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Carini FC, Munshi L, Novitzky-Basso I, Dozois G, Heredia C, Damouras S, Ferreyro BL, Mehta S. Incidence of venous thromboembolic disease and risk of bleeding in critically ill patients with hematologic malignancies: A retrospective study. Med Intensiva 2024:S2173-5727(24)00141-3. [PMID: 38906793 DOI: 10.1016/j.medine.2024.06.003] [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: 03/15/2024] [Accepted: 05/27/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE Our objectives were to describe the use of thromboprophylaxis and the incidence of VTE/bleeding in critically ill patients with hematologic malignancies (HM). DESIGN Retrospective cohort study (2014-2022). SETTING Medic-Surgical Intensive Care Unit (ICU) in a tertiary care academic center. PATIENTS Adult patients admitted to ICU with a concomitant diagnosis of a hematological malignancy. INTERVENTIONS None. MAIN VARIABLES OF INTEREST We analyzed demographic data, use of thromboprophylaxis and secondary outcomes that included incidence of VTE (venous thromboembolism), bleeding, mortality, severity scores and organ support. We applied a multivariable logistic regression model to examine the risk of thrombosis in the ICU. RESULTS We included 862 ICU admissions (813 unique patients). Thromboprophylaxis was given during 65% of admissions (LMWH 14%, UFH 8%, and SCDs 43%); in 21% it was contraindicated due to thrombocytopenia; 14% of cases lacked documentation on prophylaxis. There were 38 unique incident cases of VTE (27 DVT, 11 PE), constituting 4.4% of ICU episodes. Most of VTE cases happened in patients with various degrees of thrombocytopenia. In the multivariable analysis, SOFA score on the first ICU day was independently associated (OR 0.85, 95% CI 0.76-0.96) with the risk of VTE. Bleeding occurred in 7.2% (minor) and 14.4% (major) of episodes; most frequent sites being CNS, abdomen/GI and pulmonary. CONCLUSIONS In this cohort of critically ill patients with HM, there was considerable variability in the utilization of DVT prophylaxis, with predominant use of SCDs. The incidence of VTE was 4.4% and major bleeding 14%. CLINICAL TRIAL REGISTRATION NCT05396157. Venous Thromboembolism in Hematologic Malignancy and Hematopoietic Cell Transplant Patients: a Retrospective Study (https://clinicaltrials.gov/).
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Affiliation(s)
- Federico C Carini
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Laveena Munshi
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Igor Novitzky-Basso
- Princess Margaret Cancer Centre, Department of Medical Oncology; University Health Network, Toronto, Ontario, Canada
| | - Graham Dozois
- Princess Margaret Cancer Centre, Department of Medical Oncology; University Health Network, Toronto, Ontario, Canada
| | - Camila Heredia
- Faculty of Health, York University, Toronto, Ontario, Canada
| | - Sotirios Damouras
- Department of Computer & Mathematical Sciences, University of Toronto Scarborough, Ontario, Canada
| | - Bruno L Ferreyro
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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2
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Othman S, Bertolaccini CM, Pannucci CJ. Unfractionated Heparins, Low-Molecular-Weight Heparins, and Indirect Factor Xa Inhibitors in Plastic and Reconstructive Surgery: An Evidence-Based Review. Plast Reconstr Surg 2024; 153:1224e-1231e. [PMID: 37189249 DOI: 10.1097/prs.0000000000010695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
SUMMARY Venous thromboembolism can present with devastating complications and sequalae, particularly in the surgical patient. Current data support prophylactic anticoagulant use in high-risk hospitalized patients, defined as those with a Caprini Risk Assessment Model score of 7 or greater. The most frequently used chemoprophylaxis agents include unfractionated heparin, low-molecular-weight heparin, and indirect factor Xa inhibitors. The authors review the mechanisms of action, metabolism, reversal agents, indications, contraindications, advantages, and disadvantages of these medications in plastic and reconstructive surgery.
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Affiliation(s)
- Sammy Othman
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health
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3
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John S, Wilkinson M, Ho KM. Monitoring anti-Xa Levels to Optimize Low-Molecular-Weight-Heparin Thromboprophylaxis in High-Risk Hospitalized Patients: A Stratified Meta-Analysis. Angiology 2024; 75:249-266. [PMID: 36606749 DOI: 10.1177/00033197221150673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
It is uncertain whether monitoring or targeting anti-Xa levels is necessary when using low-molecular-weight-heparin (LMWH) to prevent venous thromboembolism (VTE). This stratified meta-analysis assessed whether monitoring trough or peak anti-Xa levels with LMWH dosing would reduce risk of VTE. Twelve non-randomized studies involving 3604 hospitalized patients met the inclusion criteria and were subject to meta-analysis. Eight studies assessed the association between VTE and peak anti-Xa levels (between .2 and .5 IU/ml) and four studies assessed the benefits of targeting the trough anti-Xa levels (>.1 IU/ml). Achieving an adequate peak or trough anti-Xa level was associated with a reduced risk of VTE (random-effects model odds ratio [OR] .52, 95% confidence interval [CI] .34-.77; P = .001, I2 = 30% and P-value for heterogeneity = .171) compared with using a fixed standard dose of LMWH. Targeting the trough level (OR .40, 95%CI 0.22-.75, P = .004) appeared to be more effective than targeting the peak level (OR .62, 95%CI 0.37-1.03, P = .066), although a formal interaction analysis did not confirm they were statistically different (ratio of ORs = 1.52, 95%CI 0.68-3.40; z score = 1.03, P = .306). Targeting a higher anti-Xa level did not appear to increase the risk of bleeding or transfusion (OR 1.20, 95%CI 0.46-3.17, P = .707).
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Affiliation(s)
- Sunil John
- Department of Intensive Care Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Molly Wilkinson
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - Kwok M Ho
- Department of Intensive Care Medicine, Fiona Stanley Hospital, Perth, WA, Australia
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA, Australia
- Medical School, The University of Western Australia, Perth, WA, Australia
- School of Veterinary & Life Sciences, Murdoch University, Perth, WA, Australia
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4
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care 2024; 40:1-37. [PMID: 38040992 PMCID: PMC10861627 DOI: 10.1007/s12028-023-01871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 12/03/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Affiliation(s)
| | | | - Edilberto Amorim
- San Francisco-Weill Institute for Neurosciences, University of California, San Francisco, USA
| | - Mary Kay Bader
- Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
| | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, USA
| | | | | | | | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK
- Royal United Hospital, Bath, UK
| | - Mauro Oddo
- CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | | | - Anezi Uzendu
- St. Luke's Mid America Heart Institute, Kansas City, USA
| | - Brian Walsh
- University of Texas Medical Branch School of Health Sciences, Galveston, USA
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5
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024; 149:e168-e200. [PMID: 38014539 PMCID: PMC10775969 DOI: 10.1161/cir.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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6
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Mishra L, Lee D, Ho KM. Incidence of factor XII deficiency in critically ill patients with a prolonged activated partial thromboplastin time: a prospective observational study. Blood Coagul Fibrinolysis 2023; 34:364-369. [PMID: 37395184 DOI: 10.1097/mbc.0000000000001235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Limited data is available on factor XII deficiency in critically ill patients with prolonged activated partial thromboplastin time (aPTT). The association of factor XII deficiency with an increased risk of thromboembolism is unclear. This prospective observational study assessed the incidence of factor XII deficiency among critically ill patients with prolonged aPTT (>40 s), whether factor XII deficiency manifesting as prolonged aPTT was associated with an increased risk of thromboembolism, and clotting time on a viscoelastic (ROTEM) test was useful to predict factor XII deficiency. Of the 40 included patients, 48% [95% confidence interval (CI) 33-63) had a factor XII deficiency (mean ± standard deviation of factor XII level of all patients: 54% ± 29%). Factor XII levels were not significantly correlated with the measured aPTT ( r = -0.163, P = 0.315). Factor XII deficiency was significantly more common in patients who were less critically ill ( P = 0.027), but it was not significantly related to Disseminated Intravascular Coagulation scores ( P = 0.567). The incidence of symptomatic venous thromboembolism ( P = 0.246), allogeneic blood transfusion ( P = 0.816), and hospital mortality ( P = 0.201) were not significantly different between those with and without factor XII deficiency. The clotting time on the viscoelastic test was not predictive of factor XII deficiency (area under the receiver-operating characteristic = 0.605, P = 0.264). Factor XII deficiency was common in critically ill patients with a prolonged aPTT. There was no association between factor XII deficiency and risk of thromboembolism. The clotting time on ROTEM was not predictive of the presence of factor XII deficiency.
