Incidence of venous thromboembolism in psychiatric inpatients: a chart review

Abstract

PurposeVenous thromboembolism (VTE) is the combination of pulmonary embolism (PE) and deep vein thrombosis. In recent years, VTE has been gaining attention in the field of psychiatry as it can cause sudden deaths in patients hospitalized in psychiatric departments. The purpose of this study was to investigate the incidence of VTE in psychiatric inpatients using contrast-enhanced computed tomography (CT).Patients and methodsAt the psychiatric department of the Akita University Hospital, NANOPIA® D-dimer was measured in patients with suspected symptomatic VTE or believed to be at risk for asymptomatic VTE. A follow-up contrast-enhanced CT was also performed in cases of D-dimer values over 1 µg/mL. Patients diagnosed with VTE based on contrast-enhanced CT during hospitalizations between May 1, 2009 and April 30, 2017 were analyzed. VTE incidence was compared in restrained and unrestrained catatonic and noncatatonic patients. We also investigated whether VTE was symptomatic or asymptomatic as well as its outcomes.ResultsThe overall incidence of VTE was 2.3% (39/1,681) in the 8-year period. VTE was observed in 61.1% (11/18) of catatonic patients, 4.1% (11/270) of noncatatonic restrained patients, and 1.2% (17/1,393) of noncatatonic unrestrained patients. PE was observed in 76.9% (30/39) of VTE patients and 97.4% (38/39) of VTE patients were asymptomatic. Recovery was achieved in all cases of VTE treated with anticoagulation therapy.ConclusionThese results indicate that the risk of VTE is high in psychiatric inpatients and that PE is common in these population. The data may also suggest that contrast-enhanced CT is important in surveying thrombus in suspected cases of VTE. In the psychiatric field, proper attention must be given to VTE, regardless of the presence or absence of catatonia or restraint, particularly given that PE was observed in more than 75% of cases of VTE.

Physical Harm and Death in the Context of Coercive Measures in Psychiatric Patients: A Systematic Review

“…As stated above, this finding is also supported by de Hert et al (18). In contrast to these, the other studies observed that VTE occurred even when the restrained patients were heparinized or receiving other prophylactic measures (22, 39) and the importance of regular examination and treatment of thrombosis was emphasized (22).…”

“…Analyzed with regard to their methodology, two studies were experimental RCTs that investigated coercive measures on healthy subjects (14, 15) with small sample sizes of 13 respectively six probands, 1 study was a case-control study (16), 11 studies were classified as epidemiological studies (17–27), 12 as association studies (28–39), and the majority as case series (40–59) and case reports (60–80). A systematic quality assessment of the included studies as it is usually done with RCTs being included in meta-analyses (risk of bias) and calculation of risks was not possible due to the diverse methodology of the studies, with different designs, different investigated outcomes, and partly incomplete data.…”

“…The second most frequently analyzed harm was VTE in 14 studies: deep vein thrombosis of the leg (DVT) in 8 studies (18, 22, 38, 39, 41, 51, 70, 72) and pulmonary embolism (PE) in 12 studies (38, 39, 41, 42, 49, 51, 64, 68, 70–72, 74), with the consequence of death in 8 studies (41, 42, 49, 51, 64, 68, 71, 74). Gaertner et al (38) retrospectively found out that among the analyzed patients with VTE, the restrained patients were not more frequently affected by this harm than the unrestrained.…”

Two pulmonary emboli in a psych pod

“…These patients can be older, may be physically restrained, medically restrained, or catatonic and therefore bed‐bound, or have dementia, all of which has been associated with an increased risk of pulmonary embolism 4 . One psychiatric hospital evaluating the incidence of venous thromboembolism among their patients found an overall incidence of 2.3% but a much higher rate amongst groups that were catatonic and/or restrained 5 . In that population, the majority of venous thromboembolisms that were found (76.9%) were pulmonary embolisms, 5 and there is a case report of a patient who died secondary to massive pulmonary embolism during psychiatric hospitalization 6 .…”

“…One psychiatric hospital evaluating the incidence of venous thromboembolism among their patients found an overall incidence of 2.3% but a much higher rate amongst groups that were catatonic and/or restrained 5 . In that population, the majority of venous thromboembolisms that were found (76.9%) were pulmonary embolisms, 5 and there is a case report of a patient who died secondary to massive pulmonary embolism during psychiatric hospitalization 6 . Even patients who were restrained and receiving prophylaxis to prevent venous thrombosis were still found to have venous thromboembolisms at a rate of 11.6% at one hospital in Japan 7 …”