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Zhang M, Parikh B, Dirlikov B, Cage T, Lee M, Singh H. Elevated risk of venous thromboembolism among post-traumatic brain injury patients requiring pharmaceutical immobilization. J Clin Neurosci 2020; 75:66-70. [PMID: 32245600 DOI: 10.1016/j.jocn.2020.03.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/20/2020] [Indexed: 11/19/2022]
Abstract
Traumatic brain injury (TBI) patients are known to have a high rate of venous thromboembolism (VTE), and additional neuromuscular blockade or barbiturate coma therapy has the theoretical risk of exacerbating baseline hemostasis and elevating the incidence of thromboembolic events. We conducted a single-institution retrospective review of patients surviving severe TBI, as determined by need for intracranial pressure (ICP) monitoring, who further required paralytics or barbiturate therapy to maintain ICP control. Patients were administered VTE prophylaxis as clinically appropriate. Predictors for VTE were subsequently determined with univariate and logistic multivariate regression analyses. The main cohort includes 144 patients, 34 of whom received pharmaceutical immobilization for ICP control. Mean ISS and GCS at intake were 31.9 and 5.2, respectively. Among those receiving vs not-receiving paralytics and/or barbiturate therapy, there was a statistical difference of 12/34 (35.3%) vs 18/110 (16.4%, p = 0.0280) in VTE events, at a mean time greater than two weeks from the time of trauma. Multivariate logistics regression indicated 3.2 times increased odds of developing a VTE (log odds = 1.17, p = 0.023). No pediatric patients were positive for an event (0/12 vs 7/22, p = 0.0356), and infections were only documented among those with VTE (0/22 vs 4/12, p = 0.0107). Overall, paralytics and barbiturate therapy were correlated with a higher incidence of VTE among TBI patients. Although the need for ICP control will outweigh an increase in thromboembolic risk, there is value for increased surveillance and screening during the prolonged inpatient stay of these patients.
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Affiliation(s)
- Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA 94305, USA
| | - Bhavya Parikh
- Meharry Medical College, School of Medicine, 1005 Dr. D.B. Todd Jr. Blvd, Nashville, TN 37208, USA; Department of Neurosurgery, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Ben Dirlikov
- Department of Neurosurgery, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Tene Cage
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA 94305, USA; Department of Neurosurgery, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Marco Lee
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA 94305, USA; Department of Neurosurgery, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Harminder Singh
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA 94305, USA; Department of Neurosurgery, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA.
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Arabi YM, Burns KEA, Alsolamy SJ, Alshahrani MS, Al-Hameed FM, Arshad Z, Almaani M, Hawa H, Mandourah Y, Almekhlafi GA, Al Aithan A, Khalid I, Rifai J, Rasool G, Abdukahil SAI, Jose J, Afesh LY, Al-Dawood A. Surveillance or no surveillance ultrasonography for deep vein thrombosis and outcomes of critically ill patients: a pre-planned sub-study of the PREVENT trial. Intensive Care Med 2020; 46:737-746. [PMID: 32095845 DOI: 10.1007/s00134-019-05899-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/11/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE We examined the association between surveillance for deep vein thrombosis (DVT) among medical-surgical critically ill patients by twice-weekly ultrasonography and 90-day all-cause mortality. METHODS This was a pre-planned sub-study of the Pneumatic Compression for Preventing Venous Thromboembolism (PREVENT) trial (Clinicaltrials.gov: NCT02040103) that compared addition of intermittent pneumatic compression (IPC) to pharmacologic prophylaxis versus pharmacologic prophylaxis alone. The surveillance group included enrolled patients in the trial, while the non-surveillance group included eligible non-enrolled patients. Using logistic regression and Cox proportional hazards models, we examined the association of surveillance with the primary outcome of 90-day mortality. Secondary outcomes were DVT and pulmonary embolism (PE). RESULTS The surveillance group consisted of 1682 patients and the non-surveillance group included 383 patients. Using Cox proportional hazards model with bootstrapping, surveillance was associated with a decrease in 90-day mortality (adjusted HR 0.75; 95% CI 0.57, 0.98). Surveillance was associated with earlier diagnosis of DVT [(median 4 days (IQR 2, 10) vs. 20 days (IQR 16, 22)] and PE [median 4 days (IQR 2.5, 5) vs. 7.5 days (IQR 6.1, 28.9)]. There was an increase in diagnosis of DVT (adjusted HR 5.49; 95% CI 2.92, 13.02) with no change in frequency in diagnosis of PE (adjusted HR 0.56; 95% CI 0.19, 1.91). CONCLUSIONS Twice-weekly surveillance ultrasonography was associated with an increase in DVT detection, reduction in diagnostic testing for non-lower limb DVT and PE, earlier diagnosis of DVT and PE, and lower 90-day mortality. TRIAL REGISTRATION The PREVENT trial is registered at ClinicalTrials.gov, ID: NCT02040103. Registered on 3 November 2013; Current controlled trials, ID: ISRCTN44653506. Registered on 30 October 2013.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia. .,King Abdullah International Medical Research Center, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia. .,King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, Unity Health Toronto-St Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Sami J Alsolamy