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Affiliation(s)
- Lipi Mishra
- Medical School, University of Western Australia, and School of Veterinary & Life Sciences, Murdoch University, Intensive Care Unit, Royal Perth Hospital, Western Australia, Australia
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7
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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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8
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Alshaqaq HM, Al-Sharydah AM, Alshahrani MS, Alqahtani SM, Amer M. Prophylactic Inferior Vena Cava Filters for Venous Thromboembolism in Adults With Trauma: An Updated Systematic Review and Meta-Analysis. J Intensive Care Med 2023; 38:491-510. [PMID: 36939472 DOI: 10.1177/08850666231163141] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Background: Trauma is an independent risk factor for venous thromboembolism (VTE). Due to contraindications or delay in starting pharmacological prophylaxis among trauma patients with a high risk of bleeding, the inferior vena cava (IVC) filter has been utilized as alternative prevention for pulmonary embolism (PE). Albeit, its clinical efficacy has remained uncertain. Therefore, we performed an updated systematic review and meta-analysis on the effectiveness and safety of prophylactic IVC filters in severely injured patients. Methods: Three databases (MEDLINE, EMBASE, and Cochrane) were searched from August 1, 2012, to October 27, 2021. Independent reviewers performed data extraction and quality assessment. Relative risk (RR) at 95% confidence interval (CI) pooled in a randomized meta-analysis. A parallel clinical practice guideline committee assessed the certainty of evidence using the GRADE approach. The outcomes of interest included VTE, PE, deep venous thrombosis, mortality, and IVC filter complications. Results: We included 10 controlled studies (47 140 patients), of which 3 studies (310 patients) were randomized controlled trials (RCTs) and 7 were observational studies (46 830 patients). IVC filters demonstrated no significant reduction in PE and fatal PE (RR, 0.27; 95% CI, 0.06-1.28 and RR, 0.32; 95% CI, 0.01-7.84, respectively) by pooling RCTs with low certainty. However, it demonstrated a significant reduction in the risk of PE and fatal PE (RR, 0.25; 95% CI, 0.12-0.55 and RR, 0.09; 95% CI, 0.011-0.81, respectively) by pooling observational studies with very low certainty. IVC filter did not improve mortality in both RCTs and observational studies (RR, 1.44; 95% CI, 0.86-2.43 and RR, 0.63; 95% CI, 0.3-1.31, respectively). Conclusion: In trauma patients, moderate risk reduction of PE and fatal PE was demonstrated among observational data but not RCTs. The desirable effect is not robust to outweigh the undesirable effects associated with IVC filter complications. Current evidence suggests against routinely using prophylactic IVC filters.
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Affiliation(s)
- Hassan M Alshaqaq
- Emergency Medicine Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Abdulaziz M Al-Sharydah
- Diagnostic and Interventional Radiology Department, King Fahd Hospital of the University, 48023Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammed S Alshahrani
- Department of Emergency and Critical Care, King Fahd Hospital of the University, 48023Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Saad M Alqahtani
- Department of Orthopedics surgery, 48102King Fahd Hospital of the University, 48023Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Marwa Amer
- Medical/Critical Pharmacy Division, 37852King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,College of Medicine, 101686Alfaisal University, Riyadh, Saudi Arabia
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Marturano MN, Khan AR, DeBlieux P, Wang H, Ross SW, Cunningham KW, Sing RF, Thomas BW. Timing of venous thromboembolism chemoprophylaxis using objective hemoglobin criteria in blunt solid organ injury. Injury 2022; 54:1356-1361. [PMID: 36581480 DOI: 10.1016/j.injury.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/19/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the safety and efficacy of early venous thromboembolism (VTE) chemoprophylaxis following blunt solid organ injury. METHODS A retrospective review of patients was performed for patients with blunt solid organ injury between 2009-2019. Enoxaparin was initiated when patients had <1g/dl Hemoglobin decline over a 24 h period. These patients were then categorized by initiation: ≤48 h and >48 h. RESULTS There were 653 patients: 328 (50.2%) <48 h and 325 (49.8%) ≥48 h. Twenty-nine (4.4%) developed VTE. Patients in ≥48 h group suffered more frequent VTE events (6.5% vs 2.4%, p = 0.021). Non-operative failure occurred in 6 patients (1.9%) in ≥48 h group, and 5 patients (1.5%) < 48 h group. Blood transfusion following chemophrophylaxis initiation was required in 69 (21.3%) in ≥48 h group, and 46 (14.0%) in < 48 h group, occurring similarly between groups (p=0.021). CONCLUSION Stable hemoglobin in the first 24 h is an efficacious, objective measure that allows early initiation of VTE chemoprophylaxis in solid organ injury. This practice is associated with earlier initiation of and fewer VTE events.
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Affiliation(s)
- Matthew N Marturano
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | | | - Paige DeBlieux
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Huaping Wang
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | - Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | - Kyle W Cunningham
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | - Ronald F Sing
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | - Bradley W Thomas
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA.
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Tang X, Lyu WR, Jin Y, Wang R, Li XY, Li Y, Zhang CY, Zhao W, Tong ZH, Sun B. Modern thromboprophylaxis protocol based on guidelines applied in a respiratory intensive care unit: a single-center prospective cohort study. Thromb J 2022; 20:76. [PMID: 36510234 PMCID: PMC9746213 DOI: 10.1186/s12959-022-00439-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Critically ill patients in intensive care units (ICUs) are at high risk of venous thromboembolism (VTE). This study aimed to explore the prophylaxis effect under a guideline-based thromboprophylaxis protocol among critically ill patients in a respiratory ICU. METHODS For this single-center prospective cohort study, we followed the thromboprophylaxis protocol, which was drawn up based on relevant guidelines and Chinese experts' advice. Clinical data were entered into an electronic case report form and analyzed. Multivariate logistic regression was conducted to explore independent risk factors of VTE event under this protocol. RESULTS From August 1, 2014, to December 31, 2020, 884 patients underwent thromboprophylaxis according to this protocol; 10.5% of them received mechanical prophylaxis, 43.8% received pharmacological prophylaxis, and 45.7% received pharmacological combined with mechanical prophylaxis. The proportion of VTE events was 14.3% for patients who received the thromboprophylaxis protocol, of which 0.1% had pulmonary thromboembolism (PTE), 2.0% had proximal deep vein thrombosis (DVT), and 12.1% had isolated distal DVT. There was no significant difference between different thromboprophylaxis measures. Cirrhosis (OR 5.789, 95% CI [1.402, 23.894], P = 0.015), acute asthma exacerbation (OR 39.999, 95% CI [4.704, 340.083], P = 0.001), and extracorporeal membrane oxygenation treatment (OR 22.237, 95%CI [4.824, 102.502], P < 0.001) were independent risk factors for proximal DVT under thromboprophylaxis. CONCLUSIONS The thromboprophylaxis protocol based on guidelines applied in the ICU was practicable and could help decrease the proportion of PTE and proximal DVT events. The risk factors of VTE events happening under the thromboprophylaxis protocol require more attention. TRIAL REGISTRATION ClinicalTrials.gov: NCT02213978.
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Affiliation(s)
- Xiao Tang
- grid.24696.3f0000 0004 0369 153XDepartment of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang, Beijing, 100020 China
| | - Wen-Rui Lyu
- grid.24696.3f0000 0004 0369 153XDepartment of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang, Beijing, 100020 China
| | - Yu Jin
- grid.24696.3f0000 0004 0369 153XDepartment of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang, Beijing, 100020 China
| | - Rui Wang
- grid.24696.3f0000 0004 0369 153XDepartment of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang, Beijing, 100020 China
| | - Xu-Yan Li
- grid.24696.3f0000 0004 0369 153XDepartment of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang, Beijing, 100020 China
| | - Ying Li
- grid.24696.3f0000 0004 0369 153XDepartment of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang, Beijing, 100020 China
| | - Chun-Yan Zhang
- grid.24696.3f0000 0004 0369 153XDepartment of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang, Beijing, 100020 China
| | - Wei Zhao
- grid.411607.5Department of Ultrasonic diagnosis, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhao-Hui Tong
- grid.24696.3f0000 0004 0369 153XDepartment of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang, Beijing, 100020 China
| | - Bing Sun
- grid.24696.3f0000 0004 0369 153XDepartment of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang, Beijing, 100020 China
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Jagiasi BG, Chhallani AA, Dixit SB, Kumar R, Pandit RA, Govil D, Prayag S, Zirpe KG, Mishra RC, Chanchalani G, Kapadia FN. Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit. Indian J Crit Care Med 2022; 26:S51-S65. [PMID: 36896363 PMCID: PMC9989869 DOI: 10.5005/jp-journals-10071-24195] [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: 10/15/2021] [Accepted: 01/03/2022] [Indexed: 11/05/2022] Open
Abstract
Deep vein thrombosis (DVT) is a preventable complication of critical illness, and this guideline aims to convey a pragmatic approach to the problem. Guidelines have multiplied over the last decade, and their utility has become increasingly conflicted as the reader interprets all suggestions or recommendations as something that must be followed. The nuances of grade of recommendation vs level of evidence are often ignored, and the difference between a "we suggest" vs a "we recommend" is overlooked. There is a general unease among clinicians that failure to follow the guidelines translates to poor medical practice and legal culpability. We attempt to overcome these limitations by highlighting ambiguity when it occurs and refraining from dogmatic recommendations in the absence of robust evidence. Readers and practitioners may find the lack of specific recommendations unsatisfactory, but we believe that true ambiguity is better than inaccurate certainty. We have attempted to comply with the guidelines on how to create guidelines.1 And to overcome the poor compliance with these guidelines.2 Some observers have expressed concern that DVT prophylaxis guidelines may cause more harm than good.3 We have placed greater emphasis on large randomized controlled trials (RCTs) with clinical end point and de-emphasized RCTs with surrogate end points and also de-emphasized hypothesis generating studies (observational studies, small RCTs, and meta-analysis of these studies). We have de-emphasized RCTs in non-intensive care unit populations like postoperative patients or those with cancer and stroke. We have also considered resource limitation settings and have avoided recommending costly and poorly proven therapeutic options. How to cite this article Jagiasi BG, Chhallani AA, Dixit SB, Kumar R, Pandit RA, Govil D, et al. Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit. Indian J Crit Care Med 2022;26(S2):S51-S65.
