamilton, ON - all in Canada
| | - James D Douketis
- From the Population Health and Optimal Health Practices Research Unit, Centre de Recherche du Centre Hospitalier Universitaire de Québec-Université Laval, and the Departments of Medicine and Anesthesiology and Critical Care Medicine, Université Laval, Quebec, QC (F.L.), and the Departments of Medicine (J.D.D., D.J.C.) and Health Research Methods, Evidence, and Impact (D.J.C.), McMaster University, and the Department of Medicine (J.D.D., D.J.C.) and the Division of Critical Care (D.J.C.), St. Joseph's Healthcare, Hamilton, ON - all in Canada
| | - Deborah J Cook
- From the Population Health and Optimal Health Practices Research Unit, Centre de Recherche du Centre Hospitalier Universitaire de Québec-Université Laval, and the Departments of Medicine and Anesthesiology and Critical Care Medicine, Université Laval, Quebec, QC (F.L.), and the Departments of Medicine (J.D.D., D.J.C.) and Health Research Methods, Evidence, and Impact (D.J.C.), McMaster University, and the Department of Medicine (J.D.D., D.J.C.) and the Division of Critical Care (D.J.C.), St. Joseph's Healthcare, Hamilton, ON - all in Canada
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Sauro K, Bagshaw SM, Niven D, Soo A, Brundin-Mather R, Parsons Leigh J, Cook DJ, Stelfox HT. Barriers and facilitators to adopting high value practices and de-adopting low value practices in Canadian intensive care units: a multimethod study. BMJ Open 2019; 9:e024159. [PMID: 30878979 PMCID: PMC6429967 DOI: 10.1136/bmjopen-2018-024159] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To compare and contrast illustrative examples of the adoption of high value practices and the de-adoption of low value practices. DESIGN (1) Retrospective, population-based audit of low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis (high value practice) and albumin for fluid resuscitation (low value practice) and (2) cross-sectional survey of healthcare providers. SETTING Data were collected from nine adult medical-surgical intensive care units (ICUs) in two large Canadian cities. Patients are managed in these ICUs by a group of multiprofessional and multidisciplinary healthcare providers. PARTICIPANTS Participants included 6946 ICU admissions and 309 healthcare providers from the same ICUs. MAIN OUTCOME MEASURES (1) The use of LMWH for VTE prophylaxis (per cent ICU days) and albumin for fluid resuscitation (per cent of patients); and (2) provider knowledge of evidence underpinning these practices, and barriers and facilitators to adopt and de-adopt these practices. RESULTS LMWH was administered on 38.7% of ICU days, and 20.0% of patients received albumin.Most participants had knowledge of evidence underpinning VTE prophylaxis and fluid resuscitation (59.1% and 84.2%, respectively). Providers perceived these practices to be followed. The most commonly reported barrier to adoption was insufficient knowledge/understanding (32.8%), and to de-adoption was clinical leader preferences (33.2%). On-site education was the most commonly identified facilitator for adoption and de-adoption (67.8% and 68.6%, respectively). CONCLUSIONS Despite knowledge of and self-reported adherence to best practices, the audit demonstrated opportunity to improve. Provider-reported barriers and facilitators to adoption and de-adoption are broadly similar.
