Failure of Anticoagulant Thromboprophylaxis: Risk Factors in Medical-Surgical Critically Ill Patients.
Crit Care Med. 2014 Dec 3;
Authors: Lim W, Meade M, Lauzier F, Zarychanski R, Mehta S, Lamontagne F, Dodek P, McIntyre L, Hall R, Heels-Ansdell D, Fowler R, Pai M, Guyatt G, Crowther MA, Warkentin TE, Devereaux PJ, Walter SD, Muscedere J, Herridge M, Turgeon AF, Geerts W, Finfer S, Jacka M, Berwanger O, Ostermann M, Qushmaq I, Friedrich JO, Cook DJ, for the PROphylaxis for ThromboEmbolism in Critical Care Trial Investigators, the Canadian Critical Care Trials Group, and the Australian and New Zealand Intensive Care Society Clinical Trials Group
OBJECTIVES:: To identify risk factors for failure of anticoagulant thromboprophylaxis in critically ill patients in the ICU.
DESIGN:: Multivariable regression analysis of thrombosis predictors from a randomized thromboprophylaxis trial.
SETTING:: Sixty-seven medical-surgical ICUs in six countries.
PATIENTS:: Three thousand seven hundred forty-six medical-surgical critically ill patients.
INTERVENTIONS:: All patients received anticoagulant thromboprophylaxis with low-molecular-weight heparin or unfractionated heparin at standard doses.
MEASUREMENTS AND MAIN RESULTS:: Independent predictors for venous thromboembolism, proximal leg deep vein thrombosis, and pulmonary embolism developing during critical illness were assessed. A total of 289 patients (7.7%) developed venous thromboembolism. Predictors of thromboprophylaxis failure as measured by development of venous thromboembolism included a personal or family history of venous thromboembolism (hazard ratio, 1.64; 95% CI, 1.03-2.59; p = 0.04) and body mass index (hazard ratio, 1.18 per 10-point increase; 95% CI, 1.04-1.35; p = 0.01). Increasing body mass index was also a predictor for developing proximal leg deep vein thrombosis (hazard ratio, 1.25; 95% CI, 1.06-1.46; p = 0.007), which occurred in 182 patients (4.9%). Pulmonary embolism occurred in 47 patients (1.3%) and was associated with body mass index (hazard ratio, 1.37; 95% CI, 1.02-1.83; p = 0.035) and vasopressor use (hazard ratio, 1.84; 95% CI, 1.01-3.35; p = 0.046). Low-molecular-weight heparin (in comparison to unfractionated heparin) thromboprophylaxis lowered pulmonary embolism risk (hazard ratio, 0.51; 95% CI, 0.27-0.95; p = 0.034) while statin use in the preceding week lowered the risk of proximal leg deep vein thrombosis (hazard ratio, 0.46; 95% CI, 0.27-0.77; p = 0.004).
CONCLUSIONS:: Failure of standard thromboprophylaxis using low-molecular-weight heparin or unfractionated heparin is more likely in ICU patients with elevated body mass index, those with a personal or family history of venous thromboembolism, and those receiving vasopressors. Alternate management or incremental risk reduction strategies may be needed in such patients.
PMID: 25474533 [PubMed - as supplied by publisher]