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Surgical Critical Care Therapy pp 311–319Cite as

Venous Thromboembolism, Prophylaxis, and Treatment (Including Fat Embolism Syndrome)

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Abstract

DVT (deep venous thrombosis) and PE (pulmonary embolism), collectively known as VTE (venous thromboembolism), are common in critically ill patients. With proper prophylaxis, VTE is preventable in many patients. Critically ill patients are at high risk due to their underlying disease state and secondary to vasopressor use, venous catheterization, sedation, and/or mechanical ventilation. Most (if not all) ICU patients require pharmacologic prophylaxis unless contraindicated. If contraindicated, mechanical prophylaxis with sequential compression devices or, less commonly, IVC (inferior vena cava) filters can be used. Diagnosis is challenging as VTE often presents with non-specific findings. Gold standard for diagnosis remains duplex ultrasound for DVT and CT pulmonary angiography for PE. Evaluation by echocardiogram can help determine severity of the PE. Therapeutic anticoagulation remains the basic cornerstone treatment for VTE. Some patients may also require catheter-directed or surgical therapies for those who manifest with cardiac or hemodynamic compromise. Appropriate risk stratification, prophylactic measures, proper diagnostic workup, and treatment are critical for the care of ICU patients.

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References

  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/.

  2. 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. Agency for Healthcare Research and Quality: Rockville, MD; 2008.

    Google Scholar 

  3. 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.

    Article  Google Scholar 

  4. Haut ER, Lau BD. Chapter 28: prevention of venous thromboembolism: brief update review. In: Making health care safer II: an updated critical analysis of the evidence for patient safety practices, vol. 211. Rockville, MD: Agency for Healthcare Research and Quality; 2013. p. C-62.

    Google Scholar 

  5. 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 

  6. Streiff MB, Haut ER. The CMS ruling on venous thromboembolism after Total knee or hip arthroplasty: weighing risks and benefits. JAMA – J Am Med Assoc. 2009;301(10):1063–5.

    Article  CAS  Google Scholar 

  7. 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.

    Article  CAS  Google Scholar 

  8. Minet C, Potton L, Bondadona A, et al. Venous thromboembolism in the ICU: main characteristics, diagnosis and thromboprophylaxis. Crit Care. 2015;19(1):287.

    Article  Google Scholar 

  9. McLeod AG, Geerts W. Venous thromboembolism prophylaxis in critically ill patients. Crit Care Clin. 2011;27:765–80.

    Article  Google Scholar 

  10. Kabrhel C, Rosovsky R, Channick R, et al. A multidisciplinary pulmonary embolism response team (PERT): initial 30-month experience with a novel approach to delivery of care to patients with sub-massive and massive PE. Chest. 2016;150(2):384–93.

    Article  Google Scholar 

  11. 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.

    Article  Google Scholar 

  12. 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.

    Article  Google Scholar 

  13. Haut ER, Lau BD, Kraus PS, et al. Preventability of hospital-acquired venous thromboembolism. JAMA Surg. 2015;150(9):912–5.

    Article  Google Scholar 

  14. 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.

    Article  Google Scholar 

  15. 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.

    Article  CAS  Google Scholar 

  16. Kaplan D, Casper TC, Elliott CG, et al. VTE incidence and risk factors in patients with severe sepsis and septic shock. Chest. 2015;148(5):1224–30.

    Article  Google Scholar 

  17. 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.

    PubMed  Google Scholar 

  18. Kapoor A, et al. Comparative effectiveness of venous thromboembolism prophylaxis options for the patient undergoing total hip and knee replacement: a network meta-analysis. J Thromb Haemost. 2016;14:1–11.

    Google Scholar 

  19. Ruíz-Giménez N, Suárez C, González R, et al. Predictive variables for major bleeding events in patients presenting with documented acute venous thromboembolism. Findings from the RIETE registry. Thromb Haemost. 2008;100:26–31.

    Article  Google Scholar 

  20. Kearon C. Natural history of venous thromboembolism. Circulation. 2003;107(23 Suppl 1):I22–30.

    PubMed  Google Scholar 

  21. 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.

    Article  Google Scholar 

  22. Ozier Y, Dubourg O, Farcot JC, Bazin M, Jardin F, Margairaz A. Circulatory failure in acute pulmonary embolism. Intensive Care Med. 1984;10(2):91–7.

    Article  CAS  Google Scholar 

  23. Gazmuri RJ, Patel DJ, Stevens R, Smith S. Circulatory collapse, right ventricular dilation, and alveolar dead space: a triad for the rapid diagnosis of massive pulmonary embolism. Am J Emerg Med. 2016;35:936.e1–4. (online publication).

    Article  Google Scholar 

  24. Bilimoria KY. Facilitating quality improvement: pushing the pendulum back toward process measures. JAMA. 2015;314(13):1333–4.

