Prophylaxis and treatment of venous thromboembolism in the critically ill

Reducing unnecessary use of intermittent pneumatic compression in intensive care: A before-and-after pilot study with environmental perspective

BACKGROUND

The healthcare sector in Australia has committed to reducing carbon emissions associated with care delivery. Thirty percent of care delivered in the Australian hospital sector is considered low-value care. Intensive care uses chemical prophylaxis to reduce risk of venous thromboembolism (VTE). Mechanical prophylaxis methods, which include intermittent pneumatic compression (IPC), are often used as an adjunct to chemical prophylaxis but can also be used in patients where chemical prophylaxis is contraindicated. Recent literature demonstrates, however, that there is no additional benefit to the routine use of IPC, in reducing VTE risk when used as an adjunct to chemical VTE prophylaxis.

OBJECTIVE

The aims of this study were to assess the effect of the implementation of an education package on the use of single-use IPC devices in the intensive care unit to determine the carbon footprint of a pair of IPC devices, and to determine change in waste production, greenhouse gas emissions, and the financial cost associated with change in IPC use.

METHODS

A before-and-after pilot study was undertaken in a single, level III intensive care unit. An audit was conducted to determine the appropriate use of IPC over a 3-month period before and after the delivery of an education package to guide prescription and use of IPC.

RESULTS

Unnecessary use of IPC reduced from 33/58 (56.9%) to 3/31 (9.7%) after delivery of an education package. According to a bottom-up carbon footprinting analysis, embodied carbon of a single pair of IPC devices was 432.2 g carbon dioxide equivalent (CO2e). This study represents a minimum annual saving of $7682.40, 14.9 Kg waste and 51.8 KgCO2e associated with reduced unnecessary use of IPC.

CONCLUSION

Staff education and behaviour change reduced the number of IPC devices used. The number of IPC devices applied inappropriately also reduced, as did associated greenhouse gas emissions and financial cost.

Optimal Dosing of Enoxaparin in Critically Ill Patients with Venous Thromboembolism

Background: Evidence suggests that goal anti-Xa levels are achieved in only 33% of critically ill patients receiving standard prophylactic enoxaparin dosing. There has been limited focus on the potential suboptimal anticoagulation effect on medical intensive care unit (MICU) patients receiving therapeutic enoxaparin dosing for venous thromboembolism (VTE). Methods: MICU patients receiving enoxaparin 1 mg/kg twice daily or 1.5 mg/kg daily for VTE treatment in a 350-bed community teaching hospital between 2013 and 2019 with at least one peak anti-Xa level measured were included. The primary outcome was the proportion who achieved therapeutic anti-Xa levels with standard dosing. Secondary outcomes included types of dose-adjustments required and the proportion requiring subsequent dose-adjustments. Descriptive statistics were presented for all outcomes. Results: Fifty-three patients were evaluated, including those receiving either twice-daily or once-daily standard therapeutic dosing. Optimal anti-Xa levels at first measurement were recorded after the initiation of enoxaparin in 26.4% (n=14) patients. Dose adjustments were required in 70.7% (n=29) of patients receiving twice-daily dosing and in 83.3% (n=10) receiving once-daily dosing (P=0.97) to appropriately increase or decrease the enoxaparin dose. By the third anti-Xa level measurement, 3 patients remained outside of the therapeutic range. Conclusions: Standard therapeutic enoxaparin dosing did not result in optimal anti-Xa levels for a majority of MICU patients regardless of dosing regimen used or patient specific factors. Future studies should identify patient factors associated with the requirement for higher or lower enoxaparin dosing.

The Pattern of Heparin Dosing as Venous Thromboembolism Prophylaxis in Adult Underweight Patients Admitted to Critical Care Units at a Tertiary Hospital

BACKGROUND

 Venous thromboembolism (VTE) is one of the causes of hospital-related deaths in critically ill patients. Guidelines recommended VTE prophylaxis with standardized, fixed doses for most patients. The underweight population has limited data to guide the appropriate drug and dosing regimen.

OBJECTIVE

 The aim of this study was to describe the pattern of VTE prophylaxis dose regimens for underweighted critically ill adult patients and the prevalence of associated VTE and bleeding.

