Question 2 from the first paper of 2003 and Question 10 from the first paper of 2010 discuss thromboprophylaxis in the ICU. One question was a straightforward "critically evaluate" piece, and the other was related more to the setting of neurotrauma. The delicate issue of giving chemical anticoagulants to somebody who has bled into the brain is discussed in the separate chapter on thromboprophylaxis in neurosurgical patients. The summary below is derived largely from the excellent LITFL page on this subject, as well as from a nice recent article (Boonyawat and Crowther, 2015).
The table of undifferentiated risk factors for VTE is reproduced below:
Inherited risk factors
Acute risk factors
Chronic risk factors
If one finds this loosely assembled list of risk factors satisfying, it may be because it does not in any way describe the relative contribution of risk for each risk factor. A mch better list (but one which is more difficult to remember) can be generated from the 30-item Caprini inventory. This is discussed in greater detail in the chapter on DVT in ICU.
|(1 point)||(2 points)||(3 points)||(5 points)|
- Age <41
|- Age 41-60
- Major surgery
- confined to bed for > 72 hrs
- CVC device
|- Age 61-74
- History of DVT
- Inherited thrombotic disorder
|- Age >75
- Lower limb fracture
-Acute spinal cord injury
Female-specific risk factors:
The main options are:
The limitations of these options:
LIFL have an excellent page on VTE prophylaxis in the ICU.
Cook, Deborah, et al. "Dalteparin versus unfractionated heparin in critically ill patients." The New England journal of medicine 364.14 (2011): 1305-1314.
Attia, John, et al. "Deep vein thrombosis and its prevention in critically ill adults." Archives of Internal Medicine 161.10 (2001): 1268-1279.
Arabi, Yaseen M., et al. "Use of Intermittent Pneumatic Compression and Not Graduated Compression Stockings Is Associated With Lower Incident VTE in Critically Ill Patients Mechanical Prophylaxis in Critically Ill Patients A Multiple Propensity Scores Adjusted Analysis." CHEST Journal 144.1 (2013): 152-159.
Sachdeva, Ashwin, et al. "Elastic compression stockings for prevention of deep vein thrombosis." Cochrane Database Syst Rev 7.7 (2010).
Alikhan, Raza, Rachel Bedenis, and Alexander T. Cohen. "Heparin for the prevention of venous thromboembolism in acutely ill medical patients (excluding stroke and myocardial infarction)." status and date: New search for studies and content updated (no change to conclusions), published in 5 (2014). Cochrane Database of Systematic Reviews 2014, Issue 5.
Boonyawat, Kochawan, and Mark A. Crowther. "Venous thromboembolism prophylaxis in critically ill patients." Seminars in thrombosis and hemostasis. Vol. 41. No. 1. 2015.
Ribic, Christine, et al. "Low-molecular-weight heparin thromboprophylaxis in medical-surgical critically ill patients: a systematic review." Journal of critical care 24.2 (2009): 197-205.
Ho, Kwok M., Shaila Chavan, and David Pilcher. "Omission of early thromboprophylaxis and mortality in critically ill patients: a multicenter registry study." CHEST Journal 140.6 (2011): 1436-1446.
Decousus, Hervé, et al. "Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators." CHEST Journal 139.1 (2011): 69-79.