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Krishnamoorthy A, Hansdak SG, Peter JV, Pichamuthu K, Rajan SJ, Sudarsan TI, Gibikote S, Jeyaseelan L, Sudarsanam TD. Incidence and Risk Factors for Deep Venous Thrombosis and Its Impact on Outcome in Patients Admitted to Medical Critical Care. Indian J Crit Care Med 2024; 28:607-613. [PMID: 39130389 PMCID: PMC11310670 DOI: 10.5005/jp-journals-10071-24723] [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: 02/13/2024] [Accepted: 04/23/2024] [Indexed: 08/13/2024] Open
Abstract
Objectives This study evaluated the incidence and risk factors for deep venous thrombosis (DVT) while on thromboprophylaxis, in patients admitted to the medical intensive care unit (MICU), and to assess its impact on outcomes. Methods Consecutive patients admitted to the MICU underwent compression ultrasound of the jugular, axillary, femoral, and popliteal veins at admission, day 3 and 7 to screen for DVT. All patients were on pharmacological and/or mechanical thromboprophylaxis as per protocol. The primary outcome was the incidence of DVT (defined as occurrence on day 3 or 7). Secondary outcomes were death and duration of hospitalization. Risk factors for DVT were explored using bivariate and multivariable logistic regression analysis and expressed as risk ratio (RR) with 95% confidence intervals (CIs). Results The incidence of DVT was 17.2% (95% CI 12.0, 22.3) (n = 35/203); two-thirds were catheter associated (23/35). There was no difference in mortality between those with and without incident DVT (9/35 vs 40/168, p = 0.81). The mean (SD) duration of hospitalization was longer in the DVT group (20.1 (17) vs 12.9 (8.5) days, p = 0.007). Although day 3 INR (RR 2.1, 95% CI 0.9-5.3), age >40 years (2.1, 0.8-5.3), vasopressor use (1.0, 0.4-2.9) and SOFA score (0.9, 0.85-1.1) were associated with the development of DVT on bivariate analysis, only central venous catheters (15.97, 1.9-135.8) was independently associated with DVT on multivariable analysis. Conclusions Despite thromboprophylaxis, 17% of ICU patients develop DVT. The central venous catheter is the main risk factor. DVT is not associated with increased mortality in the setting of prophylaxis. How to cite this article Krishnamoorthy A, Hansdak SG, Peter JV, Pichamuthu K, Rajan SJ, Sudarsan TI, et al. Incidence and Risk Factors for Deep Venous Thrombosis and Its Impact on Outcome in Patients Admitted to Medical Critical Care. Indian J Crit Care Med 2024;28(6):607-613.
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Affiliation(s)
| | - Samuel G Hansdak
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - John V Peter
- Department of Critical Care, Christian Medical College, Vellore, Tamil Nadu, India
| | - Kishore Pichamuthu
- Department of Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sudha J Rajan
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Thomas I Sudarsan
- Department of Critical Care, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sridhar Gibikote
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Lakshmanan Jeyaseelan
- Department of Biostatistics, Mohammed Bin Rashid University of Medicine and Health Sciences College of Medicine, Dubai, United Arab Emirates
| | - Thambu D Sudarsanam
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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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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Arabi YM, Burns KEA, Alsolamy SJ, Alshahrani MS, Al-Hameed FM, Arshad Z, Almaani M, Hawa H, Mandourah Y, Almekhlafi GA, Al Aithan A, Khalid I, Rifai J, Rasool G, Abdukahil SAI, Jose J, Afesh LY, Al-Dawood A. Surveillance or no surveillance ultrasonography for deep vein thrombosis and outcomes of critically ill patients: a pre-planned sub-study of the PREVENT trial. Intensive Care Med 2020; 46:737-746. [PMID: 32095845 DOI: 10.1007/s00134-019-05899-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/11/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE We examined the association between surveillance for deep vein thrombosis (DVT) among medical-surgical critically ill patients by twice-weekly ultrasonography and 90-day all-cause mortality. METHODS This was a pre-planned sub-study of the Pneumatic Compression for Preventing Venous Thromboembolism (PREVENT) trial (Clinicaltrials.gov: NCT02040103) that compared addition of intermittent pneumatic compression (IPC) to pharmacologic prophylaxis versus pharmacologic prophylaxis alone. The surveillance group included enrolled patients in the trial, while the non-surveillance group included eligible non-enrolled patients. Using logistic regression and Cox proportional hazards models, we examined the association of surveillance with the primary outcome of 90-day mortality. Secondary outcomes were DVT and pulmonary embolism (PE). RESULTS The surveillance group consisted of 1682 patients and the non-surveillance group included 383 patients. Using Cox proportional hazards model with bootstrapping, surveillance was associated with a decrease in 90-day mortality (adjusted HR 0.75; 95% CI 0.57, 0.98). Surveillance was associated with earlier diagnosis of DVT [(median 4 days (IQR 2, 10) vs. 20 days (IQR 16, 22)] and PE [median 4 days (IQR 2.5, 5) vs. 7.5 days (IQR 6.1, 28.9)]. There was an increase in diagnosis of DVT (adjusted HR 5.49; 95% CI 2.92, 13.02) with no change in frequency in diagnosis of PE (adjusted HR 0.56; 95% CI 0.19, 1.91). CONCLUSIONS Twice-weekly surveillance ultrasonography was associated with an increase in DVT detection, reduction in diagnostic testing for non-lower limb DVT and PE, earlier diagnosis of DVT and PE, and lower 90-day mortality. TRIAL REGISTRATION The PREVENT trial is registered at ClinicalTrials.gov, ID: NCT02040103. Registered on 3 November 2013; Current controlled trials, ID: ISRCTN44653506. Registered on 30 October 2013.