    Article  CAS  Google Scholar 

  25. 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.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  28. 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(2):48–52.

    Article  Google Scholar 

  29. 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.

    Article  Google Scholar 

  30. Cohen AT, Tapson VF, Bergmann JF, Goldhaber SZ, Kakkar AK, Deslandes B, Huang W, Zayaruzny M, Emery L, Anderson FA Jr, Investigators ENDORSE. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet. 2008;371(9610):387–94.

    Article  Google Scholar 

  31. 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.

    Article  Google Scholar 

  32. 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.

    Article  CAS  Google Scholar 

  33. 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.

    Article  CAS  Google Scholar 

  34. Devereaux PJ, et al. Aspirin in patients undergoing non-cardiac surgery. NEJM. 2014;370(16):1494–502.

    Article  CAS  Google Scholar 

  35. Van P, Cho D, Underwood S, et al. Thromboelastography versus antifactor Xa levels in the assessment of prophylactic dose enoxaparin in critically ill patients. J Trauma. 2009;66(6):1509–15.

    Article  CAS  Google Scholar 

  36. Cotton BA, Minei KM, Radwan Z, et al. Admission rapid thromboelastography predicts development of pulmonary embolism in trauma patients. J Trauma Acute Care Surg. 2012;72(6):1470–5.

    Article  Google Scholar 

  37. Harr J, Moore E, Chin T, et al. Platelets are dominant contributors to hypercoagulability after injury. J Trauma Acute Care Surg. 2013;74(3):756–65.

    Article  CAS  Google Scholar 

  38. Allen C, Clark M, Meizoso J, et al. Coagulation profile changes due to thromboprophylaxis and platelets in trauma patients at high risk for venous thromboembolism. Am Surg. 2015;81:663–8.

    PubMed  Google Scholar 

  39. 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.

    Article  Google Scholar 

  40. Hemmila M, Osborne N, Henke P, Kepros J, Patel S, Cain-Nielsen A, Birkmeyer N. Prophylactic inferior vena cava filter placement does not results in a survival benefit for trauma patients. Ann Surg. 2015;262(4):577–85.

    Article  Google Scholar 

  41. Sing RF, Camp SM, Heniford BT, Rutherford EJ, Dix S, Reilly PM, Holmse JH, Haut E, Hayanga A. Timing of pulmonary emboli after trauma: implications for retrievable vena cava filters. J Trauma. 2006;60:732–4; discussion 734–5.

    Article  Google Scholar 

  42. Taccone FS, Bunker N, Waldmann C, De Backer D, Brohi K, Jones RG, Vincent JL. A new device for the prevention of pulmonary embolism in critically ill patients: results of the European Angel Catheter Registry. J Trauma Acute Care Surg. 2015;79(3):456–62.

    Article  Google Scholar 

  43. Sachdeva A, Dalton M, Amaragiri SV, Lees T. Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev. 2014;17(12):CD001484.

    Google Scholar 

  44. 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.

    Article  Google Scholar 

  45. Hobson DB, Chang TY, Aboagye JK, Lau BD, Shihab HM, Fisher B, Young S, Sujeta N, Shaffer DL, Popoola VO, Kraus PS, Knorr G, Farrow NE, Streiff MB, Haut ER. Prevalence of graduated compression stocking associated pressure injuries in surgical intensive care units. J Crit Care. 2017;40:1–6. accepted, in press.

    Article  Google Scholar 

  46. Boelig M, Streiff MB, Hobson DB, Kraus PS, Pronovost PJ, Haut ER. Are sequential compression devices commonly associated with in-hospital falls? A myth-busters review using the patient safety net database. J Patient Saf. 2011;7:77–9.

    Article  Google Scholar 

  47. Chang D, Velmahos G, Jindal A, Baker D, Phillips J, Bonar J, Campbell K. Compliance with sequential compression device prophylaxis in at-risk trauma patients: a prospective analysis. Am Surg. 2002;68(5):470–3.

    PubMed  Google Scholar 

  48. 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. 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.

    Google Scholar 

  49. 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.

    Article  Google Scholar 

  50. Goktay A, Senturk C. Endovascular treatment of thrombosis and embolism. In: Shaidul Islam M, editor. Thrombosis and embolism: from research to clinical practice. 1st ed. Philadelphia, PA: Elsevier; 2016. p. 195–213.

    Google Scholar 

  51. 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.

    Article  CAS  Google Scholar 

  52. 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.

    Article  CAS  Google Scholar 

  53. 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.

    Article  CAS  Google Scholar 

  54. Oks M, Cleven KL, Cardenas-Garcia J, Schaub JA, Koenig S, Cohen RI, Mayo PH, Narasimhan M. The effect of point-of-care ultrasonography on imaging studies in the medical ICU: a comparative study. Chest. 2014;146(6):1574–7.