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Affiliation(s)
- Khara Sauro
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Jeanna Parsons Leigh
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
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A multicentre controlled pre-post trial of an implementation science intervention to improve venous thromboembolism prophylaxis in critically ill patients. Intensive Care Med 2019; 45:211-222. [PMID: 30707246 DOI: 10.1007/s00134-019-05532-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/14/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE To test whether a multicomponent intervention would increase the use of low molecular weight heparin (LMWH) over unfractionated heparin (UFH) for venous thromboembolism (VTE) prophylaxis in critically ill patients and change patient outcomes and healthcare utilization. METHODS Controlled pre-post trial of 12,342 adults admitted to 11 ICUs (five intervention, six control) May 1, 2015 to April 30, 2017 with no contraindication to pharmacological prophylaxis and an ICU stay longer than 24 h. Models were developed to examine temporal changes in ICU VTE prophylaxis (primary outcome), VTE, major bleeding, heparin-induced thrombocytopenia (HIT), death and hospital costs. RESULTS The use of LMWH increased from 45.9% to 78.3% of patient days in the intervention group and from 37.9% to 53.3% in the control group, an absolute increase difference of 17.0% (32.4% vs. 15.4%, p = 0.001). Changes in the administration of UFH were inversely related to those of LMWH. There were no significant differences in the adjusted odds of VTE (ratio of odds ratios [rOR] 1.13, 95% CI 0.51-2.46) or major bleeding (rOR 1.22, 95% CI 0.97-1.54) post-implementation of the intervention (compared to pre-implementation) between the intervention group and the control group. HIT was uncommon in both groups (n = 20 patients). There were no significant changes for ICU and hospital mortality, length of stay and costs. Results were similar when stratified according to reason for ICU admission, patient weight and kidney function. CONCLUSIONS A multicomponent intervention changed practice, but not clinical and economic outcomes. The benefit of implementing LMWH for VTE prophylaxis under real-world conditions is uncertain.
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11
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Ramakrishnan N, Detect-Dvt Investigators. Prophylaxis and Incidence of Symptomatic Deep Vein Thrombosis in Indian Patients with Sepsis: DETECT-Deep Vein Thrombosis Registry. Indian J Crit Care Med 2017; 21:765-771. [PMID: 29279638 PMCID: PMC5699005 DOI: 10.4103/ijccm.ijccm_205_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To assess thromboprophylaxis rate and incidence of symptomatic deep vein thrombosis (DVT) in Indian patients with acute sepsis. MATERIALS AND METHODS Adult patients with sepsis, within 48 h of sepsis onset/hospital admission were included. DVT was assessed using Doppler ultrasonography if clinical signs were present. Data were collected at inclusion, discharge, and 30 ± 7 days (if discharged before 30 days). RESULTS The study included 278 patients (men: 69.4%; mean age: 56.3 ± 17.99 years). Out of 275 patients (data missing for 3 patients), 188 (68.4%; 95% confidence interval: 62.5-73.8) received DVT prophylaxis (185 at admission and 3 at discharge; pharmacological prophylaxis: n = 88, mechanical prophylaxis: n = 65, pharmacological + mechanical prophylaxis: n = 35) and 87 received no prophylaxis. In line with American College of Chest Physicians 2008 recommendations, among patients who received pharmacological prophylaxis (n = 123), low-molecular-weight heparin was given to 85.4% (n = 105) patients (duration: 9.1 ± 6.36 days), unfractionated heparin to 12.2% (n = 15) patients (duration: 9.2 ± 9.18 days), and fondaparinux to 5.7% (n = 7) patients (duration: 6.8 ± 3.30 days); 27/63 patients at high-risk of bleeding received mechanical prophylaxis; no patient received aspirin. Of 9 patients who developed DVT, 7 received no thromboprophylaxis (data missing for 2 patients). In total, 186/274 (67.9%) patients recovered from sepsis. CONCLUSIONS Two-third patients received thromboprophylaxis. The substantial role of thromboprophylaxis in DVT prevention mandates monitoring and control of thromboprophylaxis through internal audits in hospitals.