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia. .,King Abdullah International Medical Research Center, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia. .,King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, Unity Health Toronto-St Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Sami J Alsolamy
- Intensive Care Department, Ministry of National Guard Health Affairs, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia
| | - Mohammed S Alshahrani
- Department of Emergency and Critical Care Medicine, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Fahad M Al-Hameed
- Intensive Care Department, Ministry of National Guard Health Affairs, Jeddah, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Zia Arshad
- Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, India
| | - Mohammed Almaani
- Department of Pulmonary and Critical Care Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Hassan Hawa
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Yasser Mandourah
- Military Medical Services, Ministry of Defense, Riyadh, Kingdom of Saudi Arabia
| | - Ghaleb A Almekhlafi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Abdulsalam Al Aithan
- Intensive Care Division, Department of Medicine, King Abdulaziz Hospital, Al Ahsa, Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Al Ahsa, Saudi Arabia.,King Abdullah International Medical Research Center, Al Ahsa, Kingdom of Saudi Arabia
| | - Imran Khalid
- Critical Care Section, Department of Medicine, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
| | - Jalal Rifai
- Intensive Care Department, Ministry of National Guard Health Affairs, Jeddah, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Gulam Rasool
- Intensive Care Department, Ministry of National Guard Health Affairs, Jeddah, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Sheryl Ann I Abdukahil
- Intensive Care Department, Ministry of National Guard Health Affairs, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia
| | - Jesna Jose
- King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,Department of Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Lara Y Afesh
- King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,Research Office, Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Abdulaziz Al-Dawood
- Intensive Care Department, Ministry of National Guard Health Affairs, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia
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Beitland S, Wimmer H, Lorentsen T, Jacobsen D, Drægni T, Brunborg C, Kløw NE, Sandset PM, Sunde K. Venous thromboembolism in the critically ill: A prospective observational study of occurrence, risk factors and outcome. Acta Anaesthesiol Scand 2019; 63:630-638. [PMID: 30623406 DOI: 10.1111/aas.13316] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/13/2018] [Accepted: 11/23/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND The aim of the study was to explore occurrence, risk factors and outcome of venous thromboembolism (VTE) in intensive care unit (ICU) patients. METHODS Prospective observational study of ICU patients receiving thromboprophylaxis at Oslo University Hospital in Norway. Adult medical and surgical patients with ICU length of stay (LOS) longer than 48 hours were included. For detection of VTE, Doppler ultrasound screening of neck, upper and lower extremity veins was used, and computed tomography angiography when clinically indicated for any medical reason. RESULTS Among 70 included patients, 79% were males and mean age was 62 (±12.1) years. All received thromboprophylaxis with dalteparin, and 44 (63%) used graduated compression stockings. VTE was found in 19 (27%) patients; deep vein thrombosis in 15 (21%) and pulmonary embolism in 4 (6%). Among the VTEs, 11 (58%) presented within the first 48 hours after admission, two (11%) were located in the lower limbs and five (26%) were symptomatic. Risk factors for VTE in multivariable analyses were malignancy, abdominal surgery and SAPS II score <41 with an AuROC (95% CI) of 0.72 (0.58-0.85, P = 0.01). Patients with and without VTE had comparable ICU LOS (13 vs 11 days, P = 0.27) and mortality (16% vs 20%, P = 0.72). CONCLUSION Venous thromboembolism was observed in 27% of ICU patients receiving thromboprophylaxis. Factors associated with increased risk of VTE were malignancy, abdominal surgery and SAPS II score <41. Presence of VTE did not impact on patient outcome.
