scholarly journals Venous Thromboembolism Prophylaxis in Critically Ill Patients

2015 ◽  
Vol 41 (01) ◽  
pp. 068-074 ◽  
Author(s):  
Kochawan Boonyawat ◽  
Mark Crowther
Keyword(s):  
Venous Thromboembolism ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Preventive Measure ◽  
Venous Catheter ◽  
Bleeding Risk ◽  
Contributing Factors ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Vein Thrombosis

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is recognized as a common complication in critically ill patients. Risk factors including critical illness, mechanical ventilation, sedative medications, and central venous catheter insertion are major contributing factors to the high risk of VTE. Because of their impaired cardiopulmonary reserve, PE arising from thrombosis in the deep veins of the calf that propagates proximally is poorly tolerated by critically ill patients. Pharmacologic prophylaxis with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) has been shown to decrease the incidence of VTE in medical, surgical, and critically ill patients. As a result, over the past decades, VTE prophylaxis had become a standard of preventive measure in the intensive care unit (ICU). In clinical practice, the rate of VTE prophylaxis varies and may be inadequate in some centers. A perception of a high bleeding risk in critically ill patients is a major concern for most physicians that may lead to inadequate prophylaxis.

Venous Thromboembolism Prophylaxis

2006 ◽  
Author(s):  
Richard C. Becker ◽  
Frederick A. Spencer
Keyword(s):  
Venous Thromboembolism ◽  
Orthopedic Surgery ◽  
Large Scale ◽  
Development Program ◽  
Thromboembolism Prophylaxis ◽  
Double Blind ◽  
Vte Prophylaxis ◽  
Vein Thrombosis ◽  
Disease States ◽  
Phase Ii Studies

Venous thromboembolism represents a true worldwide medical problem that is encountered within all realms of practice. Venous thromboembolism (VTE) occurs in approximately 100 patients per 100,000 population yearly in the United States and increases exponentially with each decade of life (White, 2003). Approximately one-third of patients with symptomatic deep vein thrombosis (DVT) experience a pulmonary embolism (PE). Death occurs within 1 month in 6% of patients with DVT and 12% of those with PE. Early mortality is associated strongly with presentation as PE, advanced age, malignancy, and underlying cardiovascular disease. An experience dating back several decades has provided a better understanding of disease states and conditions associated with VTE (Anderson and Spencer, 2003). Given the potential morbidity and mortality associated with VTE, it is apparent that prophylaxis represents an important goal in clinical practice. A variety of anticoagulants including unfractionated heparin, low-molecular-weight heparin (LMWH), and warfarin have been studied. More recently, two new agents have been developed that warrant discussion. Fondaparinux underwent a worldwide development program in orthopedic surgery for the prophylaxis of VTE. The program consisted mainly of four large, randomized, double-blind phase II studies comparing fondaparinux (SC), at a dose of 2.5 mg starting 6 hours postoperatively, with the two enoxaparin regimens approved for VTE prophylaxis—40 mg qd or 30 mg twice daily beginning 12 hours postoperatively. The results support a greater protective effect with fondaparinux, yielding a 55.2% relative risk reduction of VTE (Bauer et al., 2001; Eriksson et al., 2001; Lassen et al., 2002; Turpie et al., 2001, 2002; ). A European program of three large-scale clinical trials (MElagatran for THRombin inhibition in Orthopedic surgery [METHRO] I, II, and III, and EXpanded PRophylaxis Evaluation Surgery Study [EXPRESS]) (Eriksson et al., 2002a, b, 2003a, b) evaluated the safety and efficacy of subcutaneous melagatran followed by oral ximelagatran compared with LMWH for thromboprophylaxis following total hip replacement (THR) and total knee replacement (TKR) surgery.