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Clinical audits to improve critical care: Part 1 Prepare and collect data. Aust Crit Care 2017; 31:101-105. [PMID: 28550968 DOI: 10.1016/j.aucc.2017.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 03/21/2017] [Accepted: 04/28/2017] [Indexed: 12/27/2022] Open
Abstract
Clinical audits are used to examine current practice, compare this with established best practice and implementing change, to ensure patients receive the most effective treatment. They are successful in improving the quality and safety of care provided, and thereby clinical outcomes. Clinical audits are ubiquitous throughout critical care practice, but without the necessary focus, engagement, preparation, method, evaluation and communication, they may be a waste of resources. This article is the first of a two-paper series regarding audits in critical care. The article provides an overview of the structures and processes needed to prepare and collect data for clinical audits, to make them as effective as possible to improve patient outcomes. This is accomplished through a practical step-by-step guide, including links to valuable resources, which are relevant to all critical care clinicians planning on undertaking clinical audits.
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Northup A, Wilcox S. Thromboprophylaxis Failure in the Adult Medical Inpatient. Am J Med Sci 2017; 354:107-116. [PMID: 28864367 DOI: 10.1016/j.amjms.2017.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/01/2017] [Accepted: 03/03/2017] [Indexed: 01/12/2023]
Abstract
Venous thromboembolism (VTE), a leading cause of morbidity and mortality among hospitalized patients, is often due to prophylaxis failure rather than omission, but few studies have identified the risk factors for failure. Risk factors for thromboprophylaxis failure include personal or family history of VTE, use of vasopressors or inotropes, increased body mass index, cranial surgery, intensive care patient, leukocytosis, indwelling central venous catheter and admission from a long-term care facility. Identifying patients at risk for thromboprophylaxis failure should prompt close observation during hospitalization for signs of VTE, close observation after discharge and potentially more aggressive prophylaxis strategies, although no specific guidelines exist for medical patients at this time.
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Affiliation(s)
- Amanda Northup
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina.
| | - Susan Wilcox
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina; Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina; Division of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
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14
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García-Olivares P, Guerrero JE, Keough E, Galdos P, Carriedo D, Murillo F, Rivera A. Clinical factors associated with inappropriate prophylaxis of venous thromboembolic disease in critically ill patients. A single day cross-sectional study. Thromb Res 2016; 143:111-7. [PMID: 27233040 DOI: 10.1016/j.thromres.2016.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/27/2016] [Accepted: 05/10/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE A poor implementation of VTE prophylactic measures recommended for critically ill patients has been observed in several epidemiological studies. The clinical factors associated with this have not been clearly established. The objective of our study was to identify which factors could be related to the inappropriate use of VTE prophylaxis. METHODS Analytic epidemiological study based on different aspects of VTE prophylaxis performed on Spanish ICU patients. A multiple logistic regression analysis was conducted to identify the risk factors associated with inappropriate prophylaxis, according to the American College of Chest Physicians 2012 guidelines. RESULTS We enrolled 777 patients. On admission, 62% presented medical, 30% surgical and 8% major trauma pathology. Of all patients, 41% were receiving an inappropriate prophylaxis, including 19% which did not receive any prophylaxis. The presence of a contraindication for pharmacological prophylaxis (OR 3.91, 95% CI 2.50-6.10) and non-medical pathology at ICU admission (OR 11.09; 95% CI 7.63-16.12) were associated with inappropriate prophylaxis. In contrast, mechanical ventilation (OR 0.70, 95% CI 0.45-0.98), bed rest>48h (OR 0.61, 95% CI 0.49-0.98), the use of a protocol for VTE prophylaxis (OR 0.66, 95% CI 0.45-0.98) and a VTE risk scoring system (OR 0.49, 95% CI 0.24-0.98) were associated with adequate prophylaxis. CONCLUSIONS Our study highlighted a poor compliance with the VTE prophylaxis recommendations proposed for critical patients. The implementation of specific protocols for prophylaxis that include a correct evaluation according to VTE and haemorrhage risk, would allow for optimisation of mechanical and combined prophylaxis, improving adherence to the clinical practice guidelines.
