Venous thromboembolism and its prevention in critical care,☆☆

https://doi.org/10.1053/jcrc.2002.33941Get rights and content

Abstract

Background: Evidence-based guidelines for the prevention of venous thromboembolism (VTE) are available for most major surgical and medical patient groups. Such guidelines have not been established for critically ill patients. Objective: To perform a systematic review of the prevalence of deep vein thrombosis (DVT), the efficacy of thromboprophylaxis, and the rates of thromboprophylaxis use in critically ill patients. Methods: Computerized literature search for relevant studies meeting prespecified criteria. Results: The rates of objectively confirmed DVT in 4 prospective studies ranged from 13% to 31%. We identified only 3 randomized trials (1 in abstract form) of thromboprophylaxis in critical care unit patients. These studies show the efficacy of low-dose heparin and low molecular weight heparin compared with no prophylaxis; however, we found no trials comparing these 2 interventions. Eleven compliance studies reported that some form of thromboprophylaxis was used in 33% to 100% of critically ill patients, although only 1 study addressed the issue of appropriate prophylaxis use. Conclusions: Data on the epidemiology of VTE and its prevention in critically ill patients are very limited. Further research is needed to better define patient risk factors for VTE, optimal methods of thromboprophylaxis, and strategies to improve compliance with prophylaxis recommendations. In the meantime, prevention strategies, shown to be effective in other related patient groups, and general principles of individual pharmacotherapy should guide the routine use of prophylaxis during critical illness. Copyright 2002, Elsevier Science (USA). All rights reserved.

Section snippets

Methods

We conducted a computerized, English-language, literature search by using Medline and Embase, from 1966 to January, 2002, using the keywords “venous thromboembolism” or “venous thrombosis” or “pulmonary embolism” and “critical care” or “intensive care units.” In addition, we reviewed the bibliographies of retrieved articles and our personal files. To be included, studies addressing the prevalence of DVT had to (1) be prospective, (2) enroll patients who did not receive thromboprophylaxis, and

VTE prevalence studies in critical care

Six studies have examined the rates of PE and fatal PE shown by autopsy in critically ill patients (Table 1).25, 26, 27, 28, 29, 30

. Autopsy studies of pulmonary embolism in critically Ill patients

Author (yr)ICU SettingAdmissions to ICUDeaths, n (% ICU Admissions)Autopsies n (% Deaths)PE, n (% Autopsies)Fatal PE,* n (% Autopsies)
Neuhaus (1978)25Medical/surgical617102 (17%)66 (65%)18 (27%)8 (12%)
Moser (1981)26Respiratory3416 (47%)10 (63%)2 (20%)0
Pingleton (1981)27Medical19756 (28%)40 (71%)9 (23%)

Discussion

Our main conclusion is that the risk for DVT and PE in critically ill patients is moderate to high, although the available studies are small and have methodologic limitations. The optimal methods of thromboprophylaxis in the intensive care unit are uncertain because of the paucity of randomized trials in critically ill patients. Therefore, current strategies for the prevention of VTE must largely be derived from studies in other patient populations.

For many reasons it is not surprising that

Future directions

It is clear that substantially more ICU-specific data about thromboembolic risks, risk factors, and prevention are required. In Table 9, we outline some of the areas that warrant further research.

. Future research objectives for thromboembolism in critical care

Epidemiology
 Prevalence of VTE on admission to the ICU
 Incidence of ICU-acquired VTE in heterogeneous ICU patients
 Analyses of the relative importance of VTE risk factors (genetic, pre-ICU, and ICU-acquired)
 Accuracy of noninvasive diagnostic

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      Risk factors for DVT in trauma include surgical trauma per se, vascular/cardiac catheters, immobility, application of tourniquet, and use of muscular blockade agents [7-9]. Identification of DVT in these cases is paramount because trauma patients frequently have significantly impaired cardio-respiratory reserves [16,17]; therefore, they cannot tolerate even a small pulmonary embolism or other pulmonary disturbances that an otherwise healthy patient can tolerate without difficulty [16-18]. Studies in trauma patients have reported varying rates of overall DVT events ranging from 0.36% to 58%, depending on the patients studied and the methods used to diagnose the DVT [19,20].

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    D.C. is a Chair of the Canadian Institutes for Health Research and Chair of the Canadian Critical Care Trials Group. R.S. holds a New Investigator Award from the Canadian Institutes for Health Research.

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