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Affiliation(s)
- Bharat G Jagiasi
- Critical Care Department, Reliance Hospital, Navi Mumbai, Maharashtra, India
| | | | - Subhal B Dixit
- Department of Critical Care, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Rishi Kumar
- Department of Critical Care, PD Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Rahul A Pandit
- Critical Care, Fortis Hospital, Mumbai, Maharashtra, India
| | - Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - Shirish Prayag
- Critical Care, Prayag Hospital, Pune, Maharashtra, India
| | - Kapil G Zirpe
- Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Rajesh C Mishra
- Department of MICU, Shaibya Comprehensive Care Clinic, Ahmedabad, Gujarat, India
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Wang M, Wang W, Jia X, He Q, Zhu S, Kang Y, Zhang R, Ren Y, Li L, Zou K, Zong Z, Sun X. Associations Between Antithrombosis and Ventilator-Associated Events, ICU Stays, and Mortality Among Mechanically Ventilated Patients: A Registry-Based Cohort Study. Front Pharmacol 2022; 13:891178. [PMID: 35924051 PMCID: PMC9339989 DOI: 10.3389/fphar.2022.891178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background: The effect of thromboembolism prophylaxis on clinical outcomes, such as ventilator-associated events (VAEs), ICU stays, and mortality, remains controversial. This study was conducted to evaluate the effect of pharmacological thromboprophylaxis on VAEs, ICU stays, and ICU mortality among patients receiving mechanical ventilation (MV). Materials and Methods: A retrospective cohort study was conducted based on a well-established registry of healthcare-associated infections at ICUs in the West China Hospital system. Patients who consistently received MV for at least 4 days from 1 April 2015 to 31 December 2018 were included. Hazard ratios (HRs) were compared for three tiers of VAEs, ICU stays, and ICU mortality among patients receiving pharmacological thromboprophylaxis versus those without using the time-dependent Cox model. For the analyses of ICU stays and ICU mortality, we also used Fine-Gray models to disentangle the competing risks and outcomes of interest. Results: Overall, 6,140 patients were included. Of these, 3,805 received at least one prescription of antithrombosis agents. Treatments with antithrombosis agents were associated with lower risk of VAEs (HR: 0.87, 95% CI: 0.77, 0.98) and ICU mortality (HR: 0.72, 95% CI: 0.61, 0.86) than those without. Anticoagulants but not antiplatelet agents were associated with decreased risk of VAEs (HR: 0.86, 95% CI: 0.75, 0.98), ICU mortality (HR: 0.62, 95% CI: 0.51, 0.76), and less time to ICU discharge (HR: 1.15, 95% CI: 1.04, 1.28). Antithrombosis may be associated with decreased risk of VAEs in patients with D-dimer >5 mg/LFEU (HR: 0.84, 95%CI: 0.72, 0.98). Conclusions: Pharmacological thromboprophylaxis was associated with lower risk of VAEs and ICU mortality. Similar effects were observed between unfractionated heparins versus low-molecular-weight heparins.
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Affiliation(s)
- Mingqi Wang
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Wen Wang
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Xue Jia
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- Department of Postgraduate, West China Hospital of Sichuan University, Chengdu, China
| | - Qiao He
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Shichao Zhu
- Department of Infection Control, West China Hospital of Sichuan University, Chengdu, China
| | - Yan Kang
- Intensive Care Unit, West China Hospital of Sichuan University, Chengdu, China
| | - Rui Zhang
- Information Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Ren
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Ling Li
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Kang Zou
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Zhiyong Zong
- Department of Infection Control, West China Hospital of Sichuan University, Chengdu, China
- Center of Infection Diseases, West China Hospital of Sichuan University, Chengdu, China
- *Correspondence: Xin Sun, ; Zhiyong Zong,
| | - Xin Sun
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
- *Correspondence: Xin Sun, ; Zhiyong Zong,
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Falksen JA, Duby JJ, Wilson MD, Fine JR, Cocanour CS. Effect of Delay and Disruption in Venous Thromboembolism Prophylaxis in Trauma Patients: Case-Control Study. J Am Coll Surg 2022; 235:34-40. [PMID: 35703960 PMCID: PMC9204836 DOI: 10.1097/xcs.0000000000000232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma patients are at high risk for venous thromboembolism (VTE) and bleeding. The purpose of this study was to characterize percentage of VTE chemoprophylaxis given to trauma patients with and without a VTE. STUDY DESIGN This retrospective case-control study evaluated trauma patients admitted to a Level I trauma center. Adult patients were included when hospitalized at least 2 days and had a head abbreviated injury score of 1 or less. Non-VTE patients were matched by decade of life and injury severity score (ISS). The primary outcome was percentage of VTE chemoprophylaxis received over the first 14 days of admission. Descriptive statistics, chi-squared test, Student's t-test, and Cox proportional hazard were used for analysis. RESULTS A total of 44 VTE patients were included with 125 matched non-VTE patients. Baseline demographics included age in years (50.7 ± 19.6 vs 49.6 ± 19.4), ISS (18.9 ± 11.3 vs 19 ± 11.6), and lower extremity fracture (54.5% vs 40%), for VTE and non-VTE groups, respectively. The primary outcome of VTE chemoprophylaxis doses given was significantly lower for VTE patients than non-VTE patients (49.3% vs 59.3%, p = 0.0069). Significant predictors of VTE were percentage of VTE chemoprophylaxis doses given (p < 0.0001) and weight (p = 0.0042) based on regression analysis. Notably, there was a 7% decrease in the hazard for VTE for every 1% increase in VTE chemoprophylaxis given. CONCLUSIONS Patients who developed VTE were more likely to have delays and disruptions in VTE chemoprophylaxis, even after controlling for age, sex, ISS, lower extremity fractures, and number of operations.
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Affiliation(s)
- Jessica A Falksen
- From the Departments of Pharmacy (Falksen, Duby), University of California, Davis Health, Sacramento, CA
| | - Jeremiah J Duby
- From the Departments of Pharmacy (Falksen, Duby), University of California, Davis Health, Sacramento, CA
| | - Machelle D Wilson
- Public Health Sciences (Wilson, Fine), University of California, Davis Health, Sacramento, CA
| | - Jeffrey R Fine
- Public Health Sciences (Wilson, Fine), University of California, Davis Health, Sacramento, CA
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Trends and risk factors for omission of early thromboprophylaxis in Australian and New Zealand ICUs between 2009 and 2020. Intensive Care Med 2022; 48:590-598. [PMID: 35362763 PMCID: PMC9050753 DOI: 10.1007/s00134-022-06672-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/05/2022] [Indexed: 12/18/2022]
Abstract
Purpose Venous thromboembolism (VTE) prophylaxis is effective in reducing VTE events; however, it is underutilized in critically ill patients. We examined trends and risk factors for omission of early thromboprophylaxis within the first 24 h after admission in Australian and New Zealand intensive care units (ICUs) between 2009 and 2020. Methods Retrospective analysis of data from the Australian New Zealand Intensive Care Society Adult Patient Database. Data were obtained for 1,465,020 adult admissions between 2009 and 2020. Mixed effects logistic regression modeling (accounting for the random effects of the contributing ICUs) was used to identify factors associated with omission of early thromboprophylaxis. Results A total of 107,486 (7.3%) ICU patients did not receive any form of thromboprophylaxis within the first 24 h after ICU admission without obvious reasons. Omission of early thromboprophylaxis declined from 13.7% in 2009 to 4% in 2020 (by 70.8%) (P < 0.001). Younger patients were more like to miss out on VTE prophylaxis (odds ratios (OR)per 10-year increase 0.94, 95% CI 0.95–0.99). A documented process for monitoring VTE prophylaxis (ORs 0.90, 95% CI 0.87–0.93) and having a medical lead, dedicated for coordinating ICU quality (ORper 0.1 increase in full-time equivalent 0.97, 95% CI 0.93–0.99), are associated with less omission of VTE prophylaxis. Conclusion Omission of thromboprophylaxis within the first 24 h after ICU admission has declined steadily over the past decade. Documented process for monitoring VTE prophylaxis and having a medical lead for coordinating quality of ICU care could be potential targets for sustaining the improvement in VTE prophylaxis use. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06672-7.
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15
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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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16
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Karajizadeh M, Zand F, Sharifian R, Nikandish R, Vazin A, Davoodian L, Nasimi S. Experience with Pharmacological Prophylaxis for Venous Thromboembolism in Surgical ICUs in Tertiary Care Hospitals in Southwest Asia. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03299-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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17
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Rodriguez JJ, Munoz OC, Porres-Aguilar M, Mukherjee D. Thromboembolic Complications in Severe COVID-19: Current Antithrombotic Strategies and Future Perspectives. Cardiovasc Hematol Disord Drug Targets 2021; 21:23-29. [PMID: 33719953 DOI: 10.2174/1871529x21666210315123347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/18/2021] [Accepted: 02/15/2021] [Indexed: 01/08/2023]
Abstract
The coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus (SARS- CoV-2) is our latest pandemic and has turned out to be a global public health crisis. One of the special characteristics of this disease is that it may predispose patients to thrombotic disease both in the venous and arterial circulation. We review arterial and venous thromboembolic complications in patients with COVID-19, epidemiology, pathogenesis, hematologic biomarkers, and current antithrombotic strategies. Future perspectives and clinical trials are ongoing to determine the best thromboprophylaxis strategies in the hospitalized patients with severe COVID-19.