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Affiliation(s)
| | | | - Elena Keough
- Intensive Care Unit, Gregorio Marañón Universitary Hospital, Madrid, Spain
| | - Pedro Galdos
- Intensive Care Unit, Puerta de Hierro Universitary Hospital, Madrid, Spain
| | | | - Francisco Murillo
- Intensive Care Unit, Virgen del Rocio Universitary Hospital, Sevilla, Spain
| | - Antonio Rivera
- Intensive Care Unit, San Agustin Hospital, Asturias, Spain
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Vahtera A, Vaara S, Pettilä V, Kuitunen A. Plasma anti-FXa level as a surrogate marker of the adequacy of thromboprophylaxis in critically ill patients: A systematic review. Thromb Res 2016; 139:10-6. [DOI: 10.1016/j.thromres.2015.12.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/14/2015] [Accepted: 12/22/2015] [Indexed: 11/30/2022]
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Stelfox HT, Niven DJ, Clement FM, Bagshaw SM, Cook DJ, McKenzie E, Potestio ML, Doig CJ, O'Neill B, Zygun D. Stakeholder Engagement to Identify Priorities for Improving the Quality and Value of Critical Care. PLoS One 2015; 10:e0140141. [PMID: 26492196 PMCID: PMC4619641 DOI: 10.1371/journal.pone.0140141] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/21/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Large amounts of scientific evidence are generated, but not implemented into patient care (the 'knowledge-to-care' gap). We identified and prioritized knowledge-to-care gaps in critical care as opportunities to improve the quality and value of healthcare. METHODS We used a multi-method community-based participatory research approach to engage a Network of all adult (n = 14) and pediatric (n = 2) medical-surgical intensive care units (ICUs) in a fully integrated geographically defined healthcare system serving 4 million residents. Participants included Network oversight committee members (n = 38) and frontline providers (n = 1,790). Network committee members used a modified RAND/University of California Appropriateness Methodology, to serially propose, rate (validated 9 point scale) and revise potential knowledge-to-care gaps as priorities for improvement. The priorities were sent to frontline providers for evaluation. Results were relayed back to all frontline providers for feedback. RESULTS Initially, 68 knowledge-to-care gaps were proposed, rated and revised by the committee (n = 32 participants) over 3 rounds of review and resulted in 13 proposed priorities for improvement. Then, 1,103 providers (62% response rate) evaluated the priorities, and rated 9 as 'necessary' (median score 7-9). Several factors were associated with rating priorities as necessary in multivariable logistic regression, related to the provider (experience, teaching status of ICU) and topic (strength of supporting evidence, potential to benefit the patient, potential to improve patient/family experience, potential to decrease costs). CONCLUSIONS A community-based participatory research approach engaged a diverse group of stakeholders to identify 9 priorities for improving the quality and value of critical care. The approach was time and cost efficient and could serve as a model to prioritize areas for research quality improvement across other settings.
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Affiliation(s)
- Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Alberta, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Alberta, Canada
| | - Fiona M Clement
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- Alberta Health Services, Alberta, Canada; Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Deborah J Cook
- Departments of Medicine, Critical Care, and Clinical Epidemiology and Biostatistics, McMaster University, and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Emily McKenzie
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Melissa L Potestio
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Alberta, Canada
| | - Christopher J Doig
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Alberta, Canada
| | | | - David Zygun
- Alberta Health Services, Alberta, Canada; Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Tang X, Sun B, Yang Y, Tong Z. A Survey of the Knowledge of Venous Thromboembolism Prophylaxis among the Medical Staff of Intensive Care Units in North China. PLoS One 2015; 10:e0139162. [PMID: 26418162 PMCID: PMC4856213 DOI: 10.1371/journal.pone.0139162] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 09/08/2015] [Indexed: 11/30/2022] Open
Abstract