METHODS

 This study is a retrospective cohort study, conducted at the King Abdulaziz Medical City, Riyadh, Saudi Arabia. It included all critical patients admitted to the intensive care units (ICUs) and were above 14 years old with weight less than 50 kg or body mass index (BMI) of 18.5 kg/m² or less, and were on heparin as VTE prophylaxis for more than 72 h from January 2016 until January 2020.

RESULTS

 After screening 270 patients, only 40 patients were included in this study according to our inclusion and exclusion criteria. Only six patients (15%) received VTE prophylaxis as an adjusted dose of heparin 2500 U Q12, while the rest of the patients were taking standard dosing of heparin; 5000 U Q12 was given to 21 (52.50%) patients, and 5000 U Q8 was given to 13 (32.50%) patients. None of the adjusted doses developed any complications such as VTE or bleeding. There was no significant difference compared with the standard dose group.

CONCLUSIONS

 In this study, we described the pattern of heparin doses as VTE prophylaxis in underweight patients. We also compared the standard dosing and adjusted dosage of VTE prophylaxis on underweight patients and any complications. There was no significant difference in the complications outcome or benefits between the two groups.

Prevention, treatment, and risk factors of deep vein thrombosis in critically ill patients in Zhejiang province, China: a multicenter, prospective, observational study

PURPOSE

The aim of this study is to investigate the prevention and treatment patterns of deep vein thrombosis (DVT) in critically ill patients and to explore the risk factors for DVT in people from Zhejiang Province, China.

MATERIALS AND METHODS

This study prospectively enrolled patients admitted in intensive care units (ICUs) of 54 hospitals from 09/16/2019 to 01/16/2020. The risk of developing DVT and subsequent prophylaxis was evaluated. The primary outcome was DVT occurrence during ICU hospitalisation. Univariate and multivariate logistic regression were performed to determine the risk factors for DVT.

RESULTS

A total of 940 patients were included in the study. Among 847 patients who received prophylaxis, 635 (75.0%) patients received physical prophylaxis and 199 (23.5%) patients received drug prophylaxis. Fifty-eight (6.2%) patients were diagnosed with DVT after admission to the ICU, and 36 patients were treated with anticoagulants (all patients received low molecular weight heparin [LMWH]). D-dimer levels (OR = 1.256, 95% CI: 1.132-1.990), basic prophylaxis (OR = 0.092, 95% CI: 0.016-0.536), and physical prophylaxis (OR = 0.159, 95% CI: 0.038-0.674) were independently associated with DVT in ICU patients. The short-term survival was similar between DVT and non-DVT patients.

CONCLUSIONS

DVT prophylaxis is widely performed in ICU patients. Prophylaxis is an independent protective factor for DVT occurrence. The most common treatment of DVT patients is LMWH, although it might increase the rate of bleeding.Key messagesThis is the only multicenter and prospective study of DVT in ICUs in China.d-dimer levels were independently associated with DVT in ICU patients.Prophylaxis was an independent protective factor for DVT occurrence in ICU.

Reliability and Construct Validity of the Nurses' Intention to Use Deep Vein Thrombosis Preventive Measures Questionnaire

BACKGROUND AND PURPOSE

Valid and reliable measurements are paramount to advance the science of intensive care unit (ICU) nursing. This study aimed to evaluate the reliability and construct validity of the Nurses' Intention to Use Deep Vein Thrombosis Preventive Measures Questionnaire among critically ill patients in an Egyptian ICU. A crosssectional, predictive design pilot-tested the psychometric properties of the questionnaire in a convenience sample of 78 RNs working in ICU.

METHODS

Construct validity was examined using factor analysis.

RESULTS

The Kaiser-Meyer-Olkin measure of sampling was 0.71, and Bartlett's test of sphericity was significant (X ² = 410.16, p < .05). Four factors were identified through factor analysis. Cronbach's α assessed the internal consistency reliability with a value of .82.

CONCLUSION

Our analyses showed that the Nurses' Intention to Use Deep Vein Thrombosis Preventive Measures Questionnaire has good validity and reliability; however, further investigations will be completed.

The Cost-Effectiveness of Tocilizumab (Actemra) Therapy in Giant Cell Arteritis

BACKGROUND

Tocilizumab (Actemra) is a humanized anti-interleukin-6 receptor antibody that has been used as a steroid-sparing agent in giant cell arteritis (GCA). Although the clinical effects are well described in GCA, the cost-effectiveness of the use of tocilizumab in GCA is ill defined. The purpose of this study was to determine the cost-effectiveness of tocilizumab in GCA compared with prednisone alone.