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Affiliation(s)
- Juan J Rodriguez
- Facultad de Medicina, Universidad Autonoma Bucaramanga, Bucaramanga, Colombia
| | - Oscar C Munoz
- Department of Interventional Cardiology, Del Sol Medical Center, El Paso, TX 79925, United States
| | - Mateo Porres-Aguilar
- Division of Adult Thrombosis Medicine, Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC) at Jewish General Hospital, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Department of Medicine, Texas Tech University Health Sciences Center at El Paso, El Paso, TX 79905, United States
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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: 19] [Impact Index Per Article: 6.3] [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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Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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21
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Integrating the "best" evidence into nursing of venous thromboembolism in ICU patients using the i-PARIHS framework. PLoS One 2020; 15:e0237342. [PMID: 32760163 PMCID: PMC7410309 DOI: 10.1371/journal.pone.0237342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/23/2020] [Indexed: 11/19/2022] Open
Abstract
Objectives To explore how to integrate the “best” practice into nursing of venous thromboembolism (VTE) based on the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Methods A mixed-methods design was used. A steering group for clinical evidence implementation (EI) was established to conduct pre-implementation baseline surveys, a thorough analysis of the evidence, and an analysis of the survey results. The hindering and enabling factors associated with the clinical implementation of the evidence were analysed based on the three core elements of i-PARIHS, to formulate the clinical implementation plan for VTE nursing evidence. On-site expert reviews and focus group interviews were used to evaluate the feasibility of the draft plan, make adjustments, and finalize the evidence-based practice plan, which was then put into practice and evaluated. Results A new nursing process, a health education manual and a nursing quality checklist on VTE has been established and proved to be appropriate through the implementation. Compliance with evidence related to VTE nursing increased significantly in the two units, with better compliance in unit B than unit A. The knowledge, attitude and behaviour scores for VTE nursing increased substantially in both nurses and patients. Conclusion The EI programme of incorporating the “best” evidence on VTE nursing into clinical practice using the i-PARIHS framework demonstrated feasibility, appropriateness and effectiveness and could serve as a reference.
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Abstract
OBJECTIVES Critically ill patients with deranged conventional coagulation tests are often perceived to have an increased bleeding risk. Whether anticoagulant prophylaxis for these patients should be withheld is contentious. This study assessed the ability of using in vitro clot strength, as measured by thromboelastography, to predict thromboembolism in patients with abnormal coagulation profiles. DESIGN Prospective cohort study. SETTING A tertiary ICU. PATIENTS Two-hundred and fifteen critically ill coagulopathic patients with thrombocytopenia and/or a derangement in at least one conventional coagulation test (international normalized ratio or activated partial thromboplastin time) within 48 hours of ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thromboelastography was performed for all study patients, and plasma thrombotic biomarkers were measured in a nested cohort (n = 40). Of the 215 patients included, 34 patients (16%) developed subsequent thromboembolism-predominantly among those with a normal (maximum amplitude, 54-72 mm) or increased (maximum amplitude, > 72 mm) in vitro clot strength on thromboelastography (91%; area under the receiver-operating characteristic curve, 0.74; 95% CI, 0.64-0.83). The ability of the maximum amplitude to predict thromboembolism was comparable to plasma P-selectin concentrations (thromboembolism, 78.3 ng/mL vs no thromboembolism, 59.5 ng/mL; p = 0.031; area under the receiver-operating characteristic curve, 0.73; 95% CI, 0.52-0.95). In addition, patients with an increased maximum amplitude were also less likely to receive blood product transfusions within 24 hours of testing compared with those with a subnormal maximum amplitude (12.8% vs 69.2%, respectively; area under the receiver-operating characteristic curve, 0.74; 95% CI, 0.67-0.80). CONCLUSIONS In patients with abnormal coagulation profiles, an increased in vitro clot strength on thromboelastography was associated with an increased risk of thromboembolism, and a reduced risk of requiring transfusion compared with those with a normal or reduced in vitro clot strength.
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Matusov Y, Weinberg AS, Liang R, Meza J, Friedman O, Tapson VF. Use of the Bedside-Placed Angel Catheter IVC Filter for Venous Thromboembolic Disease in Critically Ill Medical Patients. J Intensive Care Med 2019; 35:225-232. [PMID: 31994987 DOI: 10.1177/0885066619874692] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Venous thromboembolic disease is a major problem among critically ill patients, with significant associated morbidity and mortality. Many critically ill patients have contraindications to systemic anticoagulation, and inferior vena cava (IVC) filters are an important alternative in preventing pulmonary emboli (PE) in this population. The Angel Catheter (Mermaid, Stenlose, Denmark) is a novel percutaneous and removable IVC filter attached to the end of a triple lumen central venous catheter which has been demonstrated to reduce PE in surgical and trauma patients. This case series describes 18 critically ill medical patients who had an Angel catheter placed either for diagnosed PE or due to high risk for PE; over half had at least submassive PE at the time of Angel catheter placement. None of the patients had a recurrence of PE during Angel catheter use, 29.4% had clot found in the filter via cavogram upon removal, and only one had a minor complication which had no clinical consequence. In 2 patients, the placement of the Angel Catheter resulted in the prevention of PE during catheter-directed thrombolysis of extensive deep vein thrombosis. This case series demonstrates that in a population of critically ill, elderly, and obese medical patients the bedside placement of the Angel IVC filter is feasible, safe, and may be effective for preventing PE.
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Affiliation(s)
- Yuri Matusov
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Aaron S Weinberg
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Richard Liang
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph Meza
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Oren Friedman
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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24
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Vena Cava filters in severely-injured patients: One size does not fit all. Anaesth Crit Care Pain Med 2019; 38:305-307. [DOI: 10.1016/j.accpm.2019.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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25
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Ho KM, Rao S, Honeybul S, Zellweger R, Wibrow B, Lipman J, Holley A, Kop A, Geelhoed E, Corcoran T, Misur P, Edibam C, Baker RI, Chamberlain J, Forsdyke C, Rogers FB. A Multicenter Trial of Vena Cava Filters in Severely Injured Patients. N Engl J Med 2019; 381:328-337. [PMID: 31259488 DOI: 10.1056/nejmoa1806515] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Whether early placement of an inferior vena cava filter reduces the risk of pulmonary embolism or death in severely injured patients who have a contraindication to prophylactic anticoagulation is not known. METHODS In this multicenter, randomized, controlled trial, we assigned 240 severely injured patients (Injury Severity Score >15 [scores range from 0 to 75, with higher scores indicating more severe injury]) who had a contraindication to anticoagulant agents to have a vena cava filter placed within the first 72 hours after admission for the injury or to have no filter placed. The primary end point was a composite of symptomatic pulmonary embolism or death from any cause at 90 days after enrollment; a secondary end point was symptomatic pulmonary embolism between day 8 and day 90 in the subgroup of patients who survived at least 7 days and did not receive prophylactic anticoagulation within 7 days after injury. All patients underwent ultrasonography of the legs at 2 weeks; patients also underwent mandatory computed tomographic pulmonary angiography when prespecified criteria were met. RESULTS The median age of the patients was 39 years, and the median Injury Severity Score was 27. Early placement of a vena cava filter did not result in a significantly lower incidence of symptomatic pulmonary embolism or death than no placement of a filter (13.9% in the vena cava filter group and 14.4% in the control group; hazard ratio, 0.99; 95% confidence interval [CI], 0.51 to 1.94; P = 0.98). Among the 46 patients in the vena cava filter group and the 34 patients in the control group who did not receive prophylactic anticoagulation within 7 days after injury, pulmonary embolism developed in none of those in the vena cava filter group and in 5 (14.7%) in the control group, including 1 patient who died (relative risk of pulmonary embolism, 0; 95% CI, 0.00 to 0.55). An entrapped thrombus was found in the filter in 6 patients. CONCLUSIONS Early prophylactic placement of a vena cava filter after major trauma did not result in a lower incidence of symptomatic pulmonary embolism or death at 90 days than no placement of a filter. (Funded by the Medical Research Foundation of Royal Perth Hospital and others; Australian New Zealand Clinical Trials Registry number, ACTRN12614000963628.).
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Affiliation(s)
- Kwok M Ho
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Sudhakar Rao
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Stephen Honeybul
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Rene Zellweger
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Bradley Wibrow
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Jeffrey Lipman
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Anthony Holley
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Alan Kop
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Elizabeth Geelhoed
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Tomas Corcoran
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Philip Misur
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Cyrus Edibam
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Ross I Baker
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Jenny Chamberlain
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Claire Forsdyke
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
| | - Frederick B Rogers
- From the Departments of Intensive Care Medicine (K.M.H., J.C.), Neurosurgery (S.H.), and Radiology (P.M.), the State Trauma Unit (S.R., R.Z., C.F.), and the Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics (A.K.), Royal Perth Hospital, the Schools of Population and Global Health (K.M.H.), Allied Health (E.G.), and Medicine and Pharmacology (B.W., T.C.), University of Western Australia, and the School of Veterinary and Life Sciences (K.M.H.) and the Western Australian Centre for Thrombosis and Haemostasis (R.I.B.), Murdoch University, Perth, WA, the Departments of Neurosurgery (S.H.) and Intensive Care Medicine (B.W.), Sir Charles Gairdner Hospital, Nedlands, WA, Critical Care Services, Royal Brisbane and Women's Hospital and University of Queensland, Brisbane (J.L., A.H.), and the Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, WA (C.E.) - all in Australia; and Trauma Services, Lancaster General Hospital, University of Pennsylvania, Lancaster (F.B.R.)