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Affiliation(s)
- Sigrid Beitland
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Anaesthesiology Oslo University Hospital Oslo Norway
| | - Henning Wimmer
- Department of Acute Medicine Oslo University Hospital Oslo Norway
| | | | - Dag Jacobsen
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Acute Medicine Oslo University Hospital Oslo Norway
| | - Tomas Drægni
- Department of Research and Development Oslo University Hospital Oslo Norway
| | - Cathrine Brunborg
- Oslo Centre for Biostatistics and Epidemiology Oslo University Hospital Oslo Norway
| | - Nils Einar Kløw
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Radiology Oslo University Hospital Oslo Norway
| | - Per Morten Sandset
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Haematology Oslo University Hospital Oslo Norway
| | - Kjetil Sunde
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Anaesthesiology Oslo University Hospital Oslo Norway
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Lewis TC, Cortes J, Altshuler D, Papadopoulos J. Venous Thromboembolism Prophylaxis: A Narrative Review With a Focus on the High-Risk Critically Ill Patient. J Intensive Care Med 2018; 34:877-888. [PMID: 30165770 DOI: 10.1177/0885066618796486] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Venous thromboembolism (VTE) is a major health concern associated with significant morbidity and mortality. Critically ill patients are at an increased risk of VTE compared to general medical patients due to unique risk factors: prolonged immobilization, invasive lines and devices, certain medications, and acquired thrombophilia. Furthermore, VTE in the critically ill is associated with increased duration of mechanical ventilation, increased length of intensive care unit and hospital stay, and a trend toward increased mortality. Clinical practice guidelines therefore recommend VTE prophylaxis with either subcutaneous heparin or low-molecular-weight heparin for all critically ill patients without contraindication. Yet, many patients will develop VTE despite appropriate pharmacologic prophylaxis, which has led to interest in risk-stratifying critically ill patients for more aggressive prophylaxis strategies. Recent research identified patients at highest risk of failure of thromboprophylaxis and provided insight into the pathophysiologic mechanisms. Obesity and the receipt of vasopressors are 2 risk factors consistently identified in observational studies; further clinical data support decreased absorption of anticoagulant administered via the subcutaneous route as the likely mechanism behind thromboprophylaxis failure in these patient populations. Several studies have investigated novel thromboprophylaxis strategies to circumvent pharmacokinetic limitations in patients who are obese or on vasopressors: increased fixed-dose, weight-based subcutaneous, or continuous intravenous infusion of a prophylactic dose of anticoagulant has shown promise in limited studies; however, the results have yet to demonstrate superiority compared to current standard-of-care. This review discusses observational studies identifying patients at risk of thromboprophylaxis failure and critiques clinical studies evaluating novel thromboprophylaxis strategies in high-risk, critically ill patients with a focus on their limitations. Future studies are currently being conducted that will provide further guidance into the appropriate use of individualized thromboprophylaxis.