METHODS

A retrospective study of 32 patients with biopsy-proven GCA comparing prednisone alone (16 patients) and prednisone with tocilizumab (16 patients) was performed. The cost for tocilizumab therapy for 26 weeks with mild and severe side effects (Groups 1 and 2, respectively) and for 52 weeks with mild and severe side effects (Group 3 and 4, respectively) was compared with estimated costs of mild and severe steroid-induced side effects (Groups 5 and 6, respectively). Statistical analysis between groups was conducted using independent sample t tests.

RESULTS

Three out of the 4 group combinations of tocilizumab with prednisone demonstrated a statistically significant (P < 0.05) difference in cost compared with prednisone alone for GCA. Group 2 (26-week tocilizumab therapy with severe steroid-induced side effects), with no statically significant difference in price when compared with steroid therapy alone and far fewer side effects, demonstrated the potential use of tocilizumab in GCA therapy. As expected, longer treatment duration with tocilizumab was associated with greater cost. With respect to side effect severity, the number of side effects of steroid therapy was inversely associated with difference in cost between tocilizumab therapy and steroid side effect treatment.

CONCLUSION

This study demonstrates that combination therapy of tocilizumab and prednisone is significantly more expensive than steroids alone with or without accounting for the cost of steroid-induced side effects in treated GCA. The difference in cost between the 2 therapy types is directly related to tocilizumab therapy duration and inversely related to the number or severity of steroid side effects. Patients with GCA who require a shorter duration of steroid therapy and are at risk for a high number of side effects from steroid use may be potential candidates for tocilizumab therapy, from an economic perspective.

Nebulized heparin and salbutamol versus salbutamol alone in acute exacerbations of chronic obstructive pulmonary disease requiring mechanical ventilation: a double-blind randomized controlled trial

Background

Nebulized heparin has been effectively used in the management of many pulmonary diseases. However, its effect on mechanically ventilated patients with acute exacerbation chronic obstructive pulmonary disease (AECOPD) has never been studied. This study aimed to assess the efficacy of nebulized heparin and salbutamol to increase ventilator-free days (VFD) in mechanically ventilated AECOPD patients and the effect of nebulized heparin on respiratory and coagulation functions.

Methods

In this double-blind controlled study, 60 mechanically ventilated adult patients with AECOPD were randomly allocated into two groups; heparin and salbutamol (HS) group and salbutamol only (S) group. In the HS group, patients received nebulized heparin (25,000 IU) and salbutamol (5 mg) every 6 hours. Patients in the S group received nebulized salbutamol only (5 mg). The treatment was continued while patients remained ventilated for a maximum of 14 days. The primary outcome was VFDs at day 14. PaCO2, PaO2/FiO2 ratio, number of nebulizations withheld, C-reactive protein (CRP) titer and activated partial thromboplastin time (APTT) were secondary outcomes.

Results

Patients in the Group HS had significantly more VFDs 4.7 ± 3.3 compared with those in the Group S 2.4 ± 2.6, P = 0.007. PaCO2 levels, PaO2/FiO2, the decrease in the CRP level and the increase in the APTT from the baseline showed no evidence of difference in both groups.

Conclusions

The co-administration of nebulized heparin and salbutamol, compared with salbutamol alone, significantly increased (VFDs) among mechanically ventilated AECOPD patients without increasing bleeding risks.

Anticoagulation in Venous Thromboembolism Prophylaxis in Medically Ill Patients: Potential Impact of NOACs

While substantial evidence supports the use of standard-duration injectable anticoagulants for venous thromboembolism (VTE) prophylaxis, consensus is mixed about which agents may be preferred in acutely ill patients with ongoing need of VTE prophylaxis past the first 10-day duration of hospital stay and post-discharge. Non-vitamin K antagonist oral anticoagulants (NOACs) provide Factor Xa inhibition to prevent the thrombin generation essential in thromboembolism development, but evidence for the efficacy and safety of most NOACs is conflicting regarding extended-duration prophylaxis. Enoxaparin, a preferred injectable anticoagulant in standard-duration VTE prophylaxis, has shown an increased risk of major bleeding events when used in extended-duration prophylaxis, which outweighs its benefit. Rivaroxaban has demonstrated efficacy in extended-duration prophylaxis, but both rivaroxaban and apixaban have shown increased risks of major bleeding. Betrixaban remains the only NOAC approved in the USA for extended-duration VTE prophylaxis, and it demonstrates efficacy, with fewer adverse effects than other NOACs. This review evaluates the appropriateness of different NOAC agents compared with current therapies for the extended-duration VTE prophylaxis setting in medically ill populations.