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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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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 676] [Impact Index Per Article: 135.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Background Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient. Electronic supplementary material The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113, Usti nad Labem, Czech Republic.,Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005, Hradec Kralove, Czech Republic.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003, Hradec Kralove, Czech Republic.,Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275, Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328, Bucharest, Romania
| | - Beverley J Hunt
- King's College and Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000, Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924, Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76, Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181, Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
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Bertoletti L, Murgier M, Stelfox HT. Direct oral anticoagulants for venous thromboembolism prophylaxis in critically ill patients: where do we go from here? Intensive Care Med 2019; 45:549-551. [PMID: 30911805 DOI: 10.1007/s00134-019-05605-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/18/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, 42055, Saint-Etienne, France
- INSERM, CHU Saint-Etienne, CIC-1408, 42055, Saint-Etienne, France
| | - Martin Murgier
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, 42055, Saint-Etienne, France
- Service de Médecine Intensive et Réanimation, CHU de St-Etienne, Saint-Etienne, France
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Alberta Health Services, Calgary, AB, Canada.
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Reynolds PM, Van Matre ET, Wright GC, McQueen RB, Burnham EL, Ho PJM, Moss M, Vandivier RW, Kiser TH. Evaluation of Prophylactic Heparin Dosage Strategies and Risk Factors for Venous Thromboembolism in the Critically Ill Patient. Pharmacotherapy 2019; 39:232-241. [PMID: 30592541 DOI: 10.1002/phar.2212] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) occurs frequently in critically ill patients without heparin prophylaxis. Although heparin prevents VTE, VTEs occur frequently despite prophylaxis. A higher heparin dosage may be more effective for preventing VTE. METHODS A retrospective study was conducted using the Premier Incorporated Perspective Database to evaluate comparatively the effects of different heparin prophylaxis dosing strategies in the critically ill patient. Critically ill adult patients who were mechanically ventilated for at least 1 day and had an intensive care unit (ICU) length of stay of at least 2 days were included. Patients received 5000 units of heparin either twice/day or 3 times/day. The primary outcome was development of a new VTE. Key secondary outcomes included clinically important bleeding, thrombocytopenia, and mortality. Patients were propensity matched to control for confounding. Multivariable analysis was conducted for VTE risk factors. RESULTS The study included 30,800 patients from 374 hospitals who were propensity matched by heparin dosage. New VTE occurred in 6.16% of patients treated with 3 times/day heparin versus 6.23% with twice/day heparin (p=0.8). No significant differences in the incidence of pulmonary embolism (0.91% vs 0.8%, p=0.29) or deep vein thrombosis (5.56% vs 5.70% p=0.59) were observed between the two types of heparin dosing. No differences were observed between the two types of heparin dosing in in-hospital mortality (15.8% vs 15.15%), bleeding (0.23% vs 0.33%), or thrombocytopenia (5.19% vs 5.34%, p>0.08 for all), respectively. Risk factors associated with VTE included intraabdominal and urinary tract infections, loop diuretics, malnutrition, obesity, thrombocytopenia, paralytics, vasopressors, female sex, peripheral vascular disease, sepsis, neutropenia, and end-stage renal disease. Antiplatelet therapy, heart failure, diabetes, and substance abuse were associated with reduced VTE (p<0.05 for all). CONCLUSIONS In critically ill patients, prophylactic dosing of heparin 3 times/day versus twice/day was not associated with differences in new VTE or safety outcomes. Several modifiable VTE risk factors were identified.
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Affiliation(s)
- Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Edward T Van Matre
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Garth C Wright
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Robert Brett McQueen
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Ellen L Burnham
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, Colorado
| | - Pei Jai Michael Ho
- Department of Medicine, Division of Cardiology, VA Eastern Colorado Health Care System, Denver, Colorado
| | - Marc Moss
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, Colorado
| | - Robert William Vandivier
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, Colorado
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
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30
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Nandwana SK, Ho KM. A comparison of different modes of pneumatic compression on muscle tissue oxygenation: An intraparticipant, randomised, controlled volunteer study. Anaesth Intensive Care 2019; 47:23-31. [DOI: 10.1177/0310057x18811725] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Intermittent pneumatic compression (IPC) to the lower limbs is widely used as a mechanical means to prevent deep vein thrombosis in hospitalised patients. Due to a theoretical concern about impairing blood flow, thromboembolic-deterrent stockings and IPC are considered contraindicated for patients with peripheral vascular diseases by some clinicians. This study assessed whether IPC would alter peripheral limb muscle tissue oxygenation (StO2), and whether such changes were different during 10 minutes of sequential and single-compartment compressions. Twenty volunteers were randomised to have their left or right arm treated with a sequential or single-compartment IPC for 10 minutes, using the contralateral arm without compression as an intraparticipant control. After a five-minute wash-out period, the procedure was repeated on the same arm using the alternative mode of IPC. Both hands’ thenar muscles StO2 was monitored every two minutes for 10 minutes using the same near-infrared spectroscopy StO2 monitor. Both sequential (3.5%, 95% confidence intervals (CI) 2.7–4.2; p < 0.001) and single-compartment IPC (1.6%, 95% CI 0.4–2.8; p = 0.039) significantly increased muscle StO2 within 10 minutes compared to no compression; and the increments were higher during sequential compressions compared to during single-compartment compressions (2.1%, 95% CI 0.7–3.5; p = 0.023). This mechanistic study showed that both modes of IPC increased upper limb muscle StO2 compared to no compression, but the StO2 increments were higher with the multiple-chamber sequential compressions mode. Contrary to the theoretical concern that IPC may impair peripheral limb tissue oxygenation, our results showed that IPC actually increases oxygenation of the peripheral limb muscles, especially during the sequential compressions mode.
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Affiliation(s)
- Sanat K Nandwana
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Australia
- The University of Queensland, Brisbane, Australia
| | - Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Australia
- School of Population and Global Health, University of Western Australia, Perth, Australia
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31
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Harahsheh Y, Ho KM. Use of viscoelastic tests to predict clinical thromboembolic events: A systematic review and meta-analysis. Eur J Haematol 2018; 100:113-123. [DOI: 10.1111/ejh.12992] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Yusrah Harahsheh
- Department of Intensive Care Medicine; Royal Perth Hospital; Perth WA Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth WA Australia
| | - Kwok M. Ho
- Department of Intensive Care Medicine; Royal Perth Hospital; Perth WA Australia
- School of Population and Global Health; University of Western Australia; Perth WA Australia
- School of Veterinary and Life Sciences; Murdoch University; Perth WA Australia
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32
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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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33
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Baumann S, Becher T, Giannakopoulos K, Jabbour C, Rutsch M, Fastner C, El-Battrawy I, Ansari U, Lossnitzer D, Behnes M, Alonso A, Kirschning T, Michels G, Stern D, Dissmann R, Kueck O, Taccone FS, Waldmann C, Bunker N, Postiglione M, Borggrefe M, Akin I. Bedside implantation of a new temporary vena cava inferior filter - Safety and efficacy results of the European ANGEL-Registry. J Crit Care 2017; 44:39-44. [PMID: 29054070 DOI: 10.1016/j.jcrc.2017.10.009] [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: 09/07/2017] [Revised: 10/08/2017] [Accepted: 10/10/2017] [Indexed: 12/01/2022]
Abstract
PURPOSE Pulmonary embolism (PE) is a frequently occurring complication in critically ill patients. Simultaneous occurrence of PE and life-threatening bleeding, may render medical anticoagulation impossible. For these patients, inferior vena cava filters (IVCF) present a valuable therapeutic alternative. The Angel® catheter is a novel IVCF that provides temporary protection from PE and is implanted at bedside. The primary objective of the European Angel® catheter registry is to evaluate the safety and efficacy of this IVCF. MATERIAL AND METHODS The European Angel® catheter registry is an observational, multi-centre registry. Patients from four countries and eight sites that have undergone Angel® catheter implantation between March 2013 and February 2017 were enrolled. RESULTS A total of 114 critically ill patients were included. The main indication for implantation was a high-risk for PE in combination with contraindications for anticoagulation (69.3%). One clinically non-significant PE (0.9%) occurred in a patient with an indwelling Angel® catheter. No cases of catheter associated serious complications were observed. CONCLUSION Data shows that the Angel® catheter is a safe and effective approach to overcome the acute phase of critically ill patients with a high risk for the development of PE or an established PE, when an anticoagulation therapy is contraindicated.