Venous thromboembolism in critically ill patients

2009 ◽  
Vol 101 (01) ◽  
pp. 139-144 ◽  
Author(s):  
Mark Williams ◽  
Andrew Shorr
Keyword(s):  
Severe Sepsis ◽  
Venous Thromboembolism ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Controlled Trial ◽  
Double Blind ◽  
Vte Prophylaxis ◽  
Drotrecogin Alfa Activated ◽  
History Of ◽  
Sepsis And Septic Shock

SummaryVenous thromboembolism (VTE) is a central concern in the intensive care unit (ICU). However, little is known about both current practices for VTE prevention in the ICU and the risk for VTE in persons with severe sepsis and septic shock. XPRESS was a randomized, double-blind, placebo-controlled trial of prophylactic heparin in patients with severe sepsis and higher disease severity who were treated with drotrecogin alfa (activated) (DAA). Subjects were randomized to unfractionated heparin, low-molecular-weight heparin, or placebo during the DAA infusion period. All patients underwent ultrasonography between days 4-6 to screen for VTE. We assessed baseline utilization of VTE prophylaxis along with application of these methods after completion of the DAA infusion. The study included 1,935 subjects and, prior to enrollment approximately half were given no form of prophylaxis. By day 6, 5% of subjects developed a VTE, and the rate of VTE did not vary based on type of heparin administered. The vast majority of VTE detected by day 6 were clinically silent. Of factors analyzed, history of VTE was the only variable independently associated with development of a VTE (odds ratio, 3.66, 95% confidence interval 1.77–7.56, p=0.005). Strikingly, patients who were initially receiving heparin prophylaxis prior to enrollment but who then had this discontinued because of randomization to placebo suffered more VTE that persons continuing on some form of heparin. Despite multiple guidelines, physicians do not uniformly prescribe VTE prophylaxis. Nonetheless, early VTE occurs even in persons given DAA. Most VTE in critically ill patients are clinically silent.

scholarly journals Evaluation of coagulation function by rotation thromboelastometry in critically ill patients with severe COVID-19 pneumonia

2020 ◽  
Author(s):  
Vittorio Pavoni ◽  
LARA GIANESELLO ◽  
Maddalena Pazzi ◽  
Caterina Stera ◽  
Tommaso Meconi ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Blood Clot ◽  
Bleeding Risk ◽  
Rotational Thromboelastometry ◽  
Clot Strength ◽  
Vein Thrombosis ◽  
Coagulation Function ◽  
Secondary Hyperfibrinolysis ◽  
Deep Vein

Abstract Critically ill patients with COVID-19 pneumonia suffered both high thrombotic and bleeding risk. The effect of SARS-CoV-2 on coagulation and fibrinolysis is not well known. We conducted a retrospective study of critically ill patients admitted to an intensive care unit (ICU) a cause of severe COVID-19 pneumonia and we evaluated coagulation function using rotational thromboelastometry (ROTEM) on day of admission (T0) and 5 (T5) and 10 (T10) days after admission to ICU. Coagulation standard parameters were also evaluated. Forty patients were enrolled into the study. The ICU and the hospital mortality were 10% and 12.5%, respectively. On ICU admission, prothrombin time was slightly reduced and it increased significantly at T10 (T0=65.1±9.8 vs T10=85.7±1.5, p=0.002), while activated partial thromboplastin time and fibrinogen values were higher at T0 than T10 (32.2±2.9 vs 27.2±2.1, p=0.017 and 895.1±110 vs 332.5±50, p= 0.002, respectively); moreover, whole blood thromboelastometry profiles were consistent with hypercoagulability characterized by an acceleration of the propagation phase of blood clot formation [i.e., CFT below the lower limit in INTEM 16/40 patients (40%) and EXTEM 20/40 patients (50%)] and significant higher clot strength [MCF above the upper limit in INTEM 20/40 patients (50%), in EXTEM 28/40 patients (70%) and in FIBTEM 29/40 patients (72.5%)]; however, this hypercoagulable state persists in the first five days, but it decreases ten day after, without returning to normal values. No sign of secondary hyperfibrinolysis or sepsis induced coagulopathy (SIC) were found during the study period. In six patients (15%) a deep vein thrombosis and in 2 patients (5%) a thromboembolic event, were found; 12 patients (30%) had a catheter-related thrombosis. ROTEM analysis confirms that patients with severe COVID-19 pneumonia had a hypercoagulation state that persisted over time.

scholarly journals A comparison of aspirin against rivaroxaban for venous thromboembolism prophylaxis after hip or knee arthroplasty: A meta-analysis

