Preventing Venous Thromboembolism in Critically Ill Patients

ABSTRACT

Critically ill patients in the medical-surgical intensive care unit are at high risk of both venous thromboembolism (VTE) and bleeding. Although thromboprophylaxis is of proven effectiveness in other settings, relatively little data exist to inform “best practice” for the prevention of VTE for these patients. This narrative review article presents the rate, clinical consequences, and optimal strategies to prevent VTE in critically ill patients, focusing primarily on medical-surgical intensive care unit (ICU) patients, but also addressing other specific subgroups of critically ill patients. Despite the large number of medical-surgical ICU patients, their moderately high risk of VTE, and the morbidity and mortality likely to be associated with the development of VTE, relatively little methodologically rigorous data are available to guide practice. Large, well-designed randomized trials, powered to detect differences in clinically relevant end points, are required to advance the care of this highly vulnerable patient population.

KEYWORDS

Venous thrombosis - prevention - critical illness

REFERENCES

• 1 Attia J, Ray J G, Cook D J, Douketis J, Ginsberg J S, Geerts W H. Deep vein thrombosis and its prevention in critically ill adults.  Arch Intern Med. 2001;  161 1268-1279
• 2 Geerts W H, Heit J A, Clagett G P et al.. Prevention of venous thromboembolism.  Chest. 2001;  119(1, Suppl) 132S-175S
• 3 Kakkar V V, Howe C T, Flanc C, Clarke M B. Natural history of postoperative deep-vein thrombosis.  Lancet. 1969;  2 230-232
• 4 Barritt D W, Jordan S C. Anticoagulant drugs in the treatment of pulmonary embolism: a controlled clinical trial.  Lancet. 1960;  1 1309-1312
• 5 Halkin H, Goldberg J, Modan M, Modan B. Reduction of mortality in general medical in-patients by low-dose heparin prophylaxis.  Ann Intern Med. 1982;  96 561-565
• 6 Clagett G P, Reisch J S. Prevention of venous thromboembolism in general surgical patients. Results of meta-analysis.  Ann Surg. 1988;  208 227-240
• 7 Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery.  N Engl J Med. 1988;  318 1162-1173
• 8 Hirsch D R, Ingenito E P, Goldhaber S Z. Prevalence of deep venous thrombosis among patients in medical intensive care.  JAMA. 1995;  274 335-337
• 9 Geerts W H, Jay R M, Code K I et al.. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma.  N Engl J Med. 1996;  335 701-707
• 10 Marik P E, Andrews L, Maini B. The incidence of deep venous thrombosis in ICU patients.  Chest. 1997;  111 661-664
• 11 Cook D J, Crowther M A, Meade M et al.. Deep vein thrombosis in medical-surgical ICU patients: prevalence, incidence and risk factors.  Crit Care Med. 2005;  33 1565-1571
• 12 Cook D, Douketis J, Meade M et al.. Venous thromboembolism and bleeding in critically ill patients with severe renal insufficiency receiving dalteparin thromboprophylaxis: prevalence, incidence and risk factors.  Crit Care. 2008;  12 R32
• 13 Cook D J, Rocker G, Meade M et al.. Prophylaxis of Thromboembolism in Critical Care (PROTECT) Trial: a pilot study.  J Crit Care. 2005;  20 364-372
• 14 Crowther M A, Cook D J, Griffith L E et al.. Deep venous thrombosis: clinically silent in the intensive care unit.  J Crit Care. 2005;  20 334-340
• 15 McKelvie P A. Autopsy evidence of pulmonary thromboembolism.  Med J Aust. 1994;  160 127-128
• 16 Moser K M, Fedullo P F, LitteJohn J K, Crawford R. Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis.  JAMA. 1994;  271 223-225
• 17 Douketis J D, Kearon C, Bates S, Duku E K, Ginsberg J S. Risk of fatal pulmonary embolism in patients with treated venous thromboembolism.  JAMA. 1998;  279 458-462