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Affiliation(s)
- Stefan Baumann
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Tobias Becher
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Konstantinos Giannakopoulos
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Claude Jabbour
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Marlon Rutsch
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Christian Fastner
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Ibrahim El-Battrawy
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Uzair Ansari
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Dirk Lossnitzer
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Michael Behnes
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Angelika Alonso
- Department of Neurology, University Medical Centre Mannheim, University of Heidelberg, Germany.
| | - Thomas Kirschning
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Centre Mannheim, Mannheim, Germany.
| | - Guido Michels
- Department III of Internal Medicine, Heart Centre of the University of Cologne, Cologne, Germany.
| | - Daniel Stern
- Department III of Internal Medicine, Heart Centre of the University of Cologne, Cologne, Germany.
| | - Ruediger Dissmann
- Clinic of Cardiology, Nephrology and Intensive Care, Bremerhaven, Germany.
| | - Olaf Kueck
- Clinic of Anesthesia and Intensive Care, Bremerhaven, Germany.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | | | - Nicholas Bunker
- Department of Anesthesia, The Royal London Hospital, London, United Kingdom.
| | | | - Martin Borggrefe
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
| | - Ibrahim Akin
- First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany.
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34
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Prophylaxis for Venous Thromboembolism. Crit Care Nurs Q 2017; 40:219-229. [PMID: 28557893 DOI: 10.1097/cnq.0000000000000161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Venous thromboembolisms are major risk factors for many of our hospitalized patients. These events, however, can be prevented with prophylactic measurements when administered appropriately and on a timely basis. As patients are admitted, discharged, transferred, and scheduled for procedures on an hourly basis, anticoagulation and deep vein thrombosis prophylaxis are held or discontinued in anticipation for possible procedures. This results in delay of care and intervals where patients may not be covered with any prophylactic measurements. Similarly, alterations in clinical status can quickly change such as an increase in creatinine levels or the development of a new bleed, thus requiring a revision in their deep vein thrombosis prophylaxis. Nurses, therefore, play an integral role in not only administering the medicine but also routinely assessing the patients' clinical status and, therefore, their deep vein thrombosis prophylactic regimens as well. This article will review the indications, scoring systems, common prophylactic methods, and special populations at increased risks for venous thromboembolisms.
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Sutzko DC, Georgoff PE, Obi AT, Healy MA, Osborne NH. The association of venous thromboembolism chemoprophylaxis timing on venous thromboembolism after major vascular surgery. J Vasc Surg 2017; 67:262-271.e1. [PMID: 28870681 DOI: 10.1016/j.jvs.2017.06.087] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 06/04/2017] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is reported to occur in up to 33% of patients undergoing major vascular surgery. Despite this high incidence, patients inconsistently receive timely VTE chemoprophylaxis. The true incidence of VTE among patients receiving delayed VTE chemoprophylaxis is unknown. We sought to identify the association of VTE chemoprophylaxis timing on VTE risk, postoperative transfusion rates, and 30-day mortality and morbidity in patients undergoing major open vascular surgery. METHODS Patients undergoing major open vascular surgery (open abdominal aortic aneurysm [oAAA] repair, aortofemoral bypass, and lower extremity infrainguinal bypass [LEB]) were identified using the Michigan Surgical Quality Collaborative (MSQC) between July 2012 and June 2015. The VTE rate was compared between patients receiving early versus delayed VTE chemoprophylaxis. VTE chemoprophylaxis delay was defined as therapy initiation more than 24 hours after surgery. The risk-adjusted association of the chemoprophylaxis timing and VTE development was determined using multivariable logistic regression. Blood transfusion rates, 30-day mortality, and postoperative complications were compared across groups. RESULTS A total of 2421 patients underwent major open vascular surgery, including 196 oAAA repair, 259 aortofemoral bypass, and 1966 LEB. The overall incidence of 30-day VTE was 1.40%, ranging from 1.12% for LEB to 3.57% for oAAA repair. Among patients receiving early VTE chemoprophylaxis, the rate of VTE was 0.78% versus 2.26% among those with a delay in VTE chemoprophylaxis (P = .002). When accounting for the preoperative risk of VTE, delayed chemoprophylaxis was associated with a significantly higher risk of VTE (odds ratio, 2.38; 95% confidence interval, 1.12-5.06; P = .024). The early VTE chemoprophylaxis group was associated with a significantly decreased risk of bleeding compared with those with a delay (14.31% vs 18.90%; P = .002). Overall 30-day mortality and postoperative complications were similar with the exception of an associated higher rate of infectious complications in the delayed VTE chemoprophylaxis group, including superficial surgical site infection (6.00% vs 4.06%; P = .028), pneumonia (3.25% vs 1.85%; P = .028), urinary tract infection (2.95% vs 1.57%; P = .020), and severe sepsis (3.05% vs 1.71%; P = .029). CONCLUSIONS Although patients undergoing major open vascular surgery have a low risk of VTE at baseline, there is a significantly greater risk of developing VTE among patients who have a delay in the administration of VTE chemoprophylaxis. Postoperative transfusion rates were significantly lower among patients receiving early chemoprophylaxis. There were no differences in the 30-day mortality and postoperative complications, except for infectious complications. Given these findings, surgeons should consider early chemoprophylaxis in the postoperative setting after major open vascular surgery without contraindication.
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Affiliation(s)
- Danielle C Sutzko
- Section of Vascular Surgery, University of Michigan Health System, Ann Arbor, Mich.
| | - Patrick E Georgoff
- Section of Vascular Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Andrea T Obi
- Section of Vascular Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Mark A Healy
- Section of Vascular Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Nicholas H Osborne
- Section of Vascular Surgery, University of Michigan Health System, Ann Arbor, Mich
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Ho KM, Rao S, Honeybul S, Zellweger R, Wibrow B, Lipman J, Holley A, Kop A, Geelhoed E, Corcoran T. Detailed assessment of benefits and risks of retrievable inferior vena cava filters on patients with complicated injuries: the da Vinci multicentre randomised controlled trial study protocol. BMJ Open 2017; 7:e016747. [PMID: 28706106 PMCID: PMC5541499 DOI: 10.1136/bmjopen-2017-016747] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Retrievable inferior vena cava (IVC) filters have been increasingly used in patients with major trauma who have contraindications to anticoagulant prophylaxis as a primary prophylactic measure against venous thromboembolism (VTE). The benefits, risks and cost-effectiveness of such strategy are uncertain. METHODS AND ANALYSIS Patients with major trauma, defined by an estimated Injury Severity Score >15, who have contraindications to anticoagulant VTE prophylaxis within 72 hours of hospitalisation to the study centre will be eligible for this randomised multicentre controlled trial. After obtaining consent from patients, or the persons responsible for the patients, study patients are randomly allocated to either control or IVC filter, within 72 hours of trauma admission, in a 1:1 ratio by permuted blocks stratified by study centre. The primary outcomes are (1) the composite endpoint of (A) pulmonary embolism (PE) as demonstrated by CT pulmonary angiography, high probability ventilation/perfusion scan, transoesophageal echocardiography (by showing clots within pulmonary arterial trunk), pulmonary angiography or postmortem examination during the same hospitalisation or 90-day after trauma whichever is earlier and (B) hospital mortality; and (2) the total cost of treatment including the costs of an IVC filter, total number of CT and ultrasound scans required, length of intensive care unit and hospital stay, procedures and drugs required to treat PE or complications related to the IVC filters. The study started in June 2015 and the final enrolment target is 240 patients. No interim analysis is planned; incidence of fatal PE is used as safety stopping rule for the trial. ETHICS AND DISSEMINATION Ethics approval was obtained in all four participating centres in Australia. Results of the main trial and each of the secondary endpoints will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ACTRN12614000963628; Pre-results.
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Affiliation(s)
- Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- School of Population Health, University of Western Australia, Perth, Western Australia, Australia
- School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia
| | - Sudhakar Rao
- State Trauma Unit, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Stephen Honeybul
- Department of Neurosurgery, Royal Perth Hospital and Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rene Zellweger
- State Trauma Unit, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Bradley Wibrow
- Department of Intensive Care Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jeffrey Lipman
- Critical Care Services, Royal Brisbane and Women’s Hospital and University of Queensland, Herston, Queensland, Australia
| | - Anthony Holley
- Critical Care Services, Royal Brisbane and Women’s Hospital and University of Queensland, Herston, Queensland, Australia
| | - Alan Kop
- Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Elizabeth Geelhoed
- School of Population Health, University of Western Australia, Perth, Western Australia, Australia
| | - Tomas Corcoran
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
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Baumann S, Becher T, Giannakopoulos K, Jabbour C, Fastner C, El-Battrawy I, Ansari U, Lossnitzer D, Behnes M, Alonso A, Kirschning T, Dissmann R, Kueck O, Stern D, Michels G, Borggrefe M, Akin I. [Bedside implantation of a new temporary vena cava inferior filter : German results from the European ANGEL registry]. Med Klin Intensivmed Notfmed 2017; 113:184-191. [PMID: 28470480 DOI: 10.1007/s00063-017-0294-9] [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: 02/18/2017] [Revised: 03/16/2017] [Accepted: 03/30/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a frequently occurring complication in critically ill patients, and the simultaneous occurrence of PE and life-threatening bleeding is a therapeutic dilemma. Inferior vena cava filters (IVCF) may represent an important therapeutic alternative in these cases. The Angel® catheter (Bio2 Medical Inc., San Antonio, TX, USA) is a novel IVCF that provides temporary protection from PE and is implanted at bedside without fluoroscopy. MATERIAL AND METHODS The European Angel® Catheter Registry is an observational, multicenter study. In our German substudy, we investigated patients from three German hospitals and four intensive care units, who underwent Angel® catheter implantation between February 2016 and December 2016. RESULTS A total of 23 critically ill patients (68 ± 9 years, 43% male) were included. The main indication for implantation was a high risk for or an established PE, combined with contraindications for prophylactic or therapeutic anticoagulation due to either an increased risk of bleeding (81%) or active bleeding (13%). The Angel® catheter was successfully inserted in all patients at bedside. No PE occurred in patients with an indwelling Angel® catheter. Clots with a diameter larger the 20 mm, indicating clot migration, were detected in 5% of the patients by cavography before filter retrieval. Filter retrieval was uneventful in all of our cases, while filter dislocation occurred in 3% of the patients. CONCLUSION The German data from the multicenter European Angel® Catheter Registry show that the Angel® catheter is a safe and effective approach for critically ill patients with a high risk for the development of PE or an established PE, when an anticoagulation therapy is contraindicated.
