PROF-ETEV study: prophylaxis of venous thromboembolic disease in critical care units in Spain
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Venous thromboembolic disease (VTE) in critically ill patients has a high incidence despite prophylactic measures. This fact could be related to an inappropriate use of these measures due to the absence of specific VTE risk scores. To assess the current situation in Spain, we have performed a cross-sectional study, analyzing if the prophylactic measures were appropriate to the patients’ VTE risk.
Through an electronic questionnaire, we carried out a single day point prevalence study on the VTE prophylactic measures used in several critical care units in Spain. We performed a risk stratification for VTE in three groups: low, moderate–high, and very high risk. The American College of Chest Physicians guidelines were used to determine if the patients were receiving the recommended prophylaxis.
A total of 777 patients were included; 62 % medical, 30 % surgical, and 7 % major trauma patients. The median number of the risk factors for VTE was four. According to the proposed VTE risk score, only 2 % of the patients were at low risk, whereas 83 % were at very high risk. Sixty-three percent of patients received pharmacological prophylaxis, 12 % mechanical prophylaxis, 6 % combined prophylaxis, and 19 % did not receive any prophylactic measure. According to criteria suggested by the guidelines, 23 % of medical, 71 % of surgical, and 70 % of major trauma patients received an inappropriate prophylaxis.
Most critically ill patients are at high or very high risk of VTE, but there is a low rate of appropriate prophylaxis. The efforts to improve the identification of patients at risk, and the implementation of appropriate prevention protocols should be enhanced.
KeywordsVenous thromboembolic disease Critically ill patients Antithrombotic therapy Critical care unit
Conflicts of interest
Pablo Garcia Olivares and Jose Eugenio Guerrero Sanz have participated in several symposiums about venous thromboembolic disease in critically ill patients, organized by Covidien Spain S.L.
- 1.Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, Geer IA, Heit JA, Hutchinson JL, Kakkar AK, Mottier D, Oger E, Samama MM, Spannagl M, VTE Impact Assessment Group in Europe (VITAE) (2007) Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 98:756–764PubMedGoogle Scholar
- 3.PROTECT Investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group, Cook DD, Meade M, Guyatt G, 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 364:1305–1314. doi: 10.1056/NEJMoa1014475 PubMedCrossRefGoogle Scholar
- 7.Sud S, Mittmann N, Cook DJ, Geerts W, Chan B, Dodek P, Gould MK, Guyatt G, Arabi Y, Fowler RA (2011) Screening and prevention of venous thromboembolism in critically ill patients a decision analysis and economic evaluation. Am J Respir Crit Care Med 184:1289–1298. doi: 10.1164/rccm.201106-1059OC PubMedCrossRefGoogle Scholar
- 8.Quality indicators in critically ill patients (2011) Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC). ISBN:978-84-615-3670-2. http://www.semicyuc.org/sites/default/files/quality_indicators_update_2011.pdf. Accessed 1 Jan 2014
- 10.Tapson VF, Decousus H, Pini M, Chong BH, Froehlich JB, Monreal M, Spyropoulos AC, Merli GJ, Zotz RB, Bergmann JF, Pavanello R, Turpie AG, Nakamura M, Piovella F, Kakkar AK, Spencer FA, Fitzgerald G, Anderson FA Jr, IMPROVE investigators (2007) Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on venous thromboembolism. Chest 132:936–945PubMedCrossRefGoogle Scholar
- 11.Robertson MS, Nichol AD, Higgins AM, Bailey MJ, Presneill JJ, Cooper DJ, Webb SA, McArthur C, Maclsaac CM, VTE Point Prevalence Investigators for the Australian and New Zealand Intensive Care Research Centre, Australian and New Zealand Intensive Care Society Clinical Trials Group (2010) Venous thromboembolism prophylaxis in the critically ill: a point prevalence survey of current practice in Australian and New Zealand intensive care units. Crit Care Resusc 12:9–15PubMedGoogle Scholar
- 12.Schaden E, Metnitz PG, Pfanner G, Heil S, Pernerstorfer T, Perger P, Schoechl H, Fries D, Guetl M, Kozek-Langenecker S (2012) Coagulation day 2010: an Austrian survey on the routine of thromboprophylaxis in intensive care. Intensive Care Med 38:984–990. doi: 10.1007/s00134-012-2533-0 PubMedCrossRefGoogle Scholar
