Francois Lamontagne1, Lauralyn McIntyre2, Peter Dodek3, Diane Heels-Ansdell4, Maureen Meade5, Julia Pemberton6, Yoanna Skrobik7, Ian Seppelt8, Nicholas E Vlahakis9, John Muscedere10, Graham Reece11, Marlies Ostermann12, Soundrie Padayachee13, Jamal Alhashemi14, Michael Walsh5, Bradley Lewis15, David Schiff16, Alan Moody17, Nicole Zytaruk4, Martine Leblanc7, Deborah J Cook5. 1. Centre de recherche Clinique Étienne-Le Bel, Université de Sherbrooke, Sherbrooke, Quebec, Canada. 2. Department of Medicine (Division of Critical Care), The Ottawa Hospital, Ottawa, Ontario, Canada. 3. Center for Health Evaluation and Outcome Sciences and Department of Medicine, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada. 4. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. 5. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada5Department of Medicine, McMaster University, Hamilton, Ontario, Canada. 6. Department of Surgery, McMaster University, Hamilton, Ontario, Canada. 7. Department of Medicine, Hôpital Maisonneuve Rosemont, Montreal, Quebec, Canada. 8. Department of Intensive Care Medicine, Nepean Hospital, University of Sydney, Sydney, Australia. 9. Department of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota. 10. Department of Critical Care, Queen's University, Kingston, Ontario, Canada. 11. Department of Intensive Care Medicine, Blacktown Hospital, Sydney, Australia. 12. Department of Critical Care, Guys and St Thomas Hospital, London, England. 13. Department of Ultrasonic Angiology, Guys and St Thomas Hospital, London, England. 14. Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia. 15. Department of Radiology, Mayo Clinic, Rochester, Minnesota. 16. Department of Radiology, McMaster University, Hamilton, Ontario, Canada. 17. Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
Abstract
IMPORTANCE: Critically ill patients are at risk of venous thrombosis, and therefore guidelines recommend daily thromboprophylaxis. Deep vein thrombosis (DVT) commonly occurs in the lower extremities but can occur in other sites including the head and neck, trunk, and upper extremities. The risk of nonleg deep venous thromboses (NLDVTs), predisposing factors, and the association between NLDVTs and pulmonary embolism (PE) or death are unclear. OBJECTIVE: To describe the frequency, anatomical location, risk factors, management, and consequences of NLDVTs in a large cohort of medical-surgical critically ill adults. DESIGN, SETTING, AND PARTICIPANTS: A nested prospective cohort study in the setting of secondary and tertiary care intensive care units (ICUs). The study population comprised 3746 patients, who were expected to remain in the ICU for at least 3 days and were enrolled in a randomized clinical trial of dalteparin vs standard heparin for thromboprophylaxis. MAIN OUTCOMES AND MEASURES: The proportion of patients who had NLDVTs, the mean number per patient, and the anatomical location. We characterized NLDVTs as prevalent or incident (identified within 72 hours of ICU admission or thereafter) and whether they were catheter related or not. We used multivariable regression models to evaluate risk factors for NLDVT and to examine subsequent anticoagulant therapy, associated PE, and death. RESULTS Of 3746 trial patients, 84 (2.2%) developed 1 or more non-leg vein thromboses (superficial or deep, proximal or distal). Thromboses were more commonly incident (n = 75 [2.0%]) than prevalent (n = 9 [0.2%]) (P < .001) and more often deep (n = 67 [1.8%]) than superficial (n = 31 [0.8%]) (P < .001). Cancer was the only independent predictor of incident NLDVT (hazard ratio [HR], 2.22; 95% CI, 1.06-4.65). After adjusting for Acute Physiology and Chronic Health Evaluation (APACHE) II scores, personal or family history of venous thromboembolism, body mass index, vasopressor use, type of thromboprophylaxis, and presence of leg DVT, NLDVTs were associated with an increased risk of PE (HR, 11.83; 95% CI, 4.80-29.18). Nonleg DVTs were not associated with ICU mortality (HR, 1.09; 95% CI, 0.62-1.92) in a model adjusting for age, APACHE II, vasopressor use, mechanical ventilation, renal replacement therapy, and platelet count below 50 × 10(9)/L. CONCLUSIONS AND RELEVANCE Despite universal heparin thromboprophylaxis, nonleg thromboses are found in 2.2% of medical-surgical critically ill patients, primarily in deep veins and proximal veins. Patients who have a malignant condition may have a significantly higher risk of developing NLDVT, and patients with NLDVT, compared with those without, appeared to be at higher risk of PE but not higher risk of death. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00182143.