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Affiliation(s)
- S Baumann
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - T Becher
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - K Giannakopoulos
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - C Jabbour
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - C Fastner
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - I El-Battrawy
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - U Ansari
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - D Lossnitzer
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - M Behnes
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - A Alonso
- Neurologische Klinik, Universitätsklinikum Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - T Kirschning
- Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - R Dissmann
- Medizinische Klinik II - Kardiologie, Nephrologie und Dialyse, Klinikum Bremerhaven, Bremerhaven, Deutschland
| | - O Kueck
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Bremerhaven, Bremerhaven, Deutschland
| | - D Stern
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Köln, Deutschland
| | - G Michels
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Köln, Deutschland
| | - M Borggrefe
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - I Akin
- I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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Ho KM, Pavey W. Applying the Cell-Based Coagulation Model in the Management of Critical Bleeding. Anaesth Intensive Care 2017; 45:166-176. [DOI: 10.1177/0310057x1704500206] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
The cell-based coagulation model was proposed 15 years ago, yet has not been applied commonly in the management of critical bleeding. Nevertheless, this alternative model may better explain the physiological basis of current coagulation management during critical bleeding. In this article we describe the limitations of the traditional coagulation protein cascade and standard coagulation tests, and explain the potential advantages of applying the cell-based model in current coagulation management strategies. The cell-based coagulation model builds on the traditional coagulation model and explains many recent clinical observations and research findings related to critical bleeding unexplained by the traditional model, including the encouraging results of using empirical 1:1:1 fresh frozen plasma:platelets:red blood cells transfusion strategy, and the use of viscoelastic and platelet function tests in patients with critical bleeding. From a practical perspective, applying the cell-based coagulation model also explains why new direct oral anticoagulants are effective systemic anticoagulants even without affecting activated partial thromboplastin time or the International Normalized Ratio in a dose-related fashion. The cell-based coagulation model represents the most cohesive scientific framework on which we can understand and manage coagulation during critical bleeding.
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Affiliation(s)
- K. M. Ho
- Intensive Care Specialist, Department of Intensive Care, Royal Perth Hospital, Clinical Associate Professor, School of Population Health, University of Western Australia, Adjunct Associate Professor, School of Veterinary & Life Sciences, Murdoch University, Perth, Western Australia
| | - W. Pavey
- Consultant Cardiac Anaesthetist, Department of Anaesthesia, Fiona Stanley Hospital and Adjunct Lecturer, School of Veterinary & Life Sciences, Murdoch University, Perth, Western Australia
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Vázquez-Alonso E, Iturri Clavero F, Valencia Sola L, Fábregas N, Ingelmo Ingelmo I, Valero R, Cassinello C, Rama-Maceiras P, Jorques A. Clinical practice guideline on thromboprophylaxis and management of anticoagulant and antiplatelet drugs in neurosurgical and neurocritical patients. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:406-418. [PMID: 26965554 DOI: 10.1016/j.redar.2016.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 01/18/2016] [Indexed: 06/05/2023]
Affiliation(s)
- E Vázquez-Alonso
- Servicio de Anestesiología, Complejo Hospitalario Universitario Granada, Granada, España.
| | - F Iturri Clavero
- Servicio de Anestesiología, Hospital Universitario Cruces, , Bilbao, Vizcaya, España
| | - L Valencia Sola
- Servicio de Anestesiología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, España
| | - N Fábregas
- Servicio de Anestesiología, Hospital Clinic, Universitat de Barcelona, Barcelona, España
| | - I Ingelmo Ingelmo
- Servicio de Anestesiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - R Valero
- Servicio de Anestesiología, Hospital Clinic, Universitat de Barcelona, Barcelona, España
| | - C Cassinello
- Servicio de Anestesiología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - P Rama-Maceiras
- Servicio de Anestesiología, Complejo Hospitalario Universitario Juan Canalejo, A Coruña, España
| | - A Jorques
- Servicio de Neurocirugía, Complejo Hospitalario Universitario Granada, Granada, España
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Viejo Moreno R, Sánchez-Izquierdo Riera JÁ, Molano Álvarez E, Barea Mendoza JA, Temprano Vázquez S, Díaz Castellano L, Montejo González JC. Improvement of the safety of a clinical process using failure mode and effects analysis: Prevention of venous thromboembolic disease in critical patients. Med Intensiva 2016; 40:483-490. [PMID: 27017441 DOI: 10.1016/j.medin.2016.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 02/11/2016] [Accepted: 02/15/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To improve critical patient safety in the prevention of venous thromboembolic disease, using failure mode and effects analysis as safety tool. DESIGN A contemporaneous cohort study covering the period January 2014-March 2015 was made in 4 phases: phase 1) prior to failure mode and effects analysis; phase 2) conduction of mode analysis and implementation of the detected improvements; phase 3) evaluation of outcomes, and phase 4) (post-checklist introduction impact. SETTING Patients admitted to the adult polyvalent ICU of a third-level hospital center. PATIENTS A total of 196 patients, older than 18 years, without thromboembolic disease upon admission to the ICU and with no prior anticoagulant treatment. INTERVENTIONS A series of interventions were implemented following mode analysis: training, and introduction of a protocol and checklist to increase preventive measures in relation to thromboembolic disease. VARIABLES OF INTEREST Indication and prescription of venous thrombosis prevention measures before and after introduction of the measures derived from the failure mode and effects analysis. RESULTS A total of 59, 97 and 40 patients were included in phase 1, 3 and 4, respectively, with an analysis of the percentage of subjects who received thromboprophylaxis. The failure mode and effects analysis was used to detect potential errors associated to a lack of training and protocols referred to thromboembolic disease. An awareness-enhancing campaign was developed, with staff training and the adoption of a protocol for the prevention of venous thromboembolic disease. The prescription of preventive measures increased in the phase 3 group (91.7 vs. 71.2%, P=.001). In the post-checklist group, prophylaxis was prescribed in 97.5% of the patients, with an increase in the indication of dual prophylactic measures (4.7, 6.7 and 41%; P<.05). There were no differences in complications rate associated to the increase in prophylactic measures. CONCLUSIONS The failure mode and effects analysis allowed us to identify improvements in the prevention of thromboembolic disease in critical patients. We therefore consider that it may be a useful tool for improving patient safety in different processes.
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Affiliation(s)
- R Viejo Moreno
- UCI Polivalente, Servicio de Medicina Intensiva, Hospital 12 de Octubre, Madrid, España.
| | | | - E Molano Álvarez
- UCI Polivalente, Servicio de Medicina Intensiva, Hospital 12 de Octubre, Madrid, España
| | - J A Barea Mendoza
- UCI Polivalente, Servicio de Medicina Intensiva, Hospital 12 de Octubre, Madrid, España
| | - S Temprano Vázquez
- UCI Polivalente, Servicio de Medicina Intensiva, Hospital 12 de Octubre, Madrid, España
| | - L Díaz Castellano
- UCI Polivalente, Servicio de Medicina Intensiva, Hospital 12 de Octubre, Madrid, España
| | - J C Montejo González
- UCI Polivalente, Servicio de Medicina Intensiva, Hospital 12 de Octubre, Madrid, España
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Park JY, Park S, Park SY, Sim YS, Kim JH, Hwang YI, Jang SH, Jung KS. Day 3 versus Day 1 Disseminated Intravascular Coagulation Score among Sepsis Patients: A Prospective Observational Study. Anaesth Intensive Care 2016; 44:57-64. [DOI: 10.1177/0310057x1604400110] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The role of disseminated intravascular coagulation (DIC) has not been extensively studied in patients with sepsis. A prospective study was performed in a single university hospital. The incidences of DIC at day 1 (<24 hours post-sepsis diagnosis) and day 3 (48 to 72 hours) were investigated among patients with sepsis. The International Society of Thrombosis and Haemostasis criteria for DIC were used. Among 381 patients initially screened, 219 were enrolled in this study and the incidences of overt DIC were 27.9% and 30.1% on day 1 and day 3, respectively. Patients with pneumonia had a lower incidence of DIC on day 1, but a higher hospital mortality rate compared to those with non-pneumonia sepsis. In multivariate models, although day 1 and day 3 DIC scores were not associated with hospital mortality after adjusting for existing severity scores, the change in DIC scores (odds ratio 1.862; 95% confidence interval 1.061 to 3.266) exhibited a significant association. Day 3 DIC scores were more accurate in predicting hospital mortality than day 1 DIC scores ( P <0.001), especially in patients with non-pneumonia sepsis. However, DIC scores did not give additional discriminative power to the existing prognostic scores in predicting mortality of patients with sepsis. In conclusion, the change in DIC score was significantly associated with hospital mortality. Patients with pneumonia sepsis had a lower incidence of DIC on day 1, despite their higher disease severity and mortality rate, compared to those with other sources of sepsis.