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Affiliation(s)
- Tyler C Lewis
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | - Jennifer Cortes
- Department of Pharmacy Services, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Diana Altshuler
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
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Kaplan D, Casper TC, Elliott CG, Men S, Pendleton RC, Kraiss LW, Weyrich AS, Grissom CK, Zimmerman GA, Rondina MT. VTE Incidence and Risk Factors in Patients With Severe Sepsis and Septic Shock. Chest 2016; 148:1224-1230. [PMID: 26111103 DOI: 10.1378/chest.15-0287] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Prospective studies on the incidence of VTE during severe sepsis and septic shock remain absent, hindering efficacy assessments regarding VTE prevention strategies in sepsis. METHODS We prospectively studied 113 consecutively enrolled patients in the ICU with severe sepsis and septic shock at three hospitals. All patients provided informed consent. VTE thromboprophylaxis was recorded for all patients. Patients underwent ultrasonography and were followed for VTE prior to ICU discharge. All-cause 28-day mortality was recorded. Variables from univariate analyses that were associated with VTE (including central venous catheter [CVC] insertion, age, length of stay, and mechanical ventilation) were included in a multivariable logistic regression analysis using backward stepwise elimination to determine VTE predictors. RESULTS Mean APACHE (Acute Physiology and Chronic Health Evaluation) II score was 18.2 ± 7.0, and age was 50 ± 18 years. Despite all patients receiving guideline-recommended thromboprophylaxis, the incidence of VTE was 37.2% (95% CI, 28.3-46.8). Most VTE events were clinically significant (defined as pulmonary embolism, proximal DVT, and/or symptomatic distal DVT) and associated with an increased length of stay (18.2 ± 9.9 days vs 13.4 ± 11.5 days, P < .05). Mortality was higher in patients with acute VTE but did not reach statistical significance. Insertion of a CVC and longer mechanical ventilation duration were significant VTE risk factors. VTE incidence did not differ by thromboprophylaxis type. CONCLUSIONS To our knowledge this is the first multicenter prospective study to identify a high incidence of VTE in patients with severe sepsis and septic shock, despite the use of universal, guideline-recommended thromboprophylaxis. Our findings suggest that the systemic inflammatory milieu of sepsis may uniquely predispose patients with sepsis to VTE. More effective VTE prevention strategies are necessary in patients with sepsis. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02353910; URL: www.clinicaltrials.gov.
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Affiliation(s)
- David Kaplan
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - T Charles Casper
- Study Design and Biostatistics Center, University of Utah, Salt Lake City
| | - C Gregory Elliott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, UT
| | - Shaohua Men
- Molecular Medicine Program, University of Utah, Salt Lake City
| | | | - Larry W Kraiss
- Eccles Institute of Human Genetics, and the Division of Vascular Surgery, University of Utah, Salt Lake City
| | - Andrew S Weyrich
- Department of Internal Medicine, University of Utah, Salt Lake City; Molecular Medicine Program, University of Utah, Salt Lake City
| | - Colin K Grissom
- Department of Internal Medicine, University of Utah, Salt Lake City; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, UT
| | - Guy A Zimmerman
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - Matthew T Rondina
- Department of Internal Medicine, University of Utah, Salt Lake City; Molecular Medicine Program, University of Utah, Salt Lake City.
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Beitland S, Sandven I, Kjærvik LK, Sandset PM, Sunde K, Eken T. Thromboprophylaxis with low molecular weight heparin versus unfractionated heparin in intensive care patients: a systematic review with meta-analysis and trial sequential analysis. Intensive Care Med 2015; 41:1209-19. [DOI: 10.1007/s00134-015-3840-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 04/23/2015] [Indexed: 12/23/2022]
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Physicians declining patient enrollment in a critical care trial: a case study in thromboprophylaxis. Intensive Care Med 2014; 39:2115-25. [PMID: 24022796 DOI: 10.1007/s00134-013-3074-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 08/10/2013] [Indexed: 01/08/2023]
Abstract
PURPOSE To analyze the frequency, rationale and determinants of attending physicians requesting that their eligible patients not be approached for participation in a thromboprophylaxis trial. METHODS Research personnel in 67 centers prospectively documented eligible non-randomized patients due to physicians declining to allow their patients to be approached. RESULTS In 67 centers, 3,764 patients were enrolled, but 1,460 eligible patients had no consent encounter. For 218 (14.9 %) of these, attending physicians requested that their patients not be approached. The most common reasons included a high risk of bleeding (31.2 %) related to fear of heparin bioaccumulation in renal failure, the presence of an epidural catheter, peri-operative status or other factors; specific preferences for thromboprophylaxis (12.4 %); morbid obesity (9.6 %); uncertain prognosis (6.4 %); general discomfort with research (3.7 %) and unclear reasons (17.0 %). Physicians were more likely to decline when approached by less experienced research personnel; considering those with[10 years of experience as the reference category, the odds ratios (OR) for physician refusals to personnel without trial experience was 10.47 [95 % confidence interval (CI) 2.19-50.02] and those with less than 10 years experience was 1.72 (95 % CI 0.61-4.84). Physicians in open rather than closed units were more likely to decline (OR 4.26; 95 % CI 1.27-14.34). Refusals decreased each year of enrollment compared to the pilot phase. CONCLUSIONS Tracking, analyzing, interpreting and reporting the rates and reasons for physicians declining to allow their patients to be approached for enrollment provides insights into clinicians' concerns and attitudes to trials. This information can encourage physician communication and education, and potentially enhance efficient recruitment.
