PowerPoint Presentation

SSC 2012 GuidelinesProphylaxis for Venous Thromboembolism (VTE)C. Deutschman

Copyright 2014 SCCM/ESICM

This section relates to prophylaxis for venous thromboembolic disorders. It summarizes the guidelines recently published in Critical Care Medicine and Intensive Care Medicine. We also will detail the ways in which the new recommendations differ from those published in 2008.1Prophylaxis for VTEKey Initial Findings and Preliminary ReasoningThere are no primary data on the incidence of VTE in septic patients.ICU patients are at high risk for VTE.Risk factors in patients with severe sepsis or septic shock are the same or more pronounced.The incidence in septic patients should the same or higher.VTE prevention in septic patients is desirable.Pulmonary embolism (PE) is likely to have dire consequences in hemodynamically unstable patients. Slide 2Copyright 2014 SCCM/ESICM

Risk factors for sepsis are equal to or greater than those for other ICU patients because of exaggerated physiologic derangements and enhanced hypercoagulability. 2Prophylaxis for VTEWe recommend that patients with severe sepsis receive daily pharmacoprophylaxis against VTE (Grade 1B). Slide 3Copyright 2014 SCCM/ESICM

VTE prophylaxis is generally effective in the acutely ill. Nine placebo-controlled randomized clinical trials (RCTs) and two meta-analyses support VTE prophylaxis in acutely ill patients. However, the evidence must be extrapolated to septic patients. Only 17% of patients in these studies had confirmed infection/sepsis. Therefore, the recommendation was downgraded from 1A to 1B.The complication rate of pharmacoprophylaxis is low, and the risk of not preventing a PE is high. Therefore, the strength of the recommendation was 1B.3Prophylaxis for VTEWe recommend daily subcutaneous low-molecular weight heparin (LMWH) for VTE prophylaxis.Grade 1B versus unfractionated heparin (UFH) twice dailyGrade 2C versus UFH given thrice dailySlide 4Copyright 2014 SCCM/ESICM

This recommendation supplants the 2008 recommendation with an option for low-dose UFH administered twice or three times per day in addition to LMWH.The incidence of PE is lower in critically ill patients treated with LMWH compared to similar patients treated with UFH administered twice daily. There is no difference in the incidence of deep vein thromboses (DVTs) [PROTECT Investigators et al. Dalteparin versus unfractionated heparin in critically ill patients. N Engl J Med. 2011;364:13051314]. Therefore, use of LMWH over twice-daily UFH was graded 1B.

Thrice-daily UFH is more effective than twice-daily UFH in a general population (GRADE A/B) (King CS et al. Twice vs three times daily heparin dosing for thromboembolism prophylaxis in the general medical population: A metaanalysis. Chest. 2007;131(2):507-516). No data compare twice-daily to thrice-daily UFH in critically ill/septic patients. Therefore, the need to extrapolate downgrades evidence to B. No data compare LMWH to UFH administered three times daily, further downgrading the evidence to C. Therefore, the use of LMWH is graded to 1B (vs twice-daily UFH) or 2C (vs thrice-daily UFH).

The need for the most effective form of prophylaxis is profound. LMWHs are easier to give than UFH. The complication of bleeding risk is low. Therefore, the strength of the recommendation for the use of LMWH over twice-daily UFH is strong 1B. The strength of recommendation for use of LMWH over thrice-daily UFH is not 2C.

4Prophylaxis for VTEIf creatinine clearance is