Prevention of venous thromboembolism in critically ill surgery patients: A cross-sectional study

Cook, Deborah J.; Laporta, Donald; Skrobik, Yoanna; Peters, Sharon; Sharpe, Michael D.; Murphy, Patricia; Chin, Dat; Crowther, Mark

doi:10.1053/jcrc.2001.30665

Cited by 30 publications

(14 citation statements)

References 24 publications

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“…Low-molecularweight heparin represents the most effective antithrombotic prophylaxis, but it is associated with a remarkable risk of bleeding complications [3,5,11]. Sequential pneumatic compression of the lower limbs is an efficient alternative for thromboprophylaxis, especially in those patients at high risk of bleeding complications [4][5][6][7][8]; however, sequential pneumatic compression may influence systemic hemodynamics by affecting venous flow to the heart and arterial flow in the lower limbs.…”

Section: Discussionmentioning

confidence: 99%

Systemic hemodynamic effects of sequential pneumatic compression of the lower limbs: a prospective study in healthy volunteers

Fanelli

Zasa

Baciarello

et al. 2008

Journal of Clinical Anesthesia

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Section: Discussionmentioning

confidence: 99%

Systemic hemodynamic effects of sequential pneumatic compression of the lower limbs: a prospective study in healthy volunteers

Fanelli

Zasa

Baciarello

et al. 2008

Journal of Clinical Anesthesia

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“…Goldhaber [23] recently reported that in a mixed medical-surgical ICU population DVT prophylaxis was applied only to one third of the patients. Moreover, in a mail survey of 44 ICUs in Canada [24] , the directors of the units answered that decisions about the type of VTE prophylaxis employed were made for the most part on a case-by-case basis (62.1%), rather than by preprinted orders (17.2%), institutional policies (20.7%) or practice guidelines (6.9%). Several explanations for this underuse have been proposed: physicians may feel that the overall risk of VTE among patients has decreased suffi ciently so that prophylaxis is not warranted; clinicians are more concerned about bleeding complications than about thromboembolism, and it is widely believed that the subjective perception of the magnitude of the problem underestimates its true importance [20] .…”

Section: Discussionmentioning

confidence: 99%

A Survey of Thromboprophylaxis Management in Patients with Major Trauma

Imberti

Ageno²

2005

Pathophysiol Haemos Thromb

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Background: Venous thromboembolism (VTE) is a common life-threatening complication of major trauma. Although clinical guidelines clearly suggest routine VTE prevention with low-molecular-weight heparin (LMWH) in this specific group of patients, there is still a lack of strong recommendations regarding the timing and the modality of heparin administration and the role of mechanical prophylaxis. We tested the hypothesis that there is significant practice variation in thromboprophylaxis management of patients with major trauma among intensive care unit (ICU) specialists. Methods: Two hundred Italian ICU specialists, representing 200 ICU throughout the country, were contacted by telephone and were asked (1) whether they routinely prescribe pharmacological antithrombotic prophylaxis in patients with major trauma, whether prophylaxis is prescribed to all patients or to selected patients, and the type of prophylaxis and the timing of administration and (2) whether they recommend physical prevention, whether this is prescribed to all patients or to selected patients, and the type of physical prophylaxis. Results: In patients with major trauma, 85% of the interviewed ICU specialists answered that they prescribe pharmacological prophylaxis for VTE. 37.6% of them prescribe prophylaxis only to selected patients based on the level of risk, 87.7% prescribe low-molecular-weight heparin, and 42.4% start prophylaxis immediately after hospitalization. Only 61% of the interviewed specialists prescribe physical prophylaxis; 82.8% of them use elastic stockings, 9.8% intermittent pneumatic compression, and 7.4% other mechanical devices. Physical prophylaxis is prescribed to all patients by 41%, and by 59% only in case of contraindication to pharmacological prevention. Inferior vena cava (IVC) filter insertion is considered by 47% when anticoagulation is contraindicated; 91.4% of them recommend the IVC filter only if deep vein thrombosis (DVT) has been diagnosed. Conclusions: Even when there are clinical guidelines, prescription of VTE prevention in patients with major trauma is underused and timing and modality of prophylaxis are rather heterogeneous. When anticoagulation is contraindicated, IVC filters are commonly recommended only in the presence of DVT.

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“…Case report forms and an implementation manual were developed and pretested by two research coordinators, adapted from prior studies [7,8]. We conducted a structured, independent, duplicate chart abstraction exercise to identify points of data disagreement, to clarify methodology, and to enhance the efficiency and validity of the audit process.…”

Section: Methodsmentioning

confidence: 99%

Thromboprophylaxis patterns and determinants in critically ill patients: a multicenter audit

et al. 2014

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IntroductionHeparin is safe and prevents venous thromboembolism in critical illness. We aimed to determine the guideline concordance for thromboprophylaxis in critically ill patients and its predictors, and to analyze factors associated with the use of low molecular weight heparin (LMWH), as it may be associated with a lower risk of pulmonary embolism and heparin-induced thrombocytopenia without increasing the bleeding risk.MethodsWe performed a retrospective audit in 28 North American intensive care units (ICUs), including all consecutive medical-surgical patients admitted in November 2011. We documented ICU thromboprophylaxis and reasons for omission. Guideline concordance was determined by adding days in which patients without contraindications received thromboprophylaxis to days in which patients with contraindications did not receive it, divided by the total number of patient-days. We used multilevel logistic regression including time-varying, center and patient-level covariates to determine the predictors of guideline concordance and use of LMWH.ResultsWe enrolled 1,935 patients (62.3 ± 16.7 years, Acute Physiology and Chronic Health Evaluation [APACHE] II score 19.1 ± 8.3). Patients received thromboprophylaxis with unfractionated heparin (UFH) (54.0%) or LMWH (27.6%). Guideline concordance occurred for 95.5% patient-days and was more likely in patients who were sicker (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.17, 1.75 per 10-point increase in APACHE II), heavier (OR 1.32, 95% CI 1.05, 1.65 per 10-m/kg2 increase in body mass index), had cancer (OR 3.22, 95% CI 1.81, 5.72), previous venous thromboembolism (OR 3.94, 95% CI 1.46,10.66), and received mechanical ventilation (OR 1.83, 95% CI 1.32,2.52). Reasons for not receiving thromboprophylaxis were high risk of bleeding (44.5%), current bleeding (16.3%), no reason (12.9%), recent or upcoming invasive procedure (10.2%), nighttime admission or discharge (9.7%), and life-support limitation (6.9%). LMWH was less often administered to sicker patients (OR 0.65, 95% CI 0.48, 0.89 per 10-point increase in APACHE II), surgical patients (OR 0.41, 95% CI 0.24, 0.72), those receiving vasoactive drugs (OR 0.47, 95% CI 0.35, 0.64) or renal replacement therapy (OR 0.10, 95% CI 0.05, 0.23).ConclusionsGuideline concordance for thromboprophylaxis was high, but LMWH was less commonly used, especially in patients who were sicker, had surgery, or received vasopressors or renal replacement therapy, representing a potential quality improvement target.

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Prevention of venous thromboembolism in critically ill surgery patients: A cross-sectional study

Cited by 30 publications

References 24 publications

Systemic hemodynamic effects of sequential pneumatic compression of the lower limbs: a prospective study in healthy volunteers

Systemic hemodynamic effects of sequential pneumatic compression of the lower limbs: a prospective study in healthy volunteers

A Survey of Thromboprophylaxis Management in Patients with Major Trauma

Thromboprophylaxis patterns and determinants in critically ill patients: a multicenter audit

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