Advertisement

Venous Thromboembolism in the Intensive Care Unit

  • Lisa M. Kodadek
  • Elliott R. Haut
Chapter

Abstract

Venous thromboembolism (VTE), including deep vein thrombosis (DVT), pulmonary embolism (PE), or both, is common among critically ill surgical patients and potentially preventable in many cases. Despite high-quality evidence-based guidelines for VTE prophylaxis, many patients do not receive risk-appropriate prophylaxis, and over 100,000 people continue to die from VTE in the United States (US) each year. Critical care patients are at even higher risk for VTE than other hospitalized patients secondary to additional risk factors including vasopressor use, mechanical ventilation, pharmacologic sedation, immobilization, surgery, and central venous catheters. Furthermore, VTE is often clinically silent among critical care patients and timely diagnosis may be challenging. Duplex ultrasonography and contrast-enhanced computed tomography (CT) angiography are the best modalities for diagnosis of DVT and PE, respectively. Severity of PE may be evaluated with transthoracic or transesophageal echocardiography. The mainstay of treatment for DVT and PE is systemic anticoagulation, although patients with PE and associated hemodynamic instability or cardiac failure may require more invasive treatment interventions. Management of VTE in the intensive care unit (ICU) is complicated because many patients have high risk of bleeding from concomitant major surgery, trauma, coagulopathy, or gastrointestinal bleeding. All ICU patients require risk-appropriate VTE prophylaxis because all ICU patients are at risk for VTE. The majority of patients should receive pharmacologic prophylaxis, although some will have a contraindication and should receive mechanical sequential compression devices instead. It is important to recognize risk factors, prescribe and administer effective prophylaxis, and provide timely diagnosis and treatment for patients with VTE in the ICU.

Keywords

Deep vein thrombosis Intensive care unit Pulmonary embolism Surgical critical care Venous thromboembolism Venous thromboembolism prophylaxis 

