Abstract
Venous thromboembolism (VTE) confers considerable morbidity and mortality in hospitalized patients, although few studies have focused on the critically ill population. The objective of this study was to understand current approaches to the prevention and diagnosis of deep venous thrombosis (DVT) and pulmonary embolism (PE) among patients in the intensive care unit (ICU). Mailed self-administered survey of ICU Directors in Canadian university affiliated hospitals. Of 29 ICU Directors approached, 29 (100%) participated, representing 44 ICUs and 681 ICU beds across Canada. VTE prophylaxis is primarily determined by individual ICU clinicians (20/29, 69.0%) or with a hematology consultation for challenging patients (9/29, 31.0%). Decisions are usually made on a case-by-case basis (18/29, 62.1%) rather than by preprinted orders (5/29, 17.2%), institutional policies (6/29, 20.7%) or formal practice guidelines (2/29, 6.9%). Unfractionated heparin is the predominant VTE prophylactic strategy (29/29, 100.0%) whereas low molecular weight heparin is used less often, primarily for trauma and orthopedic patients. Use of pneumatic compression devices and thromboembolic stockings is variable. Systematic screening for DVT with lower limb ultrasound once or twice weekly was reported by some ICU Directors (7/29, 24.1%) for specific populations. Ultrasound is the most common diagnostic test for DVT; the reference standard of venography is rarely used. Spiral computed tomography chest scans and ventilation-perfusion scans are used more often than pulmonary angiograms for the diagnosis of PE. ICU Directors recommend further studies in the critically ill population to determine the test properties and risk:benefit ratio of VTE investigations, and the most cost-effective methods of prophylaxis in medical-surgical ICU patients. Unfractionated subcutaneous heparin is the predominant VTE prophylaxis strategy for critically ill patients, although low molecular weight heparin is prescribed for trauma and orthopedic patients. DVT is most often diagnosed by lower limb ultrasound; however, several different tests are used to diagnose PE. Fundamental research in critically ill patients is needed to help make practice evidence-based.
Highlights
The most serious manifestation of deep venous thrombosis (DVT) is pulmonary embolism (PE), which occurs in up to 1% of hospitalized patients and in 15% of patients at postmortem [1]
Low molecular weight heparin is used in many centers for orthopedic surgery patients (26/29, 89.7%), and in all intensive care unit (ICU) that are regional trauma centers (18, 100.0%)
Topics to address included the test properties and risk:benefit ratio of noninvasive Venous thromboembolism (VTE) investigations in the ICU setting, accurate profiling of both the thrombotic and bleeding risk among critically ill subgroups, and the most cost-effective methods of VTE prophylaxis in medical–surgical ICU patients. In this survey representing practice patterns in 44 Canadian ICUs, we found that unfractionated subcutaneous heparin was the dominant method for prophylaxis against VTE in medical–surgical ICU patients, consistent with one random
Summary
The most serious manifestation of DVT is PE, which occurs in up to 1% of hospitalized patients and in 15% of patients at postmortem [1]. In a third study of 102 medical–surgical ICU patients who had duplex ultrasound during days 4–7 [10], DVT rates were 25, 19, and 7% in patients who received no prophylaxis, pneumatic compression, and unfractionated heparin, respectively. Venous thromboembolism (VTE) confers considerable morbidity and mortality in hospitalized patients, few studies have focused on the critically ill population. ICU Directors recommend further studies in the critically ill population to determine the test properties and risk:benefit ratio of VTE investigations, and the most cost-effective methods of prophylaxis in medical–surgical ICU patients. Interpretation Unfractionated subcutaneous heparin is the predominant VTE prophylaxis strategy for critically ill patients, low molecular weight heparin is prescribed for trauma and orthopedic patients. Fundamental research in critically ill patients is needed to help make practice evidence-based
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