    Article  Google Scholar 

  55. Barleben A, Bandyk D. Interpretation of peripheral venous duplex testing. Semin Vasc Surg. 2013;26(2-3):111–9.

    Article  Google Scholar 

  56. Meinel FG, Nance JW Jr, 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.

    Article  Google Scholar 

  57. Hurst JM, Davis K, Johnson DJ, Branson RD, Campbell RS, Branson PS. Cost and complications during in-hospital transport of critically ill patients: a prospective cohort study. J Trauma. 1992;33(4):582–5.

    Article  CAS  Google Scholar 

  58. Szem JW, Hydo LJ, Fischer E, Kapur S, Klemperer J, Barie PS. High-risk intrahospital transport of critically ill patients:safety and outcome of the necessary “road trip”. Crit Care Med. 1995;23(10):1660–6.

    Article  CAS  Google Scholar 

  59. Atkinson P, Bowra J, Milne J, Lewis D, Lambert M, Jarman B, Noble EV, Lamprecht H, Harris T, Connolly J. International Federation for Emergency Medicine Consensus Statement: sonography in hypotension and cardiac arrest (SHoC): an international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest. CJEM. 2016;21:1–12.

    Google Scholar 

  60. Byrne J, Geerts M, Stephanie A, Gomez D, Hoeft C, Murphy R, Neal M, Nathens A. Effectiveness of low-molecular-weight heparin versus unfractionated heparin to prevent pulmonary embolism following major trauma: a propensity-matched analysis. J Trauma Acute Care Surg. 2017;82(2):252–62.

    Article  CAS  Google Scholar 

  61. Gauss H. Pathophysiology of fat embolism, a review. Arch Surg. 1924;9:593–603.

    Article  Google Scholar 

  62. Vedantham S, Goldhaber SZ, Kahn SR, Julian J, Magnuson E, Jaff MR, Murphy TP, Cohen DJ, Comerota AJ, Gornik HL, Razavi MK, Lewis L, Kearon C. Rationale and design of the ATTRACT study: a multicenter randomized trial to evaluate pharmacomechanical catheter-directed thrombolysis for the prevention of postthrombotic syndrome in patients with proximal deep vein thrombosis. Am Heart J. 2013;165(4):523–30.

    Article  Google Scholar 

  63. Kabrhel C, Jaff MR, Channick RN, Baker JN, Rosenfield K. A multidisciplinary pulmonary embolism response team. Chest. 2013;144(5):1738–9.

    Article  Google Scholar 

  64. Provias T, Dudzinski DM, Jaff MR, et al. The Massachusetts general hospital pulmonary embolism response team (MGH PERT): creation of a multidisciplinary program to improve care of patients with massive and submassive pulmonary embolism. Hosp Pract. 2014;42(1):31–7.

    Article  Google Scholar 

  65. Deveraux PJ, et al. The perioperative ischemia evaluation-2 trial and a pooled analysis of randomized trials. Anesthesiology. 2016;125:1121–9.

    Article  Google Scholar 

  66. Scarpino M, et al. Cerebral fat embolism after video-assisted thoracic surgery. Ann Thorac Surg. 2016;102:409–11.

    Article  Google Scholar 

  67. Lehman P, Moore E. Fat embolism including experimental production without trauma. Arch Surg. 1927;14:621–62.

    Article  CAS  Google Scholar 

  68. Moreau JP. Fat embolism: a review and report of 100 cases. Can J Surg. 1974;17:196–9.

    CAS  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Franz S. Yanagawa

  2. Department of Surgery, Anesthesiology/Critical Care Medicine (ACCM), and Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Elliott R. Haut

  3. Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA

    Elliott R. Haut

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  1. Franz S. Yanagawa
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  2. Elliott R. Haut
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Correspondence to Elliott R. Haut .

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Editors and Affiliations

  1. Brigham and Womens’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

    Ali Salim

  2. Dell Medical School, University of Texas at Austin, Austin, Texas, USA

    Carlos Brown

  3. Division of Trauma Surgery, Rm C5L100, University of Southern California, Los Angeles, California, USA

    Kenji Inaba

  4. Trauma and Emergency Surgery Service, Legacy Emanuel Medical Center, Portland, Oregon, USA

    Matthew J. Martin

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Yanagawa, F.S., Haut, E.R. (2018). Venous Thromboembolism, Prophylaxis, and Treatment (Including Fat Embolism Syndrome). In: Salim, A., Brown, C., Inaba, K., Martin, M. (eds) Surgical Critical Care Therapy . Springer, Cham. https://doi.org/10.1007/978-3-319-71712-8_30

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  • DOI: https://doi.org/10.1007/978-3-319-71712-8_30

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