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Deep Vein Thrombosis and Its Prevention in Critically Ill Adults
John Attia, MD, PhD;
Joel G. Ray, MD;
Deborah J. Cook, MD, MSc;
James Douketis, MD;
Jeffrey S. Ginsberg, MD;
William H. Geerts, MD
Arch Intern Med. 2001;161:1268-1279.
Background Our objective was to systematically review the incidence of deep vein
thrombosis (DVT) and the efficacy of thromboprophylaxis in critically ill
adults, including patients admitted to intensive care units and following
trauma, neurosurgery, or spinal cord injury.
Methods Two authors independently searched MEDLINE, EMBASE, abstract databases,
and the Cochrane database. Data were extracted independently in triplicate.
Results Ten percent to 30% of medical and surgical intensive care unit patients
develop DVT within the first week of intensive care unit admission. The use
of subcutaneous low-dose heparin reduced the rate by 50% compared with no
prophylaxis. Approximately 60% of trauma patients developed DVT within the
first 2 weeks of admission. Use of unfractionated heparin appears to decrease
the incidence of DVT by only 20%, whereas low-molecular-weight heparin decreases
the incidence by a further 30%. The estimated prevalence of DVT in neurosurgical
patients not given prophylaxis is 22% to 35%. Mechanical prophylaxis is efficacious,
with a pooled odds ratio in 5 randomized trials of 0.28. Use of low-molecular-weight
heparin has been investigated as an adjunct to mechanical prophylaxis with
a pooled odds ratio of 0.59 compared with graduated compression stockings
alone. The incidence of DVT without prophylaxis in acute spinal cord injury
patients is likely in excess of 50% to 80%. Studies of prophylaxis in these
patients are too sparse to come to any definitive conclusion.
Conclusions Critically ill patients commonly develop DVT, with rates that vary from
22% to almost 80%, depending on patient characteristics. Methods of prophylaxis
proven in one group do not necessarily generalize to other critically ill
patient groups. More potent prophylactic regimens other than unfractionated
or low-molecular-weight heparins alone may be needed with higher-risk groups.
From the Departments of Medicine (Drs Attia, Ray, Cook, Douketis, and
Ginsberg) and Clinical Epidemiology and Biostatistics (Drs Attia, Ray, and
Cook), McMaster University, Hamilton, Ontario; and Departments of Medicine
and Health Administration, University of Toronto, Toronto, Ontario (Dr Geerts).
Dr Attia is now with the Centre for Clinical Epidemiology and Biostatistics,
University of Newcastle, Newcastle, Australia.
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