Background Guideline concordance for venous thromboembolism (VTE) prophylaxis in critically ill patients in intensive care units (ICUs) varies across different countries. Objective To explore how the medical staff of ICUs in China comprehend and practice VTE prophylaxis. Method Questionnaires comprising 39 questions and including 4 dimensions of thromboprophylaxis were administered in ICUs in North China. Results In all, 52 ICUs at 23 tertiary hospitals in 7 Chinese provinces and municipalities were surveyed. A total of 2500 questionnaires were sent, and 1861 were returned, corresponding to a response rate of approximately 74.4%. Of all surveyed medical staff, 36.5% of physicians and 22.2% of nurses were aware of the guidelines in China, and 19.0% of physicians and 9.5% of nurses comprehended the 9th edition of the guidelines of the American College of Chest Physicians (ACCP). Additionally, 37.6% of the medical staff chose a prophylaxis method based on the related guidelines, and 10.3% could demonstrate the exact indication for mechanical pattern application. Worries about skin injury, difficulty with removal and discomfort during mechanical thromboprophylaxis were cited by more than 30% of nurses, which was significantly more frequent than for physicians (graduated compression stockings: 54.3% VS 34.1%, 60.7% VS 49%, and 59.4% VS 54%, p = 0.000; intermittent pneumatic compression: 31% VS 22.2%, 19.2% VS 13.9%, and 37.8% VS 27.2%, p = 0.000). Conclusions and Relevance The knowledge of VTE prophylaxis among the medical staff of ICUs in North China remains limited, which may lead to a lack of standardization of VTE prophylaxis. Strengthened, standardized training may help medical staff to improve their comprehension of the relevant guidelines and may finally reduce the occurrence of VTE in ICUs and improve the prognosis of critically ill patients with VTE.
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Affiliation(s)
- Xiao Tang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Respiratory Medicine, Beijing, China
| | - Bing Sun
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Respiratory Medicine, Beijing, China
- * E-mail:
| | - Yuanhua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Respiratory Medicine, Beijing, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Respiratory Medicine, Beijing, China
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Minet C, Potton L, Bonadona A, Hamidfar-Roy R, Somohano CA, Lugosi M, Cartier JC, Ferretti G, Schwebel C, Timsit JF. Venous thromboembolism in the ICU: main characteristics, diagnosis and thromboprophylaxis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:287. [PMID: 26283414 PMCID: PMC4539929 DOI: 10.1186/s13054-015-1003-9] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep venous thrombosis (DVT), is a common and severe complication of critical illness. Although well documented in the general population, the prevalence of PE is less known in the ICU, where it is more difficult to diagnose and to treat. Critically ill patients are at high risk of VTE because they combine both general risk factors together with specific ICU risk factors of VTE, like sedation, immobilization, vasopressors or central venous catheter. Compression ultrasonography and computed tomography (CT) scan are the primary tools to diagnose DVT and PE, respectively, in the ICU. CT scan, as well as transesophageal echography, are good for evaluating the severity of PE. Thromboprophylaxis is needed in all ICU patients, mainly with low molecular weight heparin, such as fragmine, which can be used even in cases of non-severe renal failure. Mechanical thromboprophylaxis has to be used if anticoagulation is not possible. Nevertheless, VTE can occur despite well-conducted thromboprophylaxis.
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Affiliation(s)
- Clémence Minet
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France.
| | - Leila Potton
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Agnès Bonadona
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Rébecca Hamidfar-Roy
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Claire Ara Somohano
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Maxime Lugosi
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Jean-Charles Cartier
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Gilbert Ferretti
- Department of Radiology, UJF-Grenoble I, University Hospital Albert Michallon, Grenoble, F-38041, France.,UJF-Grenoble I, University Hospital Albert Michallon, U823 Institut Albert Bonniot, Team 11: Outcome of mechanically ventilated patients and airway cancers, Grenoble, F-38041, France
| | - Carole Schwebel
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Jean-François Timsit
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France.,UJF-Grenoble I, University Hospital Albert Michallon, U823 Institut Albert Bonniot, Team 11: Outcome of mechanically ventilated patients and airway cancers, Grenoble, F-38041, France
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