Abbreviations and Acronyms

AAOS

The American Academy of Orthopaedic Surgeons

ACCP

The American College of Chest Physicians

AHRQ

The Agency for Healthcare Research and Quality

CT

Computed tomography

DVT

Deep vein thrombosis

EAST

The Eastern Association for the Surgery of Trauma

ECMO

Extracorporeal membrane oxygenation

ICU

Intensive care unit

INR

International normalized ratio

IVC

Inferior vena cava

LMWH

Low molecular weight heparin

PE

Pulmonary embolism

SC

Subcutaneous

SCDs

Sequential compression devices

TEDS

Thromboembolic deterrent stockings

US

United States

V/Q scan

Ventilation/perfusion scan

VTE

Venous thromboembolism

References

  1. 1.
    US Department of Health and Human Services. Surgeon general’s call to action to prevent deep vein thrombosis and pulmonary embolism 2008. Available at: http://www.ncbi.nlm.nih.gov/books/NBK44178/. Accessed 15 Sept 2015.
  2. 2.
    Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess (Summ). 2001;i–x:1–668.Google Scholar
  3. 3.
    Maynard G, Stein J. Preventing hospital-acquired venous thromboembolism: a guide for effective quality improvement. Prepared by the Society of Hospital Medicine. AHRQ Publication No. 08–0075. Rockville: Agency for Healthcare Research and Quality. Aug 2008.Google Scholar
  4. 4.
    Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158:365–8.CrossRefGoogle Scholar
  5. 5.
    Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. (Prepared by the Southern California-RAND Evidence-based Practice Center under Contract No. 290-2007-10062-I.) AHRQ Publication No. 13-E001-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2013. www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html.Google Scholar
  6. 6.
    Cohen AT, Tapson VF, Bergmann J, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet. 2008;371(9610):387–94.CrossRefGoogle Scholar
  7. 7.
    Goldhaber SZ, Tapson VF, DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004;93(2):259–62.CrossRefGoogle Scholar
  8. 8.
    Attia J, Ray JG, Cook DJ, Douketis J, Ginsberg JS, Geerts WH. Deep vein thrombosis and its prevention in critically ill adults. Arch Intern Med. 2001;161(10):1268–79.CrossRefGoogle Scholar
  9. 9.
    Minet C, Potton L, Bondadona A, et al. Venous thromboembolism in the ICU: main characteristics, diagnosis and thromboprophylaxis. Crit Care. 2015;19(1):287.CrossRefGoogle Scholar
  10. 10.
    McLeod AG, Geerts W. Venous thromboembolism prophylaxis in critically ill patients. Crit Care Clin. 2011;27:765–80.CrossRefGoogle Scholar
  11. 11.
    Crowther MA, Cook DJ, Griffith LE, et al. Deep venous thrombosis: clinically silent in the intensive care unit. J Crit Care. 2005;20:334–40.CrossRefGoogle Scholar
  12. 12.
    Velmahos GC, Spaniolas K, Tabbara M, et al. Pulmonary embolism and deep venous thrombosis in trauma: are they related? Arch Surg. 2009;144(10):928–32.CrossRefGoogle Scholar
  13. 13.
    Kearon C. Natural history of venous thromboembolism. Circulation. 2003;107(23 Suppl 1):I22–30.PubMedGoogle Scholar
  14. 14.
    Ibrahim EH, Iregui M, Prentice D, Sherman G, Kollef MH, Shannon W. Deep vein thrombosis during prolonged mechanical ventilation despite prophylaxis. Crit Care Med. 2002;30(4):771–4.CrossRefGoogle Scholar
  15. 15.
    Kaplan D, Casper TC, Elliott CG, et al. VTE incidence and risk factors in patients with severe sepsis and septic shock. Chest. 2015. doi: 10.1378/chest.15-0287.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Cook D, Crowther M, Meade M, et al. Deep venous thrombosis in medical-surgical critically ill patients: prevalence, incidence, and risk factors. Crit Care Med. 2005;33:1565–71.CrossRefGoogle Scholar
  17. 17.
    Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001;286:700–7.CrossRefGoogle Scholar
  18. 18.
    Maynard G, Morris T, Jenkins I, et al. Optimizing prevention of hospital acquired venous thromboembolism: prospective validation of a VTE risk assessment model. J Hosp Med. 2010;5(1):10–8.PubMedGoogle Scholar
  19. 19.
    Streiff MB, Carolan HT, Hobson DB, et al. Lessons from the Johns Hopkins multi-disciplinary venous thromboembolism (VTE) prevention collaborative. Br Med J. 2012;344:e3935.CrossRefGoogle Scholar
  20. 20.
    Caprini JA, Arcelus JI, Hasty JH, et al. Clinical assessment of venous thromboembolic risk in surgical patients. Semin Thromb Hemost. 1991;17 Suppl 3:304–12.PubMedGoogle Scholar
  21. 21.
    Barbar S, Noventa F, Rossetto V, et al. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost. 2010;8:2450–7.CrossRefGoogle Scholar
  22. 22.
    Rogers Jr SO, Kilaru RK, Hosokawa P, et al. Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1211–21.CrossRefGoogle Scholar
  23. 23.
    Spyropoulos AC, Anderson FA, FitzGerald G, IMPROVE Investigators, et al. Predictive and associative models to identify hospitalized medical patients at risk for VTE. Chest. 2011;140(3):706–14.CrossRefGoogle Scholar
  24. 24.
    Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015. doi: 10.1001/jamasurg.2015.1841.CrossRefPubMedGoogle Scholar
  25. 25.
    Guyatt GH, Akl EA, Crowther M, et al. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141:7S–47.CrossRefGoogle Scholar
  26. 26.
    Rogers FB, Cipolle MD, Velmahos G, Rozycki G, Luchette FA. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group. J Trauma. 2002;53(1):142–64.CrossRefGoogle Scholar
  27. 27.
