VTE in the ICU: Characteristics, Diagnosis,Thromboprophylaxis
VTE in the ICU: Characteristics, Diagnosis,Thromboprophylaxis
Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep venous thrombosis (DVT), is a common and severe complication of critical illness. Although well documented in the general population, the prevalence of PE is less known in the ICU, where it is more difficult to diagnose and to treat. Critically ill patients are at high risk of VTE because they combine both general risk factors together with specific ICU risk factors of VTE, like sedation, immobilization, vasopressors or central venous catheter. Compression ultrasonography and computed tomography (CT) scan are the primary tools to diagnose DVT and PE, respectively, in the ICU. CT scan, as well as transesophageal echography, are good for evaluating the severity of PE. Thromboprophylaxis is needed in all ICU patients, mainly with low molecular weight heparin, such as fragmine, which can be used even in cases of non-severe renal failure. Mechanical thromboprophylaxis has to be used if anticoagulation is not possible. Nevertheless, VTE can occur despite well-conducted thromboprophylaxis.
A 77-year-old man was admitted to the ICU as a result of status epilepticus. He was mechanically ventilated for 3 days, and received 5,000 UI unfractionated heparin (UFH) daily as thromboprophylaxis. The day after his extubation, he became hypoxemic without hypotension. A contrast enhanced computed tomography (CT) scan of the chest (Fig. 1) showed a proximal bilateral pulmonary embolism from the lobar to subsegmental arteries of both sides. Transthoracic echocardiography and CT scan did not show any signs suggestive of right ventricular strain. He recovered with a therapeutic dose of heparin, and was discharged home 1 week later. This clinical case shows that clinical presentation of proximal pulmonary embolism is not typical in mechanical ventilated patients and can occur under thromboprophylaxis.
(Enlarge Image)
Figure 1.
Proximal bilateral pulmonary embolism on computed tomography scan in a mechanically ventilated ICU patient
Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is a common complication in the ICU. Critically ill patients are at high risk of VTE as they are susceptible to both general risks factors of VTE as well as those specific to ICU patients, such as sedation, immobilization, and vasopressors. The prevalence of VTE, and especially of PE, is underestimated in the ICU, as it is often clinically silent, especially in sedated and mechanically ventilated patients. ICU-acquired thromboembolic events are difficult to diagnose, as they may mimic many other diseases.
Our purpose was to conduct a review of the most relevant published clinical studies on ICU-acquired VTE in order to highlight the main characteristics and the current strategies for the diagnosis and prevention of this disease.
Abstract and Introduction
Abstract
Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep venous thrombosis (DVT), is a common and severe complication of critical illness. Although well documented in the general population, the prevalence of PE is less known in the ICU, where it is more difficult to diagnose and to treat. Critically ill patients are at high risk of VTE because they combine both general risk factors together with specific ICU risk factors of VTE, like sedation, immobilization, vasopressors or central venous catheter. Compression ultrasonography and computed tomography (CT) scan are the primary tools to diagnose DVT and PE, respectively, in the ICU. CT scan, as well as transesophageal echography, are good for evaluating the severity of PE. Thromboprophylaxis is needed in all ICU patients, mainly with low molecular weight heparin, such as fragmine, which can be used even in cases of non-severe renal failure. Mechanical thromboprophylaxis has to be used if anticoagulation is not possible. Nevertheless, VTE can occur despite well-conducted thromboprophylaxis.
Introduction
A 77-year-old man was admitted to the ICU as a result of status epilepticus. He was mechanically ventilated for 3 days, and received 5,000 UI unfractionated heparin (UFH) daily as thromboprophylaxis. The day after his extubation, he became hypoxemic without hypotension. A contrast enhanced computed tomography (CT) scan of the chest (Fig. 1) showed a proximal bilateral pulmonary embolism from the lobar to subsegmental arteries of both sides. Transthoracic echocardiography and CT scan did not show any signs suggestive of right ventricular strain. He recovered with a therapeutic dose of heparin, and was discharged home 1 week later. This clinical case shows that clinical presentation of proximal pulmonary embolism is not typical in mechanical ventilated patients and can occur under thromboprophylaxis.
(Enlarge Image)
Figure 1.
Proximal bilateral pulmonary embolism on computed tomography scan in a mechanically ventilated ICU patient
Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is a common complication in the ICU. Critically ill patients are at high risk of VTE as they are susceptible to both general risks factors of VTE as well as those specific to ICU patients, such as sedation, immobilization, and vasopressors. The prevalence of VTE, and especially of PE, is underestimated in the ICU, as it is often clinically silent, especially in sedated and mechanically ventilated patients. ICU-acquired thromboembolic events are difficult to diagnose, as they may mimic many other diseases.
Our purpose was to conduct a review of the most relevant published clinical studies on ICU-acquired VTE in order to highlight the main characteristics and the current strategies for the diagnosis and prevention of this disease.
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