Thrombo-prophylaxis in Critical Care

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Thrombo-prophylaxis in Critical Care 
Dr. Aditya Jindal Interventional Pulmonologist
Intensivist Jindal Clinics SCO 21, Sec 20D,
Chandigarh DM Pulmonary and Critical Care
Medicine (PGI Chandigarh), FCCP
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• Venous thromboembolism (VTE), including deep
  venous thrombosis (DVT) and pulmonary embolism
  (PE), is a common complication in the ICU setting
• Autopsy studies detected PE in 7 to 27 of
  critically ill patients
• Incidence of DVT ranges from 5 to 31
• Clinical suspicion is much lower

Minet et al. Critical Care (2015)
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• PE ? associated with a high mortality rate,
  especially when associated with right ventricular
  failure or shock
• Mortality
• in untreated PE ? approximately 30
• with adequate (anticoagulant) treatment ? 2 to 8

Minet et al. Critical Care (2015)
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The incidence of VTE among patients (N 113)
with severe sepsis or septic shock
Kaplan et al. CHEST 2015
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Risk factors
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Virchows Triad
Overview of venous thromboembolism. Phillipe HM.
Am J Manag Care . 2017
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Venous thromboembolism risk factors
Streiff t al. J Thromb Thrombolysis (2016)
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• Catheter-related thrombosis
• 2 to 10 with subclavian catheter
• 10 to 69 with femoral catheter
• 40 to 56 with internal jugular catheter

Superior vena cava catheter-related thrombosis ?
the risk of associated PE is 7 to 17

• Additional factors
• Platelet transfusion/ thrombocytosis
• Underlying illness

Minet et al. Critical Care (2015)
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Diagnosis
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• Clinical suspicion
• D-dimers
• Low specificity
• Can be raised in atrial fibrillation, acute
  coronary syndromes, stroke, acute upper
  gastrointestinal hemorrhage,infection,
  disseminated intravascular coagulation, and
  severe renal dysfunction
• Compression ultrasound
• Sensitivity of 85 and a specificity of 96 for
  DVT
• Can be done bedside by intensivists

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• ECHO
• Trans-thoracic echo ? right ventricular
  hypokinesis, increases in right ventricular
  end-diastolic diameter, or tricuspid
  regurgitation
• Fails to identify more than 50 of PE proven on
  pulmonary angiography
• Trans-oesophageal echo ? good sensitivity (80 )
  and specificity (100 )
• CT pulmonary angiography
• Sensitivity 83 -100
• Specificity 89 - 97
• Gold standard for diagnosis of PE
• Transportation issues

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Treatment
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• ICU patients are at higher risk of VTE events
• However, chances of bleeding are also higher than
  the general population
• Should anticoagulants be used for prophylaxis?

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Independent Risk Factors for Bleeding in 10,866
Hospitalized Medical Patient
Kahn, S. R., et al. American College of Chest
Physicians Evidence-Based Clinical Practice
Guidelines. Chest (2012)
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Should Anticoagulant Prophylaxis/ Treatment Be
Used in Hospitalized Medical Patients?
Kahn, S. R., et al. American College of Chest
Physicians Evidence-Based Clinical Practice
Guidelines. Chest (2012)
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Baron TH et al. N Engl J Med 20133682113-2124.
Overview of Traditional and Newer Antithrombotic
Agents.
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there is no clear evidence in the
current literature to support choosing one form
of pharmacoprophylaxis over another in the
medical population based on outcomes or from a
cost-effectiveness standpoint. It would be
reasonable to make choices based on patient
preference, compliance, and ease ofadministration
(eg, daily vs bid vs tid dosing), as well as on
local factors affecting acquisition costs
Kahn, S. R., et al. American College of Chest
Physicians Evidence-Based Clinical Practice
Guidelines. Chest (2012)
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• Issues with use of anticoagulants specific to
  critical care
• Bleeding risk
• Decreased absorption from subcutaneous site due
  to impaired peripheral circulation
• Renal failure leading to bioaccumulation
• Liver function abnormalities
• Interactions with other medications

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• Mechanical thromboprophylaxis
• Graduated compression stockings (GCS) or
  intermittent pneumatic compression (IPC)
• Recommended for patients at high risk of bleeding
  with contraindications to anticoagulants

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Randomized clinical trials evaluating mechanical
thromboprophylaxis in the ICU
Minet et al. Critical Care (2015)
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COVID-19 related thrombotic events
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• Predisposes to both venous and arterial
  thromboembolic disease due to excessive
  inflammation, hypoxia, immobilisation and diffuse
  intravascular coagulation (DIC)

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• 184 patients
• 31 had thrombotic events
• CTPA and/or ultrasonography confirmed VTE
• in 27
• Arterial thrombotic events in 3.7

Klok, F. A., et al. (2020). "Incidence of
thrombotic complications in critically ill ICU
patients with COVID-19." Thromb Res
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Hasan, S. S., et al. (2020). "Venous
thromboembolism in critically ill COVID-19
patients receiving prophylactic or therapeutic
anticoagulation a systematic review and
meta-analysis." J Thromb Thrombolysis
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Take home message

1. High incidence of VTE events in critical care
   setting
2. High index of suspicion
3. DVT high pickup rate with CUS
4. ECHO poor pick up rate for PTE
5. Appropriate and timely use of anticoagulants
6. Mechanical thromboprophlaxis is an alternative

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THANK YOU