Clinically important deep vein thrombosis in the intensive care unit: a survey of intensivists

Deborah Cook, Maureen Meade, Gordon Guyatt, Lauren Griffith, John Granton, William Geerts, Mark Crowther, Canadian Critical Care Trials Group, Deborah Cook, Maureen Meade, Gordon Guyatt, Lauren Griffith, John Granton, William Geerts, Mark Crowther, Canadian Critical Care Trials Group

Abstract

Introduction: Outside the intensive care unit (ICU), clinically important deep vein thrombosis (DVT) is usually defined as a symptomatic event that leads to objective radiologic confirmation and subsequent treatment. The objective of the present survey is to identify the patient factors and radiologic features of lower limb DVT that intensivists consider more or less likely to make a DVT clinically important in ICU patients.

Methods: Our definition of clinically important DVT was a DVT likely to result in short-term or long-term morbidity or mortality if left untreated, as opposed to a DVT that is unlikely to have important consequences. We asked respondents to indicate the likelihood that patient factors and ultrasonographic features make a DVT clinically important using a five-point scale (from 1 = much less likely to 5 = much more likely).

Results: Of the 71 Canadian intensivists who responded, 70 (99%) rated three patient factors as most likely to make a DVT clinically important: clinical suspicion of pulmonary embolism (mean score 4.6), acute or chronic cardiopulmonary morbidity that might limit a patient's ability to tolerate pulmonary embolism (score 4.5), and leg symptoms (score 4.2). Of the ultrasound features, proximal (score 4.7), large (score 4.2), and totally occlusive (score 3.9) thrombi were considered the three most important.

Conclusion: When labeling a DVT as clinically important, intensivists rely on different patient specific factors and thrombus characteristics than are used to assess the clinical importance of DVT outside the ICU. The clinical importance of DVT is influenced by unique factors such as cardiopulmonary reserve among mechanically ventilated patients.

Figures

Figure 1
Figure 1
Patient factors considered by respondents to make a deep venous thrombosis (DVT) clinically important in the intensive care unit setting. The scale used was as follows: 1 = much less likely to make the DVT clinically important; 2 = somewhat less likely to make the DVT clinically important; 3 = neither more nor less likely to make the DVT clinically important; 4 = somewhat more likely to make the DVT clinically important; and 5 = much more likely to make the DVT clinically important.
Figure 2
Figure 2
Ultrasonographic factors considered by respondents to make a deep venous thrombosis (DVT) clinically important in the intensive care unit setting. The scale used was as follows: 1 = much less likely to make the DVT clinically important; 2 = somewhat less likely to make the DVT clinically important; 3 = neither more nor less likely to make the DVT clinically important; 4 = somewhat more likely to make the DVT clinically important; and 5 = much more likely to make the DVT clinically important.

