VTE in the ICU: Characteristics, Diagnosis,Thromboprophylaxis
VTE in the ICU: Characteristics, Diagnosis,Thromboprophylaxis
When anticoagulant is contraindicated, mechanical thromboprophylaxis using either graduated compression stockings (GCS) or intermittent pneumatic compression (IPC) may be proposed. Thromboprophylaxis by mechanical means alone is recommended for critical care patients at high risk of bleeding with contraindications to prophylaxis with anticoagulant agents. The main RCTs that include GCS or IPC for DVT prophylaxis in ICU patients are listed in Table 5; one was conducted in patients with acute myocardial infarction, and three others in trauma patients. These four studies represent 791 patients who underwent mechanical prophylaxis (several methods were evaluated) or received LMWH. One study evaluated GCS on one leg versus nothing on the second leg in each patient; the incidence of DVT was lower with GCS (0 % versus 10 %). Combining IPC with GCS was not more effective than GCS alone. In neurosurgical patients, GCS alone prevented DVT less effectively than when combined with LMWH.
The use of vena cava filters for thromboprophylaxis is not recommended by the ACCP Evidence-Based Clinical Practice Guidelines (eighth edition).
The ENDORSE multinational study enrolled 68,183 hospitalized patients in an acute care setting and showed that only a low rate of patients had appropriate prophylaxis according to the 2004 ACCP guidelines on VTE prophylaxis. In an Asian ICU, a recent observational study revealed that 20 % of the critically ill patients did not receive the appropriate recommended prophylaxis. In North-American ICUs, Lauzier et al. recently reported appropriate guideline concordance occurred for 95.5 % patient-days, which was better in sicker patients and in patients with a previous history of VTE or cancer. LMWH was less used than UHF in sicker and surgical patients, and in patients receiving vasopressors or renal replacement therapy.
Mechanical Thromboprophylaxis in ICU Patients
When anticoagulant is contraindicated, mechanical thromboprophylaxis using either graduated compression stockings (GCS) or intermittent pneumatic compression (IPC) may be proposed. Thromboprophylaxis by mechanical means alone is recommended for critical care patients at high risk of bleeding with contraindications to prophylaxis with anticoagulant agents. The main RCTs that include GCS or IPC for DVT prophylaxis in ICU patients are listed in Table 5; one was conducted in patients with acute myocardial infarction, and three others in trauma patients. These four studies represent 791 patients who underwent mechanical prophylaxis (several methods were evaluated) or received LMWH. One study evaluated GCS on one leg versus nothing on the second leg in each patient; the incidence of DVT was lower with GCS (0 % versus 10 %). Combining IPC with GCS was not more effective than GCS alone. In neurosurgical patients, GCS alone prevented DVT less effectively than when combined with LMWH.
The use of vena cava filters for thromboprophylaxis is not recommended by the ACCP Evidence-Based Clinical Practice Guidelines (eighth edition).
Thromboprophylaxis Compliance in the ICU
The ENDORSE multinational study enrolled 68,183 hospitalized patients in an acute care setting and showed that only a low rate of patients had appropriate prophylaxis according to the 2004 ACCP guidelines on VTE prophylaxis. In an Asian ICU, a recent observational study revealed that 20 % of the critically ill patients did not receive the appropriate recommended prophylaxis. In North-American ICUs, Lauzier et al. recently reported appropriate guideline concordance occurred for 95.5 % patient-days, which was better in sicker patients and in patients with a previous history of VTE or cancer. LMWH was less used than UHF in sicker and surgical patients, and in patients receiving vasopressors or renal replacement therapy.
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