Thromboprophylaxis patterns and determinants in critically ill patients: a multicenter audit View Full Text


Ontology type: schema:ScholarlyArticle      Open Access: True


Article Info

DATE

2014-04-25

AUTHORS

François Lauzier, John Muscedere, Éric Deland, Demetrios Jim Kutsogiannis, Michael Jacka, Diane Heels-Ansdell, Mark Crowther, Rodrigo Cartin-Ceba, Michael J Cox, Nicole Zytaruk, Denise Foster, Tasnim Sinuff, France Clarke, Patrica Thompson, Steven Hanna, Deborah Cook, the Co-operative Network of Critical Care Knowledge Translation for Thromboprophylaxis (CONECCKT-T) Investigators and the Canadian Critical Care Trials Group

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/kg2 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. More... »

PAGES

r82

Journal

TITLE

Critical Care

ISSUE

2

VOLUME

18

Identifiers

URI

http://scigraph.springernature.com/pub.10.1186/cc13844

DOI

http://dx.doi.org/10.1186/cc13844

DIMENSIONS

https://app.dimensions.ai/details/publication/pub.1013074945

PUBMED

https://www.ncbi.nlm.nih.gov/pubmed/24766968


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    "description": "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\u2009\u00b1\u200916.7 years, Acute Physiology and Chronic Health Evaluation [APACHE] II score 19.1\u2009\u00b1\u20098.3). 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/kg2 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.", 
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341 grid-institutes:grid.416435.1 schema:alternateName Department of Pulmonary and Critical Care, St. Louis, St John’s Mercy Hospital, 3437 Caroline Mall, 63104-1111, Rochester, MO, USA
342 schema:name Department of Pulmonary and Critical Care, St. Louis, St John’s Mercy Hospital, 3437 Caroline Mall, 63104-1111, Rochester, MO, USA
343 rdf:type schema:Organization
344 grid-institutes:grid.66875.3a schema:alternateName Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, 55905, Rochester, MN, USA
345 schema:name Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, 55905, Rochester, MN, USA
346 rdf:type schema:Organization
347 grid-institutes:grid.86715.3d schema:alternateName Département de Médecine, Université de Sherbrooke, 3011 12e avenue Nord, J1H 5N4, Sherbrooke, Québec, Canada
348 schema:name Département de Médecine, Université de Sherbrooke, 3011 12e avenue Nord, J1H 5N4, Sherbrooke, Québec, Canada
349 rdf:type schema:Organization
 




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