Prophylaxis of Venous Thrombosis in Neurocritical Care Patients: An Evidence-Based Guideline: A Statement for Healthcare Professionals from the Neurocritical Care Society

Nyquist, Paul; Bautista, Cynthia; Jichici, Draga; Burns, Joseph D.; Chhangani, Sanjeev V.; DeFilippis, Michele; Goldenberg, Fernando D.; Kim, Keri; Liu-DeRyke, Xi; Mack, William J.; Meyer, Kim A.

doi:10.1007/s12028-015-0221-y

Cited by 138 publications

(113 citation statements)

References 138 publications

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“…We also found that late HE occurs rarely in this selected patient population, however is more common in patients with large hematomas, coagulation derangements such as thrombocytopenia and might be predicted by radiological signs (blend or island sign). Our results are consistent with previous studies and support the recommendations given by the ASA and Neurocritical Care Society . This finding is important as delayed or lack of DVT prophylaxis may be associated with higher mortality .…”

Section: Discussionsupporting

confidence: 92%

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Early thrombosis prophylaxis with enoxaparin is not associated with hematoma expansion in patients with spontaneous intracerebral hemorrhage

Ianosi

Gaasch

Rass

et al. 2018

Euro J of Neurology

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Background and purpose Early pharmacological deep vein thrombosis (DVT) prophylaxis is recommended by guidelines, but rarely started within 48 h. We aimed to analyze the effect of early (within 48 h) versus late (>48 h) DVT prophylaxis on hematoma expansion (HE) and outcome in patients with spontaneous intracerebral hemorrhage (ICH). Methods We analyzed 134 consecutive patients admitted to a tertiary neurointensive care unit with diagnosed spontaneous ICH, without previous anticoagulation, severe coagulopathy, hematoma evacuation, early withdrawal of therapy or ineligibility for DVT prophylaxis according to our institutional protocol. Significant late HE was defined as ≥6 mL increase of hematoma volume between neuroimaging within 48 h and day 3–6. Multivariate analysis was performed to identify risk factors for late HE, poor 3‐month outcome (modified Rankin Scale score ≥ 4) and mortality. Results Patients had a median Glasgow Coma Scale score of 14 [interquartile range (IQR), 10–15], ICH volume of 11 (IQR, 5–24) mL and were 71 (IQR, 61–76) years old. A total of 56% (n = 76) received early DVT prophylaxis, 37% (n = 50) received late DVT prophylaxis and 8 (6%) had unknown bleeding onset. Patients with early DVT prophylaxis had smaller ICH volume [9.5 (IQR, 4–18.5) vs. 17.5 (IQR, 8–29) mL, P = 0.038] and were more often comatose (26% vs. 10%, P = 0.025). Significant late HE [n = 5/134 (3.7%)] was associated with larger initial ICH volume (P = 0.02) and lower thrombocyte count (P = 0.03) but not with early DVT prophylaxis (P = 0.36). Early DVT prophylaxis was not associated with worse outcome. Conclusion Significant late HE is uncommon and DVT prophylaxis within 48 h of symptom onset may be safe in selected patients with ICH.

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Section: Discussionsupporting

confidence: 92%

“…Our results are consistent with previous studies and support the recommendations given by the ASA and Neurocritical Care Society [13,14,21,22]. This finding is important as delayed or lack of DVT prophylaxis may be associated with higher mortality [23].…”

Section: Discussionsupporting

confidence: 92%

Early thrombosis prophylaxis with enoxaparin is not associated with hematoma expansion in patients with spontaneous intracerebral hemorrhage

Ianosi

Gaasch

Rass

et al. 2018

Euro J of Neurology

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“…71 If IPC devices are unavailable, graduated compression stockings (GCS) can be utilised. Prophylactic doses of subcutaneous unfractionated heparin or LMWH should be started in patients with stable haematomas within 48 hours of admission.…”

Section: Deep Vein Thrombosis Prophylaxis and Treatmentmentioning

confidence: 99%

Current management of spontaneous intracerebral haemorrhage

Dastur

2017

Stroke Vasc Neurol

120

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Intracerebral haemorrhage (ICH) is the most devastating and disabling type of stroke. Uncontrolled hypertension (HTN) is the most common cause of spontaneous ICH. Recent advances in neuroimaging, organised stroke care, dedicated Neuro-ICUs, medical and surgical management have improved the management of ICH. Early airway protection, control of malignant HTN, urgent reversal of coagulopathy and surgical intervention may increase the chance of survival for patients with severe ICH. Intensive lowering of systolic blood pressure to <140 mm Hg is proven safe by two recent randomised trials. Transfusion of platelets in patients on antiplatelet therapy is not indicated unless the patient is scheduled for surgical evacuation of haematoma. In patients with small haematoma without significant mass effect, there is no indication for routine use of mannitol or hypertonic saline (HTS). However, for patients with large ICH (volume > 30 cbic centmetre) or symptomatic perihaematoma oedema, it may be beneficial to keep serum sodium level at 140–150 mEq/L for 7–10 days to minimise oedema expansion and mass effect. Mannitol and HTS can be used emergently for worsening cerebral oedema, elevated intracranial pressure (ICP) or pending herniation. HTS should be administered via central line as continuous infusion (3%) or bolus (23.4%). Ventriculostomy is indicated for patients with severe intraventricular haemorrhage, hydrocephalus or elevated ICP. Patients with large cerebellar or temporal ICH may benefit from emergent haematoma evacuation. It is important to start intermittent pneumatic compression devices at the time of admission and subcutaneous unfractionated heparin in stable patients within 48 hours of admission for prophylaxis of venous thromboembolism. There is no benefit for seizure prophylaxis or aggressive management of fever or hyperglycaemia. Early aggressive comprehensive care may improve survival and functional recovery.

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“…The search for clinical practice guidelines included all major local and international societies for critical care, interventional neuroradiology, and stroke and identified 14 guidelines for inclusion. [22][23][24][25][26][27][28][29][30][31][32][33][34][35] Of these, two were specifically aimed at management following ECR. 26,30 The majority of identified guidelines focused on the management of the broader acute stroke population, with few specifically examining the post ECR patient population.…”

Section: Resultsmentioning

confidence: 99%

Intensive Care Management Following Endovascular Clot Retrieval for Acute Stroke: A Systematic Review of the Literature

Moynihan

Donaldson

2019

J Clin Interv Radiol ISVIR

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Prophylaxis of Venous Thrombosis in Neurocritical Care Patients: An Evidence-Based Guideline: A Statement for Healthcare Professionals from the Neurocritical Care Society

Cited by 138 publications

References 138 publications

Early thrombosis prophylaxis with enoxaparin is not associated with hematoma expansion in patients with spontaneous intracerebral hemorrhage

Early thrombosis prophylaxis with enoxaparin is not associated with hematoma expansion in patients with spontaneous intracerebral hemorrhage

Current management of spontaneous intracerebral haemorrhage

Intensive Care Management Following Endovascular Clot Retrieval for Acute Stroke: A Systematic Review of the Literature

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