    Johanson NA, Lachiewicz PF, Lierberman JR, et al. American academy of orthopaedic surgeons clinical practice guideline on prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. J Bone Joint Surg Am. 2009;91(7):1756–7.CrossRefGoogle Scholar
  28. 28.
    Cook D, Meade M, Guyatt G, et al. Dalteparin versus unfractionated heparin in critically ill patients. N Engl J Med. 2011;364:1305–14.CrossRefGoogle Scholar
  29. 29.
    Beitland S, Sandven I, Lill-Kristin K, Sandset PM, Sunde K, Eken T. Thromboprophylaxis with low molecular weight heparin versus unfractionated heparin in intensive care patients: a systematic review with meta-analysis and trial sequential analysis. Intensive Care Med. 2015;4:1209–19.CrossRefGoogle Scholar
  30. 30.
    The CLOTS (Clots in Legs Or sTockings after Stroke) Trial Collaboration. Thigh-length versus below-knee stockings for deep venous thrombosis prophylaxis after stroke: a randomized trial. Ann Intern Med. 2010;153(9):553–62.CrossRefGoogle Scholar
  31. 31.
    Lau BD, Streiff MB, Kraus PS, et al. No evidence to support ambulation for reducing postoperative venous thromboembolism. J Am Coll Surg. 2014;219(5):1101–3.CrossRefGoogle Scholar
  32. 32.
    Haut ER, Garcia LJ, Shihab HM, et al. The effectiveness of prophylactic Inferior Vena Cava (IVC) filters in trauma patients: a systematic review and meta-analysis. JAMA Surg. 2014;149(2):194–202.CrossRefGoogle Scholar
  33. 33.
    Brotman DJ, Shihab HM, Prakasa KR, et al. Pharmacologic and mechanical strategies for preventing venous thromboembolism after bariatric surgery: a systematic review and meta-analysis. JAMA Surg. 2013;148(7):675–86.CrossRefGoogle Scholar
  34. 34.
    Louis SG, Sato M, Geraci T, et al. Correlation of missed doses of enoxaparin with increased incidence of deep vein thrombosis in trauma and general surgery patients. JAMA Surg. 2014;149(4):365–70.CrossRefGoogle Scholar
  35. 35.
    Haut ER, Lau BD, Kraus PS, et al. Preventability of hospital-acquired venous thromboembolism. JAMA Surg. 2015;150(9):912–5.CrossRefGoogle Scholar
  36. 36.
    Haut ER, Lau BD, Kraenzlin FS, et al. Improve prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma. Arch Surg. 2012;147(10):901–7.CrossRefGoogle Scholar
  37. 37.
    Barleben A, Bandyk DF. Interpretation of peripheral venous duplex testing. Semin Vasc Surg. 2013;26(2–3):111–9.CrossRefGoogle Scholar
  38. 38.
    Quiroz R, Kucher N, Zou KH, et al. Clinical validity of a negative computed tomography scan in patients with suspected pulmonary embolism: a systematic review. JAMA. 2005;293:2012–7.CrossRefGoogle Scholar
  39. 39.
    Meinel FG, Nance Jr JW, Schoepf UJ, et al. Predictive value of computed tomography in acute pulmonary embolism: systematic review and meta-analysis. Am J Med. 2015;128(7):747–59.CrossRefGoogle Scholar
  40. 40.
    Crowther MA, Cook DJ, Griffith LE, et al. Neither baseline tests of molecular hypercoagulability nor d dimer levels predict deep venous thrombosis in critically ill medical surgical patients. Intensive Care Med. 2005;31(1):48–55.CrossRefGoogle Scholar
  41. 41.
    Haut ER, Schenider EB, Patel A, et al. Duplex ultrasound screening for deep vein thrombosis in asymptomatic trauma patients: a survey of individual trauma surgeon opinions and current trauma center practices. J Trauma. 2011;70(1):27–34.CrossRefGoogle Scholar
  42. 42.
    Pierce CA, Haut ER, Kardooni S, et al. Surveillance bias and deep vein thrombosis in the national trauma data bank: the more we look, the more we find. J Trauma. 2008;64:932–7.CrossRefGoogle Scholar
  43. 43.
    Haut ER, Pronovost PJ. Surveillance bias in outcomes reporting. JAMA. 2011;305(23):2462–3.CrossRefGoogle Scholar
  44. 44.
    Haut ER, Noll K, Efron DT, et al. Can increased incidence of Deep Vein Thrombosis (DVT) be used as a marker of quality of care in the absence of standardized screening? The potential effect of surveillance bias on reported DVT rates. J Trauma. 2007;63(5):1132–7.CrossRefGoogle Scholar
  45. 45.
    Bilimoria KY, Chung J, Ju M, et al. Evaluation of surveillance bias and the validity of the venous thromboembolism quality measure. JAMA. 2013;310(14):1482–9.CrossRefGoogle Scholar
  46. 46.
    The ATTRACT study. Available at: http://attract.wustl.edu/#. Accessed 12 Oct 2015. [Or insert citation once published].
  47. 47.
    Yusuff HO, Zochios V, Vuylsteke A. Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a systematic review. Perfusion. 2015;30:611–6. pii: 0267659115583377.CrossRefGoogle Scholar
  48. 48.
    Bilimoria KY. Facilitating quality improvement: pushing the pendulum back toward process measures. JAMA. 2015;314(13):1333–4.CrossRefGoogle Scholar
  49. 49.
    Aboagye JK, Lau BD, Schneider EB, Streiff MB, Haut ER. Linking processes and outcomes: a key strategy to prevent and report harm from venous thromboembolism in surgical patients. JAMA Surg. 2013;148(3):299–300.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Open Access This chapter is licensed under the terms of the Creative Commons Attribution-NonCommercial 2.5 International License (http://creativecommons.org/licenses/by-nc/2.5/), which permits any noncommercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

Authors and Affiliations

  1. 1.Department of SurgeryJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Division of Acute Care Surgery, Department of Surgery, Anesthesiology/Critical Care Medicine, and Emergency MedicineJohns Hopkins University School of Medicine, Health Policy and Management, Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA

Personalised recommendations