May Contribute to up to 12% of Deaths in ICU

VTE

14/10/10

OHOA

SP Notes

- may contribute to up to 12% of deaths in ICU

- importance of asymptomatic DVT uncertain -> if seen on Doppler then significantly higher chance of embolism

- even small PE’s may be tolerated poorly by the critically unwell

RISK FACTORS

Major (relative risk 5-20) - SLOMMM

Surgery – major abdominal/pelvic, hip/knee replacements, post ICU

Lower limb problems - #, varicose veins

Obstetrics – late pregnancy, C/S, puerperium

Malignancy – abdominal/pelvic, advanced/metastatic

Mobility – hospitalization, institutional care

Miscellaneous – previous VTE

Minor (relative risk 2-4) - COM

Cardiovascular – congenital heart disease, CHF, HT, superficial venous thrombosis, CVL

Oestrogens – OCP, HRT

Miscellaneous – COPD, neurological disability, occult malignancy, thrombotic disorder, long distance travel, obesity, other (IBD, nephrotic syndrome, dialysis, myeloproliferative disorders, paroxysmal nocturnal haemoglobinuria, Bechet’s diseas)

Thrombophillia’s

- Factor V Leiden mutation

- Prothombin gene mutation (G20210A)

- Hyperhomocysteinaemia

- Antiphospholipid antibody syndrome (lupus anti-coagulant & anti-cardiolipin antibodies)

- Deficiency of antithrombin III, protein C or protein S

- High concentrations of factor VIII or XI

- Increased lipoprotein (a)

-> test in those < 50years with recurrent or a strong FHx

MANAGEMENT

- many different strategies

- risk should be considered

- reviews and recommendations are widely published -> data quality is low

- but good placebo controlled RCT’s are rare

Non-pharmacological

- TED stockings (simple, widespread use, effective for low risk patients)

- hydration (physiological basis only)

- intermittent pneumatic compression (recommended but limited evidence, useful where anticoagulation contraindicated)

- passive mobilisation (not well studied)

- early mobilisation (not well studied)

- minimisation of intraoperative duration

- optimal cardiac output

- clinical and imaging surveilance

- elective insertion of an IVC filter (risk associated, only recommended in high risk patients)

Pharmacological

- regional anaesthesia (low quality data)

- adequate analgesia

- aspirin 100-300mg OD

- heparin 5000IU SC BD

- enoxaparin 40mg SC OD (20mg OD if has renal impairment, similar or better than heparin, with less thrombocytopaenia, only slight increase in bleeding)

- IV heparin titrated to an APTT of 60-80 seconds

- petasaccharides (new, showing promise)

- hirudin (new, showing promise)

- dextran (old, not used)

- warfarn (less frequently used)

- other controversies include cost-benefit and side-effect profiles

EVIDENCE

- DVT happen in ICU

- rate with prophylaxis = 6%

- LMWH as good as SC heparin BD

MY APPROACH

- routinely used non-pharmacological techniques (SCD’s, TEDS, hydration, physio)

- LMWH 40mg SC or 20mg SC in renal failure (OD dosing, heparin not superior, bleeding not an issue, cheap), possible trend to decreased PE – PROTECT trial).

Jeremy Fernando (2010)