Nonleg Venous Thrombosis in Critically Ill Adults

Abstract

; for the PROTECT (Prophylaxis for Thromboembolism in Critical Care Trial) Investigators, on behalf of the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group IMPORTANCE Critically ill patients are at risk of venous thrombosis, and therefore guidelines recommend daily thromboprophylaxis. Deep vein thrombosis (DVT) commonly occurs in the lower extremities but can occur in other sites including the head and neck, trunk, and upper extremities. The risk of nonleg deep venous thromboses (NLDVTs), predisposing factors, and the association between NLDVTs and pulmonary embolism (PE) or death are unclear. OBJECTIVE To describe the frequency, anatomical location, risk factors, management, and consequences of NLDVTs in a large cohort of medical-surgical critically ill adults. DESIGN, SETTING, AND PARTICIPANTS A nested prospective cohort study in the setting of secondary and tertiary care intensive care units (ICUs). The study population comprised 3746 patients, who were expected to remain in the ICU for at least 3 days and were enrolled in a randomized clinical trial of dalteparin vs standard heparin for thromboprophylaxis. MAIN OUTCOMES AND MEASURES The proportion of patients who had NLDVTs, the mean number per patient, and the anatomical location. We characterized NLDVTs as prevalent or incident (identified within 72 hours of ICU admission or thereafter) and whether they were catheter related or not. We used multivariable regression models to evaluate risk factors for NLDVT and to examine subsequent anticoagulant therapy, associated PE, and death. RESULTS Of 3746 trial patients, 84 (2.2%) developed 1 or more non-leg vein thromboses (superficial or deep, proximal or distal). Thromboses were more commonly incident (n = 75 [2.0%]) than prevalent (n = 9 [0.2%]) (P < .001) and more often deep (n = 67 [1.8%]) than superficial (n = 31 [0.8%]) (P < .001). Cancer was the only independent predictor of incident NLDVT (hazard ratio [HR], 2.22; 95% CI, 1.06-4.65). After adjusting for Acute Physiology and Chronic Health Evaluation (APACHE) II scores, personal or family history of venous thromboembolism, body mass index, vasopressor use, type of thromboprophylaxis, and presence of leg DVT, NLDVTs were associated with an increased risk of PE (HR, 11.83; 95% CI, 4.80-29.18). Nonleg DVTs were not associated with ICU mortality (HR, 1.09; 95% CI, 0.62-1.92) in a model adjusting for age, APACHE II, vasopressor use, mechanical ventilation, renal replacement therapy, and platelet count below 50 × 10 9 /L. CONCLUSIONS AND RELEVANCE Despite universal heparin thromboprophylaxis, nonleg thromboses are found in 2.2% of medical-surgical critically ill patients, primarily in deep veins and proximal veins. Patients who have a malignant condition may have a significantly higher risk of developing NLDVT, and patients with NLDVT, compared with those without, appeared to be at higher risk of PE but not higher risk of death. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00182143

Central venous catheter–related thrombosis

“…7,8 Although the majority of asymptomatic CRT cases remain subclinical, symptomatic DVT occurs in 1%-5% of patients with a CVC (Table 1). [9][10][11][12] A prospective study of 444 cancer patients with a CVC reported symptomatic, ipsilateral DVT in 4% at a median of 30 days after insertion. 13 This corresponds to an incidence of 0.3 per 1000 catheter-days.…”

“…14 Among 3218 critical care patients randomized to low-dose heparin or low-molecular-weight heparin (LMWH) as thromboprophylaxis, only 1% developed symptomatic catheterrelated DVT during their intensive care unit stay. 12 …”

Diagnostic accuracy of point-of-care ultrasound for catheter-related thrombosis in children

“…The κ coefficient of 0.77 is substantial but suboptimal because it is below the κ coefficient of 0.80 typically needed to robustly ascertain the outcome in a randomized control trial [16]. In studies preparatory to a multicenter randomized control trial of thromboprophylaxis in critically ill adults, the concordance between readings using consultative US ranged from 0.29 to 0.71 in the upper extremity veins to 1.00 in the lower extremity veins [19, 20]. We will conduct calibration studies in our multicenter randomized control trial to increase the κ coefficient to at least 0.80 [19].…”

Venous Thromboembolic Disease: DVT and PE

“…Thromboses of the limbs may be further classifi ed as proximal or distal and superfi cial or deep [ 13 ]. The location of the venous thrombosis is critically important, particularly in the lower limb, as it determines the therapeutic approach.…”

“…Line removal was associated with a signifi cantly greater occurrence of clot improvement on the follow up duplex. Lamontague and colleagues screened a cohort of 3,746 medical-surgical ICU patients who were receiving pharmacologic thromboprophylaxis for the presence of non-leg DVT (NLDVT) [ 13 ]. In this study 2.2 % of patients developed one or more NLDVT.…”