- Intensive Care Department, Ministry of National Guard Health Affairs, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia
| | - Mohammed S Alshahrani
- Department of Emergency and Critical Care Medicine, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Fahad M Al-Hameed
- Intensive Care Department, Ministry of National Guard Health Affairs, Jeddah, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Zia Arshad
- Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, India
| | - Mohammed Almaani
- Department of Pulmonary and Critical Care Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Hassan Hawa
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Yasser Mandourah
- Military Medical Services, Ministry of Defense, Riyadh, Kingdom of Saudi Arabia
| | - Ghaleb A Almekhlafi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Abdulsalam Al Aithan
- Intensive Care Division, Department of Medicine, King Abdulaziz Hospital, Al Ahsa, Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Al Ahsa, Saudi Arabia.,King Abdullah International Medical Research Center, Al Ahsa, Kingdom of Saudi Arabia
| | - Imran Khalid
- Critical Care Section, Department of Medicine, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
| | - Jalal Rifai
- Intensive Care Department, Ministry of National Guard Health Affairs, Jeddah, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Gulam Rasool
- Intensive Care Department, Ministry of National Guard Health Affairs, Jeddah, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Sheryl Ann I Abdukahil
- Intensive Care Department, Ministry of National Guard Health Affairs, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia
| | - Jesna Jose
- King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,Department of Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Lara Y Afesh
- King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,Research Office, Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Abdulaziz Al-Dawood
- Intensive Care Department, Ministry of National Guard Health Affairs, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia
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Canty D, Mufti K, Bridgford L, Denault A. Point-of-care ultrasound for deep venous thrombosis of the lower limb. Australas J Ultrasound Med 2019; 23:111-120. [PMID: 34760590 DOI: 10.1002/ajum.12188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The incidence and morbidity of deep venous thrombosis (DVT) and pulmonary embolus are high. Although efforts to increase screening for DVT have been recommended, this is limited by resources. Venous duplex ultrasound has replaced venography as the first-line investigation of choice for DVT, increasing availability and reducing patient exposure to radiation and intravenous contrast. Furthermore, an abbreviated ultrasound where DVT is inferred from incomplete venous compressibility has an equivalent accuracy to venous duplex, requiring less time and training enabling its widespread use by emergency, critical care and anaesthesia clinicians. In this review, the evolution and method of lower limb venous compression ultrasound is described along with evidence for its use in patients at high risk for DVT in these clinical settings.
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Affiliation(s)
- David Canty
- Department of Surgery (Royal Melbourne Hospital) University of Melbourne Level 6 Centre for Medical Research, PO Box 2135 Melbourne Victoria 3050 Australia.,Department of Anaesthesia and Pain Management Royal Melbourne Hospital 300 Grattan Street, Parkville Melbourne Victoria 3050 Australia.,Department of Medicine, Nursing and Health Sciences Monash University Wellington Rd Clayton Victoria 3800 Australia.,Department of Anaesthesia and Perioperative Medicine Monash Health 246 Clayton Rd Clayton Victoria 3168 Australia
| | - Kavi Mufti
- Department of Medicine, Nursing and Health Sciences Monash University Wellington Rd Clayton Victoria 3800 Australia.,Intensive Care Unit Frankston Hospital 2 Hastings Road Frankston Victoria 3199 Australia
| | - Lindsay Bridgford
- Department of Surgery (Royal Melbourne Hospital) University of Melbourne Level 6 Centre for Medical Research, PO Box 2135 Melbourne Victoria 3050 Australia.,Department of Emergency Medicine Maroondah Hospital 1-15 Davey Dr Ringwood East Victoria 3135 Australia
| | - André Denault
- Department of Anesthesiology and Critical Care Faculty of Medicine University of Montreal 2900 Edouard Montpetit Blvd Montreal Quebec H3T 1J4 Canada.,Department of Anesthesiology and Critical Care Montreal Heart Institute 5000 Rue Bélanger Montreal Quebec QC H1T 1C8 Canada
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