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Deep venous thromboembolism and pulmonary embolism are still underdiagnosed in the ICU. Thromboelastography (TEG) has shown considerable variability in sensitivity and specificity as a predictor of venous thromboembolism (VTE). We designed a prospective double-blind observational study to predict the risk of VTE using TEG in a cohort of critically ill patients. Seventy-two hours after admission in the ICU and consequent prophylaxis with low-molecular-weight heparin, we performed compressive color-Doppler ultrasound and diagnosed deep venous thrombosis. Computed tomography scan was performed for the diagnosis of pulmonary embolism if pulmonary embolism was suspected based on physical examination and transthoracic echocardiography. Whole blood samples were obtained from central venous lines 6-8 h after subcutaneous administration of low-molecular-weight heparin. Native TEG and modified heparinase TEG were performed using a Thromboelastograph Coagulation Analyzer. Fifty-seven patients were consecutively enrolled of which six (10.5%) developed deep venous thrombosis; two (3.5%) also developed pulmonary embolism. The native thrombodynamic ratio (TDR) was an independent predictor of the odds of thrombosis (odds ratio 1.016, P < 0.05, 95% confidence interval 1.008-1.047), with a 0.93 area under the ROC curve. Using 10.6 as the lower cut-off point, TDR showed 100% sensitivity and 0 negative likelihood ratio (95% confidence interval 0-0.4) in excluding the clinical diagnosis of VTE. Our results show that TDR predicts VTE in the ICU. Our findings are in agreement with those reported by other investigators, who demonstrated that a TDR less that 10 is associated with prophylactic levels of anti-Xa.

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The pulmonary artery catheter (PAC) is a hemodynamic monitor commonly used during cardiac surgery. Conventionally, the PAC is inserted intraoperatively using the pressure waveform transduction technique. The measurement of changes in pressure as the PAC traverses the superior vena cava to the main pulmonary artery helps guide PAC insertion. This approach to PAC insertion, however, can be challenging in patients with certain pathologic conditions such as: systolic heart failure, moderate-to-severe tricuspid regurgitation, right atrial enlargement, right ventricular enlargement, right ventricular outflow tract obstruction, and in those with intracardiac leads. 1,2 As a consequence, multiple attempts may be required during PAC insertion using the pressure waveform transduction technique, which may lead to complications such as arrhythmias, PAC kinking, tricuspid valve injury, and pulmonary artery injury. 1,2 Considering that the pressure transduction technique does not provide the operator the ability to visualize the location of the PAC during insertion, transesophageal echocardiography (TEE) may be of value during PAC placement.In a prior issue of the Journal, Cronin et al 2 reported on the successful use of TEE guidance for PAC catheter insertion in 20 patients with chronic thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy. During PAC placement, 11 of 20 patients required PAC manipulation based on TEE findings, resulting in expedited PAC insertion while avoiding complications. The median time of PAC insertion was 43 seconds, with the catheter insertion time ranging from 16 to 370 seconds. TEE facilitated PAC insertion in a safe and timely manner in these high-risk patients without any complications.This important, single-center study by Cronin et al 2 suggested that TEE placement before PAC insertion may be a useful technique during cardiac surgery. Despite the small, homogenous, and single-center nature of the study, the findings were remarkable. At the Ohio State University Wexner Medical Center, TEE is placed routinely before central venous access to facilitate safe and expedient PAC insertion in patients requiring PAC and TEE monitoring. The ability to visualize the PAC balloon during insertion is very useful and may reduce complications associated with PAC placement. 2 As such, in cardiac cases warranting TEE monitoring, PAC placement with TEE guidance in addition to the standard pressure transduction technique should be strongly considered. References 1 Gidwani UK, Mohanty B, Chatterjee K. The pulmonary artery catheter: A critical reappraisal. Cardiol Clin 2013;31:545-65. 2 Cronin B, Robbins R, Maus T. Pulmonary artery catheter placement using transesophageal echocardiography.We read, with interest, the article by Balzer et al. 1 As the authors eloquently remarked, postoperative hypertension (HTN) is more frequent in patients with a history of preoperative HTN and is associated with increased morbidity and mortality.The 20-year debate on preoperative management of antihyperte...

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