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Affiliation(s)
- J. Y. Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
| | - S. Park
- Division of Pulmonary, Allergy and Critical Care Medicine and Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
| | - S. Y. Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
| | - Y. S. Sim
- Division of Pulmonary, Allergy and Critical Care Medicine and Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul, Korea
| | - J. H. Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
| | - Y. I. Hwang
- Division of Pulmonary, Allergy and Critical Care Medicine and Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
| | - S. H. Jang
- Division of Pulmonary, Allergy and Critical Care Medicine and Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
| | - K. S. Jung
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
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Ho KM, Harahsheh Y. Intermittent pneumatic compression is effective in reducing proximal DVT. Evid Based Nurs 2015; 19:47. [PMID: 26622066 DOI: 10.1136/eb-2015-102265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Kwok Ming Ho
- Department of Intensive Care Medicine, Royal Perth Hospital School of Population Health, University of Western Australia School of Veterinary & Life Sciences, Murdoch University
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Ho KM, Bham E, Pavey W. Incidence of Venous Thromboembolism and Benefits and Risks of Thromboprophylaxis After Cardiac Surgery: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2015; 4:e002652. [PMID: 26504150 PMCID: PMC4845147 DOI: 10.1161/jaha.115.002652] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background Optimal thromboprophylaxis after cardiac surgery is uncertain. This systematic review aimed to define the incidence and risk factors for deep vein thrombosis (DVT), fatal and nonfatal pulmonary embolism (PE), and assess whether venous thromboembolism (VTE) prophylaxis was effective in reducing VTE without complications after cardiac surgery. Methods and Results Two reviewers independently searched and assessed the quality and outcomes of randomized, controlled trials (RCTs) and observational studies on VTE after cardiac surgery in the MEDLINE, EMBASE, and Cochrane controlled trial register (1966 to December 2014). Sixty‐eight studies provided data on VTE outcomes or complications related to thromboprophylaxis after cardiac surgery. The majority of the studies were observational studies (n=49), 16 studies were RCTs, and 3 were meta‐analyses. VTE prophylaxis was associated with a reduced risk of PE (relative risk [RR], 0.45; 95% confidence interval [CI], 0.28–0.72; P=0.0008) or symptomatic VTE (RR, 0.44; 95% CI, 0.28–0.71; P=0.0006) compared to the control without significant heterogeneity. Median incidence (interquartile range) of symptomatic DVT, PE, and fatal PE were 3.2% (0.6–8.1), 0.6% (0.3–2.9), and 0.3% (0.08–1.7), respectively. Previous history of VTE, obesity, left or right ventricular failure, and prolonged bed rest, mechanical ventilation, or use of a central venous catheter were common risk factors for VTE. Bleeding or cardiac tamponade requiring reoperation owing to pharmacological VTE prophylaxis alone, without systemic anticoagulation, was not observed. Conclusions Unless proven otherwise by adequately powered RCTs, initiating pharmacological VTE prophylaxis as soon as possible after cardiac surgery for patients who have no active bleeding is highly recommended.
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Affiliation(s)
- Kwok M Ho
- Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia (K.M.H.) School of Population Health, University of Western Australia, Perth, WA, Australia (K.M.H.) School of Veterinary and Life Sciences, Murdoch University, Perth, WA, Australia (K.M.H., W.P.)
| | - Ebrahim Bham
- Department of Anesthesia, Fiona Stanley Hospital, Perth, WA, Australia (E.B., W.P.)
| | - Warren Pavey
- School of Veterinary and Life Sciences, Murdoch University, Perth, WA, Australia (K.M.H., W.P.) Department of Anesthesia, Fiona Stanley Hospital, Perth, WA, Australia (E.B., W.P.)
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46
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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: 15] [Impact Index Per Article: 1.7] [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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Fontaine GV, Vigil E, Wohlt PD, Lloyd JF, Evans RS, Collingridge DS, Stevens SM, Woller SC. Venous Thromboembolism in Critically Ill Medical Patients Receiving Chemoprophylaxis. Clin Appl Thromb Hemost 2015; 22:265-73. [DOI: 10.1177/1076029615604048] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Purpose: To compare the incidence of 90-day venous thromboembolism (VTE) in obese critically ill medical patients receiving VTE chemoprophylaxis with nonobese patients of similar illness severity. We also identified other VTE risk factors. Methods: Eligible patients spent ≥24 hours in an intensive care unit between November 2007 and November 2013 and received VTE chemoprophylaxis within 48 hours of admission. The primary outcome was 90-day VTE. Results: A total of 11 111 patients were evaluated, of which 1732 obese and 1831 nonobese patients were enrolled with mean BMIs of 38.9 ± 9.2 kg/m2 and 24.5 ± 3.1 kg/m2 and mean Acute Physiology and Chronic Health Evaluation II scores of 28.4 ± 11.8 and 26.6 ± 11.7, respectively. The rate of 90-day VTE for the total cohort, obese, and nonobese patients was 6.5%, 7.5%, and 5.5%, respectively. Obese patients were more likely to develop VTE compared with nonobese patients (odds ratio [OR]: 1.41; 95% confidence interval [CI]: 1.03 -1.93). Other risk factors significantly associated with 90-day VTE included prior VTE (OR: 3.93; 95% CI: 1.83-8.48), trauma with surgery in the previous 30 days (OR: 3.70; 95% CI: 1.39-9.86), central venous catheters (OR: 2.64; 95% CI: 1.87-3.72), surgery within 90 days (OR: 2.40; 95% CI: 1.61-3.58), mechanical ventilation (OR: 1.94; 95% CI: 1.39-2.71), male sex (OR: 1.55; 95% CI: 1.13-2.14), and increasing age using 1-year increments (OR: 1.02; 95% CI: 1.01 -1.03). Conclusions: The rate of VTE in critically ill medical patients remains high despite standard chemoprophylaxis. Obesity is among 8 risk factors independently associated with 90-day VTE.
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Affiliation(s)
- Gabriel V. Fontaine
- Department of Pharmacy, Critical Care Medicine Division, Intermountain Medical Center, Murray, UT, USA
| | - Emily Vigil
- Department of Pharmacy, Critical Care Medicine Division, Intermountain Medical Center, Murray, UT, USA
| | - Paul D. Wohlt
- Department of Pharmacy, Critical Care Medicine Division, Intermountain Medical Center, Murray, UT, USA
| | - James F. Lloyd
- Department of Medical Informatics, LDS Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - R. Scott Evans
- Department of Biomedical Informatics, Intermountain Healthcare, University of Utah, Salt Lake City, UT, USA
- Department of Medical Informatics, LDS Hospital, Salt Lake City, UT, USA
| | | | - Scott M. Stevens
- Department of Medicine, Intermountain Medical Center, Murray, UT, USA
- Division of General Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Scott C. Woller
- Department of Medicine, Intermountain Medical Center, Murray, UT, USA
- Division of General Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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48
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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: 143] [Impact Index Per Article: 15.9] [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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49
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Ho KM, Duff OC. Predictors of an Increased in Vitro Thrombotic and Bleeding Tendency in Critically Ill Trauma and Non-Trauma Patients. Anaesth Intensive Care 2015; 43:317-322. [DOI: 10.1177/0310057x1504300306] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Trauma patients are at a high risk of both bleeding and thromboembolism. This study assessed whether conventional coagulation blood tests were reliable predictors of an increased in vitro thrombotic and bleeding tendency of trauma and non-trauma patients. Conventional coagulation blood tests and thromboelastographs of 63 trauma and 63 randomly selected, critically ill non-trauma patients were compared. Increased in vitro thrombotic and bleeding tendencies were defined by a maximum amplitude >72 mm or an angle >74° on the thromboelastograph and a maximum amplitude < 54 mm or an angle <47°, respectively. In vitro thrombotic tendency was more common than bleeding tendency and this was not different between the critically ill trauma and non-trauma patients (59% versus 67% with thrombotic tendency, P=0.461; 11% versus 10% with bleeding tendency, respectively, P=0.999). Thrombocytopenia (<150 × 109 /l) and low fibrinogen concentrations (<2 g/l) were the only two factors associated with an increased in vitro bleeding tendency (both P=0.001) and thrombocytopenia was the only factor associated with a lower risk of in vitro thrombotic tendency (21% versus 75%, P=0.001). Platelet counts (Pearson's correlation coefficient [ r]: 0.59, P=0.001) and fibrinogen concentrations ( r 0.61, P=0.001) both had a relatively linear association with maximum amplitude of the thromboelastograph. Prolonged International Normalized Ratio (>1.5) and activated Partial Thromboplastin Time (>40 seconds) were, however, not significantly associated with an increased in vitro thrombotic or bleeding tendency. In conclusion, in vitro thrombotic tendency was more common than bleeding tendency in critically ill trauma and non-trauma patients. Platelet counts and fibrinogen concentrations were better predictors of increased in vitro thrombotic and bleeding risks than International Normalized Ratio or activated Partial Thromboplastin Time.
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Affiliation(s)
- K. M. Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, School of Population Health, University of Western Australia, Perth, Western Australia
| | - O. C. Duff
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia
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50
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Prévention de la thrombose veineuse chez les patients obèses en réanimation. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1022-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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