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Zochios VA, Keeshan A. Pulmonary Embolism in the Mechanically-Ventilated Critically Ill Patient: Is it Different? J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Pulmonary embolism (PE) confers significant in-hospital morbidity and mortality, and critically ill patients remain at risk for venous thromboembolism despite thromboprophylaxis. Recognition of the clinical manifestations and immediate management of PE are of paramount importance. Despite diagnostic advances, PE is often undiagnosed and untreated in patients receiving mechanical ventilation, as these patients do not exhibit the common clinical features of the condition, making the diagnosis very challenging. Computed tomographic pulmonary angiography is probably the reference standard for the diagnosis of acute PE in the haemodynamically stable, ventilated patient. In the setting of circulatory collapse, bedside echocardiography may be used to risk stratify these patients, based on the presence or absence of right ventricular dysfunction, and guide further management. Treatment options include anticoagulation alone, anticoagulation plus thrombolysis, surgical or catheter embolectomy. Inotropes, vasopressors and pulmonary artery vasodilators may be considered after initial resuscitation of the right ventricle. Few studies have focused on estimating the prevalence of PE among mechanically-ventilated intensive care unit (ICU) patients and there is notable lack of data assessing predictive factors, prevention, diagnostic strategy and management of PE in the ICU setting.
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Affiliation(s)
- Vasileios A Zochios
- ACCS Anaesthesia Core Trainee, East Midlands (South) School of Anaesthesia, University Hospitals of Leicester NHS Trust
| | - Alex Keeshan
- Consultant Intensivist, University Hospitals of Leicester NHS Trust, Leicester General Hospital
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Abstract
OBJECTIVE There is lack of evidence to guide thromboprophylaxis in the pediatric intensive care unit. We aimed to assess current prescribing practice for pharmacologic thromboprophylaxis in critically ill children. SETTING Pediatric intensive care units in the United States and Canada with at least ten beds. DESIGN Cross-sectional self-administered survey of pediatric intensivists using adolescent, child, and infant scenarios. PARTICIPANTS Pediatric intensive care unit clinical directors or section heads. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Physician leaders from 97 of 151 (64.2%) pediatric intensive care units or their designees responded to the survey. In mechanically ventilated children, 42.3% of the respondents would usually or always prescribe thromboprophylaxis for the adolescent but only 1.0% would prescribe it for the child and 1.1% for the infant. Considering all pediatric intensive care unit patients, 3.1%, 32.0%, and 44.2% of respondents would never prescribe thromboprophylaxis for the adolescent, child, and infant scenarios, respectively. These findings were significant (p < .001 for the adolescent vs. child and infant; p = .002 for child vs. infant). Other patient factors that increased the likelihood of prescribing prophylaxis to a critically ill child for all three scenarios were the presence of hypercoagulability, prior deep venous thrombosis, or a cavopulmonary anastomosis. Prophylaxis was less likely to be prescribed to patients with major bleeding or an anticipated invasive intervention. Low-molecular-weight heparin was the most commonly prescribed drug. CONCLUSIONS In these scenarios, physician leaders in pediatric intensive care units were more likely to prescribe thromboprophylaxis to adolescents compared with children or infants, but they prescribed it less often in adolescents than is recommended by evidence-based guidelines for adults. The heterogeneity in practice we documented underscores the need for rigorous randomized trials to determine the need for thromboprophylaxis in critically ill adolescents and children.