RCT Entities:
IMPORTANCE: Critically illpatients are at risk of venous thrombosis, and therefore guidelines recommend daily thromboprophylaxis. Deep vein thrombosis (DVT) commonly occurs in the lower extremities but can occur in other sites including the head and neck, trunk, and upper extremities. The risk of nonleg deep venous thromboses (NLDVTs), predisposing factors, and the association between NLDVTs and pulmonary embolism (PE) or death are unclear. OBJECTIVE: To describe the frequency, anatomical location, risk factors, management, and consequences of NLDVTs in a large cohort of medical-surgical critically ill adults. DESIGN, SETTING, AND PARTICIPANTS: A nested prospective cohort study in the setting of secondary and tertiary care intensive care units (ICUs). The study population comprised 3746 patients, who were expected to remain in the ICU for at least 3 days and were enrolled in a randomized clinical trial of dalteparin vs standard heparin for thromboprophylaxis. MAIN OUTCOMES AND MEASURES: The proportion of patients who had NLDVTs, the mean number per patient, and the anatomical location. We characterized NLDVTs as prevalent or incident (identified within 72 hours of ICU admission or thereafter) and whether they were catheter related or not. We used multivariable regression models to evaluate risk factors for NLDVT and to examine subsequent anticoagulant therapy, associated PE, and death. RESULTS Of 3746 trial patients, 84 (2.2%) developed 1 or more non-leg vein thromboses (superficial or deep, proximal or distal). Thromboses were more commonly incident (n = 75 [2.0%]) than prevalent (n = 9 [0.2%]) (P < .001) and more often deep (n = 67 [1.8%]) than superficial (n = 31 [0.8%]) (P < .001). Cancer was the only independent predictor of incident NLDVT (hazard ratio [HR], 2.22; 95% CI, 1.06-4.65). After adjusting for Acute Physiology and Chronic Health Evaluation (APACHE) II scores, personal or family history of venous thromboembolism, body mass index, vasopressor use, type of thromboprophylaxis, and presence of leg DVT, NLDVTs were associated with an increased risk of PE (HR, 11.83; 95% CI, 4.80-29.18). Nonleg DVTs were not associated with ICU mortality (HR, 1.09; 95% CI, 0.62-1.92) in a model adjusting for age, APACHE II, vasopressor use, mechanical ventilation, renal replacement therapy, and platelet count below 50 × 10(9)/L. CONCLUSIONS AND RELEVANCE Despite universal heparin thromboprophylaxis, nonleg thromboses are found in 2.2% of medical-surgical critically illpatients, primarily in deep veins and proximal veins. Patients who have a malignant condition may have a significantly higher risk of developing NLDVT, and patients with NLDVT, compared with those without, appeared to be at higher risk of PE but not higher risk of death. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00182143.
Authors: Simon Li; Cicero T Silva; Adele R Brudnicki; Kenneth E Baker; Joana A Tala; Matthew G Pinto; Lee A Polikoff; Li Qin; E Vincent S Faustino Journal: Pediatr Radiol Date: 2015-10-06
Authors: Guowei Li; Deborah J Cook; Mitchell A H Levine; Gordon Guyatt; Mark Crowther; Diane Heels-Ansdell; Anne Holbrook; Francois Lamontagne; Stephen D Walter; Niall D Ferguson; Simon Finfer; Yaseen M Arabi; Rinaldo Bellomo; D Jamie Cooper; Lehana Thabane Journal: Medicine (Baltimore) Date: 2015-09 Impact factor: 1.817