Thromboprophylaxis patterns and determinants in critically ill patients: A multicenter audit

François Lauzier, John Muscedere, Éric Deland, Demetrios J. 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, Rick Hall, Lisa Julien, Michelle St. Laurent, Maureen MeadeLori Hand, Ann Laberge, Lauralyn McIntyre, Guiseppe Pagliarello, Irene Watpool, Tracy McArdle, Allyshia Van Tol, Nicole Zito, Amanda Van Beinum, Lana Antoinette Castellucci, Shawna Reddie, Yoanna Skrobik, Johanne Harvey, Brigitte Beauregard, Martin Albert, David Williamson, Guilaine Coralie, Sangeeta Mehta, Maedean Brown, Rottem Kuint, Robert Fowler, Nicole Marinoff, Ashwati Raghunath, Alexandra Rousseau, John Marshall, Orla Smith, Yoon Lee, Melissa Wang, Pragma Roy, Raphael Faraj, Susan Fleury, Nicole Godfrey, Donald Griesdale, Susan Logie, Greg Martinka, Peter Dodek, Betty Jean Ashley, Sabrina Anis, Kelsey Brewer, Sarah Shepherd, Francois Lellouche, Marie Claude Ferland, Tim Karachi, Marleen Irwin, Shanice Hannigan, Emily Gentles, Gordon Wood, Fiona Auld, Leslie Atkins, François Lamontagne, Marylise Parent, Chantal Langevin, Bojan Paunovic, Nicole Marten, Shauna Eggerton, Darlene Jossy, Samara Bush, Hari Kumar, Patricia Shea, Marios Roussos, Sandra Stoger, Cindy Cryderman, Kathleen Romano, Amanda Carli, Deanna Hicklin, Laurie Meade, Gregory Wilson, Tami Krpata, Alberto Marquez, Jackie O'Brien, Catherine Krause, Margaret Cyton, Kimberly Fowler, Catherine Hubert, Ceilidh Barlow Cash, Katherine Krolicki, Laurel Grainger

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Abstract

Introduction: Heparin 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.Methods: We 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.Results: We 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).Conclusions: Guideline 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.

Original languageEnglish (US)
Article numberR82
JournalCritical Care
Volume18
Issue number2
DOIs
StatePublished - Apr 25 2014

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

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    Lauzier, F., Muscedere, J., Deland, É., Kutsogiannis, D. J., Jacka, M., Heels-Ansdell, D., Crowther, M., Cartin-Ceba, R., Cox, M. J., Zytaruk, N., Foster, D., Sinuff, T., Clarke, F., Thompson, P., Hanna, S., Cook, D., Hall, R., Julien, L., St. Laurent, M., ... Grainger, L. (2014). Thromboprophylaxis patterns and determinants in critically ill patients: A multicenter audit. Critical Care, 18(2), [R82]. https://doi.org/10.1186/cc13844