2020 ◽  
Vol 28 (1) ◽  
pp. 230949901989602
Author(s):  
Joshua Xu ◽  
Aran Kanagaratnam ◽  
Jacob Y Cao ◽  
Gurpreet S Chaggar ◽  
Warwick Bruce
Keyword(s):  
Venous Thromboembolism ◽  
Knee Arthroplasty ◽  
Meta Analysis ◽  
Cost Effective ◽  
Bleeding Risk ◽  
Wound Complications ◽  
Significant Heterogeneity ◽  
Thromboembolism Prophylaxis ◽  
Vein Thrombosis ◽  
Deep Vein

Purpose: Total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients are at an elevated risk of post-operative venous thromboembolism (VTE). Newer thromboprophylactic agents such as rivaroxaban are increasingly used and effective in preventing thromboembolic events but may worsen bleeding risk. Recent studies have suggested that the more cost-effective aspirin may also be effective in preventing VTE. This systematic review and meta-analysis aimed to compare the efficacy of aspirin against rivaroxaban for the prevention of VTE following TKA and THA. Methods: Electronic searches were performed using five databases from their date of inception to August 2018. Relevant studies were identified, with data extracted and meta-analyzed from the studies. Results: Five studies were included, which consisted of 2257 in the aspirin group and 2337 in the rivaroxaban group. There were no differences between aspirin and rivaroxaban for either VTE ( p = 0.48) or its components deep vein thrombosis ( p = 0.44) and pulmonary embolism ( p = 0.98). Also, there were no differences between groups for either major bleeding ( p = 0.17), any bleeding ( p = 0.62), readmissions ( p = 0.37) or wound complications ( p = 0.17). Conclusion: Aspirin was not significantly different to rivaroxaban for prevention of VTE or adverse events after TKA or THA. However, this study was limited by the significant heterogeneity of the included studies. More large randomized studies are needed to add to this body of evidence.

Bridging efforts to longitudinally improve and evaluate venous thromboembolism prophylaxis uptake in hospitalized cancer patients through interprofessional teamwork (BELIEVE IT): A study by Princess Margaret Cancer Centre.

2012 ◽  
Vol 30 (34_suppl) ◽  
pp. 170-170
Author(s):  
Jack Toshimine Seki ◽  
Triyu Vather ◽  
Vishal Kukreti ◽  
Monika Karolina Krzyzanowska
Keyword(s):  
Venous Thromboembolism ◽  
Cancer Patients ◽  
Bleeding Risk ◽  
Primary Study ◽  
Strategy Execution ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Interprofessional Teamwork ◽  
Uptake Rates ◽  
Study Population

170 Background: Thromboprophylaxis continues to be underutilized in hospitalized cancer patients despite the demonstrable risk of venous thromboembolism (VTE). Our study evaluated institutional VTE prophylaxis rates after devising a series of strategic interventions to longitudinally improve adherence rates over a period of eight years. Methods: Solid tumour patients admitted between 2004 and 2012 were selected as the primary study population for analysis. The bleeding risk associated with thromboprophylaxis was discernibly minimal. Guidelines were developed and formalized into an institutional thromboprophylaxis policy. Educational in-services were provided to physicians, nurses and pharmacists to review the most updated guidelines and tools added to encourage compliance to VTE prophylaxis. Support also arose from clinical members of the Cancer Quality Committee. An amalgamation of manual and electronic audit formats were undertaken to asses VTE prophylaxis rates prior to, and following strategy implementation. These audit formats either comprised of visiting inpatient units and examining anticoagulant orders on a per-patient basis, or viewing patient consensus reports and active anticoagulant orders electronically. Results: At the 2004 outset, 11 (19.3%) patients received appropriate pharmacological prophylaxis, and thus formed the baseline of our analysis. Post-2009 policy implementation and educational sessions, 46.5% of an eligible 185 inpatients were administered thromboprophylaxis. Following a two-year grace period to allow for policy acceptance, a series of three audits were conducted in 2011 for which an average prophylaxis rate of 62.3% resulted. In 2012, following awareness by clinicians of previous rates and rigorous strategy execution, a 96.7% rate was achieved and maintained five weeks thereafter. Conclusions: A reproducible 96.7% prophylaxis rate was the result of our cumulative eight-year efforts. A multidisciplinary approach is critical to improving thromboprophylaxis uptake rates and ensuring long-term sustainability of this outcome.

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