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Sud S, Mittmann N, Cook DJ, Geerts W, Chan B, Dodek P, Gould MK, Guyatt G, Arabi Y, Fowler RA. Screening and prevention of venous thromboembolism in critically ill patients: a decision analysis and economic evaluation. Am J Respir Crit Care Med 2011; 184:1289-98. [PMID: 21868500 DOI: 10.1164/rccm.201106-1059oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Venous thromboembolism is difficult to diagnose in critically ill patients and may increase morbidity and mortality. OBJECTIVES To evaluate the cost-effectiveness of strategies to reduce morbidity from venous thromboembolism in critically ill patients. METHODS A Markov decision analytic model to compare weekly compression ultrasound screening (screening) plus investigation for clinically suspected deep vein thrombosis (DVT) (case finding) versus case finding alone; and a hypothetical program to increase adherence to DVT prevention. Probabilities were derived from a systematic review of venous thromboembolism in medical-surgical intensive care unit patients. Costs (in 2010 $US) were obtained from hospitals in Canada, Australia, and the United States, and the medical literature. Analyses were conducted from a societal perspective over a lifetime horizon. Outcomes included costs, quality-adjusted life-years (QALY), and incremental cost-effectiveness ratios. MEASUREMENTS AND MAIN RESULTS In the base case, the rate of proximal DVT was 85 per 1,000 patients. Screening resulted in three fewer pulmonary emboli than case-finding alone but also two additional bleeding episodes, and cost $223,801 per QALY gained. In sensitivity analyses, screening cost less than $50,000 per QALY only if the probability of proximal DVT increased from a baseline of 8.5-16%. By comparison, increasing adherence to appropriate pharmacologic thromboprophylaxis by 10% resulted in 16 fewer DVTs, one fewer pulmonary emboli, and one additional heparin-induced thrombocytopenia and bleeding event, and cost $27,953 per QALY gained. Programs achieving increased adherence to best-practice venous thromboembolism prevention were cost-effective over a wide range of program costs and were robust in probabilistic sensitivity analyses. CONCLUSIONS Appropriate prophylaxis provides better value in terms of costs and health gains than routine screening for DVT. Resources should be targeted at optimizing thromboprophylaxis.
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Affiliation(s)
- Sachin Sud
- Trillium Health Center, Mississauga, Ontario, Canada
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Venous thromboembolism following microsurgical breast reconstruction: an objective analysis in 225 consecutive patients using low-molecular-weight heparin prophylaxis. Plast Reconstr Surg 2011; 127:1399-1406. [PMID: 21187811 DOI: 10.1097/prs.0b013e318208d025] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Free flap breast reconstruction involves major risk factors for postsurgical venous thromboembolism. The main study objectives were (1) to estimate objectively the incidence of symptomatic and asymptomatic lower extremity deep vein thrombosis in patients who received postoperative thromboprophylaxis after free flap breast reconstruction, (2) to evaluate the safety of low-molecular-weight heparin postoperatively, and (3) to assess the incidence of symptomatic pulmonary embolism or sudden death. METHODS A cohort study of 225 consecutive patients who underwent abdominally based free flap breast reconstruction at a single cancer center was conducted. The postoperative thromboprophylaxis regimen was based on the American College of Chest Physicians guidelines. A study group of 118 patients systematically underwent bilateral lower extremity duplex ultrasound before hospital discharge to assess objectively the status of the lower extremity deep venous system. A retrospective cohort of 107 women who were not systematically screened for deep vein thrombosis was used for comparison. RESULTS The incidence of postoperative deep vein thrombosis confirmed by duplex ultrasound was 3.4 percent in the study group, all events being clinically silent. Bleeding complications in the entire patient sample were estimated at 5.3 percent. Partial flap loss and total flap loss rates were 2.7 and 1.9 percent, respectively. No venous thromboembolism event was diagnosed in the control group. CONCLUSIONS This report shows that the objective incidence of deep vein thrombosis was 3.4 percent within 5 postoperative days in this patient population. The authors' findings support the use of triple thromboprophylaxis and demonstrate that low-molecular-weight heparin is a safe and effective method for prevention of venous thromboembolism in this population.