Evaluating Time to In-Hospital Venous Thromboembolism in Obese Patients

BACKGROUND

Currently, no consensus approach exists for optimal venous thromboembolism (VTE) prophylaxis in obese (BMI ≥30 kg/m²) patients. Time to development of in-hospital VTE is not well studied.

OBJECTIVE

This study evaluates time to in-hospital VTE in obese patients.

METHODS

A single-center, retrospective study evaluated obese patients that developed an in-hospital VTE. Patients were categorized into 3 BMI groups: 30 to 34.9 (group 1), 35 to 39.9 (group 2), and ≥40 (group 3) kg/m². The primary end point compared time to VTE between the groups.

RESULTS

A total of 246 patients were included, and time to VTE was similar between the groups, 8 (group 1) versus 8 (group 2) versus 9 days (group 3); P = .38. Secondary outcomes showed time to VTE was shorter in acute care versus ICU patients (7.5 vs 10 days; P = .01), nonsurgical versus surgical patients (6 vs 9 days; P = .004), and no prophylaxis versus mechanical plus pharmacologic prophylaxis (4.5 vs 9 days; P < .001).

CONCLUSIONS

BMI category did not significantly impact time to in-hospital VTE. This study provides insight into the timing of in-hospital VTE in obese patients. The differences in prophylactic strategies highlight the importance of optimized prophylaxis.

Mechanically Ventilating the Severe Asthmatic

The management of the critically ill patients with asthma can be rather challenging. Potentially devastating complications relating to this presentation include hypoxemia, worsening bronchospasm, pulmonary aspiration, tension pneumothorax, dynamic hyperinflation, hypotension, dysrhythmias, and seizures. In contrast to various other pathologies requiring mechanical ventilation, acute asthma is generally associated with better outcomes. This review serves as a practical guide to the physician managing patients with severe acute asthma requiring mechanical ventilation. In addition to specifics relating to endotracheal intubation, we also discuss the interpretation of ventilator graphics, the recommended mode of ventilation, dynamic hyperinflation, permissive hypercapnia, as well as the role of extracorporeal membrane oxygenation and noninvasive mechanical ventilation.

Venous Thromboembolism in Critically Ill Medical Patients Receiving Chemoprophylaxis

Purpose:

To compare the incidence of 90-day venous thromboembolism (VTE) in obese critically ill medical patients receiving VTE chemoprophylaxis with nonobese patients of similar illness severity. We also identified other VTE risk factors.

Methods:

Eligible patients spent ≥24 hours in an intensive care unit between November 2007 and November 2013 and received VTE chemoprophylaxis within 48 hours of admission. The primary outcome was 90-day VTE.

Results:

A total of 11 111 patients were evaluated, of which 1732 obese and 1831 nonobese patients were enrolled with mean BMIs of 38.9 ± 9.2 kg/m2 and 24.5 ± 3.1 kg/m2 and mean Acute Physiology and Chronic Health Evaluation II scores of 28.4 ± 11.8 and 26.6 ± 11.7, respectively. The rate of 90-day VTE for the total cohort, obese, and nonobese patients was 6.5%, 7.5%, and 5.5%, respectively. Obese patients were more likely to develop VTE compared with nonobese patients (odds ratio [OR]: 1.41; 95% confidence interval [CI]: 1.03 -1.93). Other risk factors significantly associated with 90-day VTE included prior VTE (OR: 3.93; 95% CI: 1.83-8.48), trauma with surgery in the previous 30 days (OR: 3.70; 95% CI: 1.39-9.86), central venous catheters (OR: 2.64; 95% CI: 1.87-3.72), surgery within 90 days (OR: 2.40; 95% CI: 1.61-3.58), mechanical ventilation (OR: 1.94; 95% CI: 1.39-2.71), male sex (OR: 1.55; 95% CI: 1.13-2.14), and increasing age using 1-year increments (OR: 1.02; 95% CI: 1.01 -1.03).

Conclusions:

The rate of VTE in critically ill medical patients remains high despite standard chemoprophylaxis. Obesity is among 8 risk factors independently associated with 90-day VTE.