Intensive Care Medicine

, Volume 39, Issue 5, pp 872–880

Intermittent pneumatic compression to prevent venous thromboembolism in patients with high risk of bleeding hospitalized in intensive care units: the CIREA1 randomized trial

  • Philippe Vignon
  • Pierre-François Dequin
  • Anne Renault
  • Armelle Mathonnet
  • Nicolas Paleiron
  • Audrey Imbert
  • Delphine Chatellier
  • Valérie Gissot
  • Gwenaelle Lhéritier
  • Victor Aboyans
  • Gwenael Prat
  • Denis Garot
  • Thierry Boulain
  • Jean-Luc Diehl
  • Luc Bressollette
  • Aurélien Delluc
  • Karine Lacut
  • The Clinical Research in Intensive Care and Sepsis Group (CRICS Group)
Original

Abstract

Purpose

Venous thromboembolism (VTE) is a frequent and serious problem in intensive care units (ICU). Anticoagulant treatments have demonstrated their efficacy in preventing VTE. However, when the bleeding risk is high, they are contraindicated, and mechanical devices are recommended. To date, mechanical prophylaxis has not been rigorously evaluated in any trials in ICU patients.

Methods

In this multicenter, open-label, randomized trial with blinded evaluation of endpoints, we randomly assigned 407 patients with a high risk of bleeding to receive intermittent pneumatic compression (IPC) associated with graduated compression stockings (GCS) or GCS alone for 6 days during their ICU stay. The primary endpoint was the occurrence of a VTE between days 1 and 6, including nonfatal symptomatic documented VTE, or death due to a pulmonary embolism, or asymptomatic deep vein thrombosis detected by ultrasonography systematically performed on day 6.

Results

The primary outcome was assessed in 363 patients (89.2 %). By day 6, the incidence of the primary outcome was 5.6 % (10 of 179 patients) in the IPC + GCS group and 9.2 % (17 of 184 patients) in the GCS group (relative risk 0.60; 95 % confidence interval 0.28–1.28; p = 0.19). Tolerance of IPC was poor in only 12 patients (6.0 %). No intergroup difference in mortality rate was observed.

Conclusions

With the limitation of a low statistical power, our results do not support the superiority of the combination of IPC + GCS compared to GCS alone to prevent VTE in ICU patients at high risk of bleeding.

Keywords

Intermittent pneumatic compression devices Elastic stockings Venous thromboembolism Venous thrombosis Intensive care units 