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O’Sullivan GJ. The Role of Interventional Radiology in the Management of Deep Venous Thrombosis: Advanced Therapy. Cardiovasc Intervent Radiol 2010; 34:445-61. [DOI: 10.1007/s00270-010-9977-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 08/09/2010] [Indexed: 02/03/2023]
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An evaluation of practice pattern for venous thromboembolism prevention in Lebanese hospitals. J Thromb Thrombolysis 2008; 28:192-9. [PMID: 19110614 DOI: 10.1007/s11239-008-0298-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 11/21/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major cause of death among hospitalized patients. Many VTE prophylaxis guidelines have been developed, including the American College of Chest Physicians (ACCP). VTE prophylaxis is required in specific patients; however, its practice is not always optimal, and often depends on the hospitals' protocols. In Lebanon, information about the appropriateness of VTE prophylaxis in health care centers is lacking. OBJECTIVE The primary objective of this study was to evaluate the pattern of VTE prophylaxis application, including agents, doses, duration of treatment, and route of administration, in Lebanese health care centers. METHODS A Lebanese multi-center, prospective, chart review study was conducted over 4 months. Data on demographics, VTE prophylaxis medication, dose, route, duration, and associated risk factors were collected by pharmacy students. The appropriateness of VTE prophylaxis was determined as per ACCP guidelines. Patients receiving VTE treatment were excluded from the study. Institutional review board (IRB) approval was obtained from each hospital center. RESULTS A total of 840 patients were included. Both gender groups were equally represented in the sample and the mean age was 59 +/- 19.53 years. The majority (639/840, 76.1%) of the sample were at high risk for deep venous thrombosis (DVT), and inappropriate VTE prophylaxis was reported in 35% of the low-risk group, in 70% of the moderate-risk group, and in 39% of the high-risk group (P < 0.0001). Comparing proper VTE prophylaxis practice between intensive care unit (ICU) and non-ICU patients, there was no statistical difference observed in teaching hospitals (67.2% vs. 65.5%, P = 0.312). However, in non-teaching hospitals, appropriate VTE prophylaxis practice was more prevalent in ICU than non-ICU patients (65.9% vs. 51.2%, P = 0.004). The average duration of VTE prophylaxis was less than 10 days. Missing data was a major limitation for this study, where, for instance, the duration of prophylaxis could not be accurately abstracted in half of the sample. Another limitation was the absence of laboratory results needed for clinical assessment of the regimen used. CONCLUSION This study reflected the importance of assessing VTE prophylaxis in Lebanese hospitals, thus, the need for implementing established guidelines to improve the overall patient safety.
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Determining the Clinical Probability of Deep Venous Thrombosis and Pulmonary Embolism. South Med J 2007; 100:1015-21; quiz 1004. [DOI: 10.1097/smj.0b013e3181520223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McMullin J, Cook D, Griffith L, McDonald E, Clarke F, Guyatt G, Gibson J, Crowther M. Minimizing errors of omission: Behavioural rEenforcement of Heparin to Avert Venous Emboli: The BEHAVE Study*. Crit Care Med 2006; 34:694-9. [PMID: 16505655 DOI: 10.1097/01.ccm.0000201886.84135.cb] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To improve patient safety by increasing heparin thromboprophylaxis for medical-surgical intensive care unit patients using a multiple-method approach to evidence-based guideline development and implementation. DESIGN Prospective longitudinal observational study. SETTING Medical-surgical intensive care unit. PARTICIPANTS Multidisciplinary clinicians caring for critically ill patients in a 15-bed medical-surgical closed intensive care unit. INTERVENTIONS Phase 1 was a 3-month baseline period during which we documented anticoagulation and mechanical thromboprophylaxis. Phase 2 was a 1-yr period in which we implemented a thromboprophylaxis guideline using a) interactive multidisciplinary educational in-services; b) verbal reminders to the intensive care unit team; c) computerized daily nurse recording of thromboprophylaxis; d) weekly graphic feedback to individual intensivists on guideline adherence; and e) publicly displayed graphic feedback on group performance. Phase 3 was a 3-month follow-up period 10 months later, during which we documented thromboprophylaxis. Computerized daily nurse recording of thromboprophylaxis continued in this period. MEASUREMENTS AND MAIN RESULTS Intensive care unit and hospital mortality rates were similar across phases, although patients in phase 2 had higher Acute Physiology and Chronic Health Evaluation II scores than patients in phases 1 and 3. The proportion (median % [interquartile range]) of intensive care unit patient-days of heparin thromboprophylaxis in phases 1, 2, and 3 was 60.0 (0, 100), 90.9 (50, 100), and 100.0 (60, 100), respectively (p=.01). The proportion (median % [interquartile range]) of days during which heparin thromboprophylaxis was omitted in error in phases 1, 2, and 3 was 20 (0, 53.8), 0 (0, 6.3), and 0 (0, 0), respectively (p<.001). CONCLUSIONS After development and implementation of an evidence-based thromboprophylaxis guideline, we found significantly more patients receiving heparin thromboprophylaxis. Guideline adherence was maintained 1 yr later. Further research is needed on which are the most effective strategies to implement patient safety initiatives in the intensive care unit.
