Thromboprophylaxis patterns and determinants in critically ill patients: a multicenter auditReport as inadecuate




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Critical Care

, 18:R82

First Online: 25 April 2014Received: 18 October 2013Accepted: 25 February 2014

Abstract

IntroductionHeparin is safe and prevents venous thromboembolism in critical illness. We aimed to determine the guideline concordance for thromboprophylaxis in critically ill patients and its predictors, and to analyze factors associated with the use of low molecular weight heparin LMWH, as it may be associated with a lower risk of pulmonary embolism and heparin-induced thrombocytopenia without increasing the bleeding risk.

MethodsWe performed a retrospective audit in 28 North American intensive care units ICUs, including all consecutive medical-surgical patients admitted in November 2011. We documented ICU thromboprophylaxis and reasons for omission. Guideline concordance was determined by adding days in which patients without contraindications received thromboprophylaxis to days in which patients with contraindications did not receive it, divided by the total number of patient-days. We used multilevel logistic regression including time-varying, center and patient-level covariates to determine the predictors of guideline concordance and use of LMWH.

ResultsWe enrolled 1,935 patients 62.3 ± 16.7 years, Acute Physiology and Chronic Health Evaluation APACHE II score 19.1 ± 8.3. Patients received thromboprophylaxis with unfractionated heparin UFH 54.0% or LMWH 27.6%. Guideline concordance occurred for 95.5% patient-days and was more likely in patients who were sicker odds ratio OR 1.49, 95% confidence interval CI 1.17, 1.75 per 10-point increase in APACHE II, heavier OR 1.32, 95% CI 1.05, 1.65 per 10-m-kg increase in body mass index, had cancer OR 3.22, 95% CI 1.81, 5.72, previous venous thromboembolism OR 3.94, 95% CI 1.46,10.66, and received mechanical ventilation OR 1.83, 95% CI 1.32,2.52. Reasons for not receiving thromboprophylaxis were high risk of bleeding 44.5%, current bleeding 16.3%, no reason 12.9%, recent or upcoming invasive procedure 10.2%, nighttime admission or discharge 9.7%, and life-support limitation 6.9%. LMWH was less often administered to sicker patients OR 0.65, 95% CI 0.48, 0.89 per 10-point increase in APACHE II, surgical patients OR 0.41, 95% CI 0.24, 0.72, those receiving vasoactive drugs OR 0.47, 95% CI 0.35, 0.64 or renal replacement therapy OR 0.10, 95% CI 0.05, 0.23.

ConclusionsGuideline concordance for thromboprophylaxis was high, but LMWH was less commonly used, especially in patients who were sicker, had surgery, or received vasopressors or renal replacement therapy, representing a potential quality improvement target.

AbbreviationsAPACHEAcute Physiology and Chronic Health Evaluation

CIconfidence interval

LMWHlow molecular weight heparin

ORodds ratio

PROTECTProphylaxis for Thromboembolism in Critical Care Trial

UFHunfractionated heparin.

Electronic supplementary materialThe online version of this article doi:10.1186-cc13844 contains supplementary material, which is available to authorized users.

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Author: François Lauzier - John Muscedere - Éric Deland - Demetrios Jim Kutsogiannis - Michael Jacka - Diane Heels-Ansdell - Mark

Source: https://link.springer.com/







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