- 13.Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Belekian 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–226S. doi: 10.1378/chest.11-2296 PubMedPubMedCentralGoogle Scholar
- 14.Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM, American College of Chest Physicians (2012) Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 141(2 Suppl):e227S–277S. doi: 10.1378/chest.11-2297 PubMedPubMedCentralGoogle Scholar
- 15.García-Olivares P, Guerrero JE, Tomey MJ, Hernangómez AM, Stanescu DO (2014) Prevention of venous thromboembolic disease in the critical patient: an assessment of clinical practice in the community of Madrid. Med Intensiva 38:347–355. doi: 10.1016/j.medin.2013.07.005.Epub PubMedCrossRefGoogle Scholar
- 21.Decousus H, Tapson VF, Bergman JF, Chong BH, Froehlich JB, Kakkar AK, Merli GJ, Monreal M, Nakamura M, Pavanello R, Pini M, Piovella F, Spencer FA, Spyropoulos AC, Turpie AG, Zotz RB, Fitzgerald G, Anderson FA (2011) Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest 139:69–79. doi: 10.1378/chest.09-3081 PubMedCrossRefGoogle Scholar
- 23.Lauzier F, Arnold DM, Rabbat C, Heels-Ansdell D, Zarychanski R, Dodek P, Ashley BJ, Albert M, Khwaja K, Ostermann M, Skrobik Y, Fowler R, McIntyre L, Nates JL, Karachi T, Lopes RD, Zytaruk N, Finfer S, Crowther M, Cook D (2013) Risk factors and impact of major bleeding in critically ill patients receiving heparin thromboprophylaxis. Intensive Care Med 39:2135–2143. doi: 10.1007/s00134-013-3044-3 PubMedCrossRefGoogle Scholar
- 28.Cheng SS, Nordenholz K, Matero D, Pearlman N, McCarter M, Gajdos C, Hamiel C, Baer A, Luzier E, Tran ZV, Olson T, Queensland K, Lutz R, Wischmeyer P (2012) Standard subcutaneous dosing of unfractionated heparin for venous thromboembolism prophylaxis in surgical ICU patients leads to subtherapeutic factor Xa inhibition. Intensive Care Med 38:642–6488. doi: 10.1007/s00134-011-2453-4.Epub PubMedCrossRefGoogle Scholar
- 31.Holbrook A, Schulman S, Witt DM, Olav Vandvik P, Fish J, Kovacs MJ, Svensson PJ, Veenstra DL, Crowther M, Guyatt GH, American College of Chest Physicians (2012) Evidence-based management of anticoagulant therapy antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 141(2 Suppl):e152S–184S. doi: 10.1378/chest.11-2295 PubMedPubMedCentralGoogle Scholar
- 34.Malinoski D, Jafari F, Ewing T, Ardary C, Conniff H, Baje M, Kong A, Lekawa ME, Dolich MO, Cinat ME, Barrios C, Hoyt DB (2010) Standard prophylactic enoxaparin dosing leads to inadequate anti-Xa levels and increased deep venous thrombosis rates in critically ill trauma and surgical patients. J Trauma 68:870–874. doi: 10.1097/TA.0b013e3181d32271 CrossRefGoogle Scholar
- 35.Cook D, Arabi Y, Ferguson N, Heels-Ansdell D, Freitag A, McDonald E, Clarke F, Keenan S, Pagliarello G, Plaxton W, Herridge M, Karachi T, Vallance S, Cade J, Crozier T, da Alves S Silva, Costa Filho R, Brandao N, Watpool I, McArdle T, Hollinger G, Mandourah Y, Al-Hazmi M, Zytaruk N, Adhikari NK, PROTECT Research Coordinators, PROTECT Investigators, Canadian Critical Care Trials Group, Australian and New Zealand Intensive Care Society Clinical Trials Group (2013) Physicians declining patient enrollment in a critical care trial: a case study in thromboprophylaxis. Intensive Care Med 39:2115–2125PubMedCrossRefGoogle Scholar
- 36.Vignon P, Dequin PF, Renault A et al (2013) Intermittent pneumatic compression to prevent venous thromboembolism in patients with high risk of bleeding hospitalized in intensive care units: the CIREA1 randomized trial. Intensive Care Med 39:872–880. doi: 10.1007/s00134-013-2814-2 PubMedCrossRefGoogle Scholar
- 37.Arabi YM, Khedr M, Dara SI, Dhar GS, Bhat SA, Tamim HM, Afesh LY (2013) Use of intermittent pneumatic compression and not graduated compression stockings is associated with lower incident VTE in critically ill patients: a multiple propensity scores adjusted analysis. Chest 144:152–159. doi: 10.1378/chest.12-2028 PubMedCrossRefGoogle Scholar
- 38.CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration, Dennis M, Sandercock P, Reid J, Graham C, Forbes J, Murray G (2013) Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet 382:516–524. doi: 10.1016/S0140-6736(13)61050-8 PubMedCrossRefGoogle Scholar