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Affiliation(s)
- J McMullin
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Kotsakis A, Cook D, Griffith L, Anton N, Massicotte P, MacFarland K, Farrell R, Hutchison J. Clinically important venous thromboembolism in pediatric critical care: a Canadian survey. J Crit Care 2005; 20:373-80. [PMID: 16310610 DOI: 10.1016/j.jcrc.2005.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Revised: 09/08/2005] [Accepted: 09/08/2005] [Indexed: 01/12/2023]
Abstract
PURPOSE Pediatric venous thromboembolism (VTE) is becoming an increasingly recognized morbidity associated with critical illness. The objective of this survey is to identify the patient factors and radiological features that pediatric intensivists consider more or less likely to make a venous thrombosis (VTE) clinically important in their patients. MATERIALS AND METHODS Our definition of clinically important VTE was a VTE likely to result in short- or long-term morbidity or mortality if left untreated. We asked respondents to rate the likelihood that patient factors and radiological features make a venous thrombosis clinically important using a 5-point scale (1 = much less likely to 5 = much more likely). RESULTS The 38 (58.5%) of 65 pediatric intensivists responding rated 4 patient factors as most likely to make a VTE clinically important: clinical suspicion of pulmonary embolism (mean score, 4.8), symptoms (mean, 4.5), detection by physical exam (mean, 4.4), and the presence of an acute or chronic cardiopulmonary comorbidity that might limit a patient's ability to tolerate pulmonary embolism (mean, 4.3). Of the radiological features, the 2 considered most important were VTE involving the vena cava extending into the right atrium (mean, 5) and central veins (mean, 4.5). CONCLUSIONS When labeling a VTE as clinically important, pediatric intensivists rely on several specific patient factors and thrombus characteristics.
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Affiliation(s)
- Afrothite Kotsakis
- Department of Critical Care, The Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8
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Cook D, Crowther M, Meade M, Rabbat C, Griffith L, Schiff D, Geerts W, Guyatt G. Deep venous thrombosis in medical-surgical critically ill patients: prevalence, incidence, and risk factors. Crit Care Med 2005; 33:1565-71. [PMID: 16003063 DOI: 10.1097/01.ccm.0000171207.95319.b2] [Citation(s) in RCA: 275] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Critically ill patients may be at high risk of venous thromboembolism. The objective was to determine the prevalence, incidence, and risk factors for proximal lower extremity deep venous thrombosis among critically ill medical-surgical patients. DESIGN Prospective cohort. SETTING Closed university-affiliated intensive care unit. PATIENTS We enrolled consecutive patients > or =18 yrs of age expected to be in intensive care unit for > or =72 hrs. Exclusion criteria were an admitting diagnosis of trauma, orthopedic surgery, pregnancy, and life support withdrawal. INTERVENTIONS Interventions included bilateral lower extremity compression ultrasound within 48 hrs of intensive care unit admission, twice weekly, and if venous thromboembolism was clinically suspected. Thromboprophylaxis was protocol directed and universal. We recorded deep venous thrombosis risk factors at baseline and daily, using multivariate regression analysis to determine independent predictors. Patients were followed to hospital discharge. RESULTS Among 261 patients with a mean Acute Physiology and Chronic Health Evaluation II score of 25.5 (+/-8.4), the prevalence of deep venous thrombosis was 2.7% (95% confidence interval 1.1-5.5) on intensive care unit admission, and the incidence was 9.6% (95% confidence interval 6.3-13.8) over the intensive care unit stay. We identified four independent risk factors for intensive care unit-acquired deep venous thrombosis: personal or family history of venous thromboembolism (hazard ratio 4.0, 95% confidence interval 1.5-10.3), end-stage renal failure (hazard ratio 3.7, 95% confidence interval 1.2-11.1), platelet transfusion (hazard ratio 3.2, 95% confidence interval 1.2-8.4), and vasopressor use (hazard ratio 2.8, 95% confidence interval 1.1-7.2). Patients with deep venous thrombosis had a longer duration of mechanical ventilation (p = .03), intensive care unit stay (p = .005), and hospitalization (p < .001) than patients without deep venous thrombosis. CONCLUSIONS Despite universal thromboprophylaxis, medical-surgical critically ill patients remain at risk for lower extremity deep venous thrombosis. Further research is needed to evaluate the risks and benefits of more intense venous thromboembolism prophylaxis.
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Affiliation(s)
- Deborah Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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