References

  1. 1.
    Attia J, Ray JG, Cook DJ, Douketis J, Ginsberg JS, Geerts WH (2001) Deep vein thrombosis and its prevention in critically ill adults. Arch Intern Med 161:1268–1279PubMedCrossRefGoogle Scholar
  2. 2.
    Shorr AF, Williams MD (2009) Venous thromboembolism in critically ill patients. Observations from a randomized trial in sepsis. Thromb Haemost 101:139–144PubMedGoogle Scholar
  3. 3.
    Cook D, Crowther M, Meade M, Rabbat C, Griffith L, Schiff D, Geerts W, Guyatt G (2005) Deep venous thrombosis in medical-surgical critically ill patients: prevalence, incidence, and risk factors. Crit Care Med 33:1565–1571PubMedCrossRefGoogle Scholar
  4. 4.
    Cook D, Douketis J, Meade M, Guyatt G, Zytaruk N, Granton J, Skrobik Y, Albert M, Fowler R, Hebert P, Pagliarello G, Friedrich J, Freitag A, Karachi T, Rabbat C, Heels-Ansdell D, Geerts W, Crowther M; Canadian Critical Care Trials Group (2008) Venous thromboembolism and bleeding in critically ill patients with severe renal insufficiency receiving dalteparin thromboprophylaxis: prevalence, incidence and risk factors. Crit Care 12:R32PubMedCrossRefGoogle Scholar
  5. 5.
    Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Anderson FA Jr, Wheeler HB (2001) Prevention of venous thromboembolism. Chest 119:132S–175SPubMedCrossRefGoogle Scholar
  6. 6.
    Hirsch DR, Ingenito EP, Goldhaber SZ (1995) Prevalence of deep venous thrombosis among patients in medical intensive care. JAMA 274:335–337PubMedCrossRefGoogle Scholar
  7. 7.
    McKelvie PA (1994) Autopsy evidence of pulmonary thromboembolism. Med J Aust 160:127–128PubMedGoogle Scholar
  8. 8.
    Moser KM, Fedullo PF, LitteJohn JK, Crawford R (1994) Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis. JAMA 271:223–225PubMedCrossRefGoogle Scholar
  9. 9.
    Stein PD, Henry JW (1995) Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy. Chest 108:978–981PubMedCrossRefGoogle Scholar
  10. 10.
    Karwinski B, Svendsen E (1989) Comparison of clinical and postmortem diagnosis of pulmonary embolism. J Clin Pathol 42:135–139PubMedCrossRefGoogle Scholar
  11. 11.
    Twigg SJ, McCrirrick A, Sanderson PM (2001) A comparison of post mortem findings with post hoc estimated clinical diagnoses of patients who die in a United Kingdom intensive care unit. Intensive Care Med 27:706–710PubMedCrossRefGoogle Scholar
  12. 12.
    Blosser SA, Zimmerman HE, Stauffer JL (1998) Do autopsies of critically ill patients reveal important findings that were clinically undetected? Crit Care Med 26:1332–1336PubMedCrossRefGoogle Scholar
  13. 13.
    Mort TC, Yeston NS (1999) The relationship of pre-mortem diagnoses and post-mortem findings in a surgical intensive care unit. Crit Care Med 27:299–303PubMedCrossRefGoogle Scholar
  14. 14.
    Cade JF (1982) High risk of the critically ill for venous thromboembolism. Crit Care Med 10:448–450PubMedCrossRefGoogle Scholar
  15. 15.
    Fraisse F, Holzapfel L, Couland JM, Simonneau G, Bedock B, Feissel M, Herbecq P, Pordes R, Poussel JF, Roux L (2000) Nadroparin in the prevention of deep vein thrombosis in acute decompensated COPD. Am J Respir Crit Care Med 161:1109–1114PubMedCrossRefGoogle Scholar
  16. 16.
    PROTECT Investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group, Cook D, Meade M, Guyatt G, Walter S, Heels-Ansdell D, Warkentin TE, Zytaruk N, Crowther M, Geerts W, Cooper DJ, Vallance S, Qushmaq I, Rocha M, Berwanger O, Vlahakis NE (2011) Dalteparin versus unfractionated heparin in critically ill patients. N Engl J Med 364:1305–1314PubMedCrossRefGoogle Scholar
  17. 17.
    Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, Murad MH; American College of Chest Physicians (2012) Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e195S–e226SPubMedCrossRefGoogle Scholar
  18. 18.
    Turpie AGG, Hirsh J, Gent M, Julian D, Johnson J (1989) Prevention of deep vein thrombosis in potential neurosurgical patients. A randomized trial comparing graduated compression stockings alone or graduated compression stockings plus intermittent pneumatic compression with control. Arch Intern Med 149:679–681PubMedCrossRefGoogle Scholar
  19. 19.
    Lacut K, Bressollette L, Le Gal G, Etienne E, De Tinteniac A, Renault A, Rouhart F, Besson G, Garcia JF, Mottier D, Oger E, VICTORIAh (Venous Intermittent Compression and Thrombosis Occurrence Related to Intra-cerebral Acute hemorrhage) Investigators (2005) Prevention of venous thrombosis in patients with acute intra-cerebral hemorrhage. Neurology 65:865–869PubMedCrossRefGoogle Scholar
  20. 20.
    Goodacre S, Sampson F, Thomas S, van Beek E, Sutton A (2005) Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis. BMC Med Imaging 5:6PubMedCrossRefGoogle Scholar
  21. 21.
    Limpus A, Chaboyer W, McDonald E, Thalib L (2006) Mechanical thromboprophylaxis in critically ill patients: a systematic review and meta-analysis. Am J Crit Care 15:402–410PubMedGoogle Scholar
  22. 22.
    Jacobs DG, Piotrowski JJ, Hoppensteadt DA, Salvator AE, Fareed J (1996) Hemodynamic and fibrinolytic consequences of intermittent pneumatic compression: preliminary results. J Trauma 40:710–716PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2013

Authors and Affiliations

  • Philippe Vignon
    • 1
    • 2
    • 3
  • Pierre-François Dequin
    • 4
  • Anne Renault
    • 5
  • Armelle Mathonnet
    • 6
  • Nicolas Paleiron
    • 7
  • Audrey Imbert
    • 8
  • Delphine Chatellier
    • 9
  • Valérie Gissot
    • 10
  • Gwenaelle Lhéritier
    • 1
    • 2
    • 3
  • Victor Aboyans
    • 11
  • Gwenael Prat
    • 5
  • Denis Garot
    • 4
  • Thierry Boulain
    • 6
  • Jean-Luc Diehl
    • 8
    • 12
  • Luc Bressollette
    • 13
    • 14
  • Aurélien Delluc
    • 13
    • 15
  • Karine Lacut
    • 13
    • 16
    • 17
  • The Clinical Research in Intensive Care and Sepsis Group (CRICS Group)
  1. 1.Réanimation PolyvalenteCHU DupuytrenLimogesFrance
  2. 2.INSERM, CIC-P 0801CHU DupuytrenLimogesFrance
  3. 3.Université de LimogesLimogesFrance
  4. 4.Université François Rabelais et service de Réanimation MédicaleCHU de Tours–Hôpital BretonneauToursFrance
  5. 5.Service de Réanimation MédicaleCHU de la Cavale BlancheBrestFrance
  6. 6.RéanimationCHR–Hôpital de la SourceOrléansFrance
  7. 7.Service des maladies respiratoiresHIA Clermont-TonnerreBrestFrance
  8. 8.Réanimation MédicaleHEGP AP-HPParisFrance
  9. 9.Service de Réanimation MédicaleCHU de PoitiersPoitiersFrance
  10. 10.Service de Réanimation PolyvalenteCH D’AngoulêmeSaint-MichelFrance
  11. 11.Service de CardiologieCHU de LimogesLimogesFrance
  12. 12.INSERM U765Université Paris DescartesSorbonne Paris CitéFrance
  13. 13.EA3878Université de Bretagne OccidentaleBrestFrance
  14. 14.Unité de Médecine VasculaireCHU BrestBrestFrance
  15. 15.Département de Médecine Interne et PneumologieCHU BrestBrestFrance
  16. 16.INSERM, CIC 0502BrestFrance
  17. 17.CIC 0502, Hôpital de la Cavale BlancheBrest CedexFrance

Personalised recommendations