• 18 Stein P D, Henry J W. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy.  Chest. 1995;  108 978-981
• 19 Karwinski B, Svendsen E. Comparison of clinical and postmortem diagnosis of pulmonary embolism.  J Clin Pathol. 1989;  42 135-139
• 20 Twigg S J, McCrirrick A, Sanderson P M. A comparison of post mortem findings with post hoc estimated clinical diagnoses of patients who die in a United Kingdom intensive care unit.  Intensive Care Med. 2001;  27 706-710
• 21 Griffith L, Guyatt G, Walter S et al.. Attributable morbidity and mortality of DVT.  Crit Care Med. 2008;  35 A628
• 22 Geerts W H, Pineo G F, Heit J A et al.. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.  Chest. 2004;  126(3, Suppl) 338S-400S
• 23 Cade J F. High risk of the critically ill for venous thromboembolism.  Crit Care Med. 1982;  10 448-450
• 24 Fraisse F, Holzapfel L, Couland J M et al.. Nadroparin in the prevention of deep vein thrombosis in acute decompensated COPD. The Association of Non-University Affiliated Intensive Care Specialist Physicians of France.  Am J Respir Crit Care Med. 2000;  161(4 Pt 1) 1109-1114
• 25 Macdonald R L, Amidei C, Baron J et al.. Randomized, pilot study of intermittent pneumatic compression devices plus dalteparin versus intermittent pneumatic compression devices plus heparin for prevention of venous thromboembolism in patients undergoing craniotomy.  Surg Neurol. 2003;  59 363-372
• 26 Kurtoglu M, Yanar H, Bilsel Y et al.. Venous thromboembolism prophylaxis after head and spinal trauma: intermittent pneumatic compression devices versus low molecular weight heparin.  World J Surg. 2004;  28 807-811
• 27 Spinal Cord Injury Thromboprophylaxis Investigators. . Prevention of venous thromboembolism in the acute treatment phase after spinal cord injury: a randomized, multicenter trial comparing low-dose heparin plus intermittent pneumatic compression with enoxaparin.  J Trauma. 2003;  54 1116-1124
• 28 Green D, Lee M Y, Lim A C et al.. Prevention of thromboembolism after spinal cord injury using low-molecular-weight heparin.  Ann Intern Med. 1990;  113 571-574
• 29 Agnelli G, Piovella F, Buoncristiani P et al.. Enoxaparin plus compression stockings compared with compression stockings alone in the prevention of venous thromboembolism after elective neurosurgery.  N Engl J Med. 1998;  339 80-85
• 30 Hirsh J, Levine M N. Low molecular weight heparin.  Blood. 1992;  79 1-17
• 31 Weitz J I. Low-molecular-weight heparins.  N Engl J Med. 1997;  337 688-698
• 32 Buller H R, Agnelli G, Hull R D, Hyers T M, Prins M H, Raskob G E. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.  Chest. 2004;  126(3, Suppl) 401S-428S
• 33 Rabbat C G, Cook D J, Crowther M A et al.. Dalteparin thromboprophylaxis for critically ill medical-surgical patients with renal insufficiency.  J Crit Care. 2005;  20 357-363
• 34 Lim W, Dentali F, Eikelboom J W, Crowther M A. Meta-analysis: low-molecular-weight heparin and bleeding in patients with severe renal insufficiency.  Ann Intern Med. 2006;  144 673-684
• 35 Limpus A, Chaboyer W, McDonald E, Thalib L. Mechanical thromboprophylaxis in critically ill patients: a systematic review and meta-analysis.  Am J Crit Care. 2006;  15 402-410
• 36 Limpus A, Chaboyer W. The use of graduated compression stockings in Australian intensive care units: a national audit.  Aust Crit Care. 2003;  16 53-58
• 37 Decousus H, Leizorovicz A, Parent F et al.. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prevention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group.  N Engl J Med. 1998;  338 409-415