References

    1. Attia J, Cook DJ, Douketis J, Ginsberg JS, Geerts W. Deep vein thrombosis and its prevention in critically ill patients. Arch Intern Med. 2001;161:1268–1279. doi: 10.1001/archinte.161.10.1268.
    1. Geerts WH, Heit JA, Clagett P, Pineo GF, Colwell CW, Anderson FA, Wheeler HB. Prevention of venous thromboembolism. Sixth ACCP Antithrombotic Consensus Conference on Antithrombotic Therapy. Chest. 2001;119(1 suppl):132S–175S. doi: 10.1378/chest.119.1_suppl.132S.
    1. Geerts W, Cook DJ, Selby R, Etchells E. Venous thromboembolism and its prevention in critical care. J Crit Care. 2002;17:95–104. doi: 10.1053/jcrc.2002.33941.
    1. Ibrahim EH, Iregui M, Prentice D, Sherman G, Kollef M, Shannon W. Deep vein thrombosis during prolonged mechanical ventilation despite prophylaxis. Crit Care Med. 2002;30:771–774. doi: 10.1097/00003246-200204000-00008.
    1. Cook DJ, Crowther M, Meade M, Rabbat C, Schiff D, Geerts W, Griffith L, Guyatt GH. Deep venous thrombosis in medical-surgical ICU patients: prevalence, incidence and risk factors. Crit Care. 2003;Suppl 2:S54.
    1. Kakkar VV, Howe CT, Flanc C, Clarke MB. Natural history of postoperative deep vein thrombosis. Lancet. 1969;2:230–232. doi: 10.1016/S0140-6736(69)90002-6.
    1. Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism: A controlled trial. Lancet. 1960;i:1309–1312. doi: 10.1016/S0140-6736(60)92299-6.
    1. Stein PD, Henry JW. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy. Chest. 1995;108:978–981.
    1. Karwinski B, Svendsen E. Comparison of clinical and postmortem diagnosis of pulmonary embolism. J Clin Pathol. 1989;42:135–139.
    1. Moser KM, Fedullo PF, LittleJohn JK, Crawford R. Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis. JAMA. 1994;271:223–225. doi: 10.1001/jama.271.3.223.
    1. McKelvie PA. Autopsy evidence of pulmonary thromboembolism. Med J Aust. 1994;160:127–128.
    1. Hirsch DR, Ingenito EP, Goldhaber SZ. Prevalence of deep venous thrombosis among patients in medical intensive care. JAMA. 1995;274:335–337. doi: 10.1001/jama.274.4.335.
    1. Douketis JD, Kearon C, Bates S, Duku EK, Ginsberg JS. Risk of fatal pulmonary embolism in patients with treated venous thromboembolism. JAMA. 1998;279:458–462. doi: 10.1001/jama.279.6.458.
    1. Warwick D, Samama MM. The contrast between venographic and clinical endpoints in trials of thromboprophylaxis in hip replacement. J Bone Joint Surg. 2000;82:480–482. doi: 10.1302/0301-620X.82B4.9876.
    1. Cook D, McMullin J, Hodder R, Heule M, Pinilla J, Dodek P, Stewart T, for the Canadian ICU Directors Group Prevention and diagnosis of venous thromboembolism in critically ill patients: a Canadian survey. Crit Care. 2001;5:336–342. doi: 10.1186/cc1066.
    1. Clarke FJ, Griffith L, McDonald E, Hoad N, Rabbat C, Meade M, Guyatt GH, Devereaux PJ, Geerts W, Wells P, Crowther M, Cook DJ, for the Canadian Critical Care Trials Group Deep vein thrombosis: Clinically silent in the ICU. Am J Resp Crit Care Med. 2004.
    1. Cook DJ, Todd TRJ. The Canadian Critical Care Trials Group: a collaborative educational organization for the advancement of adult clinical ICU research. Intensive Care World. 1997;14:68–70.
    1. Cook D, Attia J, Weaver B, McDonald E, Meade M, Crowther M. Venous thromboembolic disease: An observational study in medical-surgical intensive care unit patients. J Crit Care. 2000;15:127–132. doi: 10.1053/jcrc.2000.19224.
    1. Cook DJ, Laporta D, Skrobik Y, Peters S, Sharpe M, Murphy P, Chin D, Crowther V, for the Canadian ICU Directors Group Prevention of venous thromboembolism in critically ill surgery patients. J Crit Care. 2001;16(4):161–166. doi: 10.1053/jcrc.2001.30665.
    1. Cook DJ, Guyatt GH, Juniper E, Griffith LE, McIlroy W, Willan A, Jaeschke R, Epstein R. Interviewer versus self-administered questionnaires in developing a disease-specific, health related quality of life instrument for asthma. J Clin Epidemiol. 1993;46(6):529–534. doi: 10.1016/0895-4356(93)90125-K.
    1. Griffith LE, Cook DJ, Guyatt GH, Charles C. Comparison of open versus closed questionnaire formats in obtaining demographic information from Canadian general internists. J Clin Epidemiol. 1999;52:997–1005. doi: 10.1016/S0895-4356(99)00106-7.
    1. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol. 1997;50:1129–1136. doi: 10.1016/S0895-4356(97)00126-1.
    1. Linkins LA, Choi P, Douketis J. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med. 2003;139:893–900.
    1. Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L, Clement C, Robinson KS, Lewandowski B. Application of a diagnostic clinical model for the management of hospitalized patients with suspected deep-vein thrombosis. Thromb Haemost. 1999;81:493–497.
    1. Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L, Clement C, Robinson KS, Lewandowski B. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350:1795–1798. doi: 10.1016/S0140-6736(97)08140-3.
    1. Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D'Ovidio R, Cogo A, Prandoni P. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345:1326–1330. doi: 10.1016/S0140-6736(95)92535-X.
    1. Kearon C, Salzman EW, Hirsh J. Epidemiology, pathogenesis, and natural history of venous thrombosis. In: Colman RW, Hirsh J, Marder VJ, Clowes AW, George JN, editor. In Hemostasis and Thrombosis: Basic Principles and Clinical Practice. 4. Philadelphia, PA: JB Lippincott; 2001. pp. 1153–1177.
    1. Kearon C. Noninvasive diagnosis of deep venous thrombosis in postoperative patients. Semin Thromb Hemost. 2001;27:3–8. doi: 10.1055/s-2001-12842.
    1. Sonaglia F, Rossi R, Agnelli G. End points in studies on the prevention of deep vein thrombosis. Semin Thromb Hemost. 2001;27:41–46. doi: 10.1055/s-2001-12850.
    1. Leizorovicz A, Kassai B, Becker F, Cucherat M. The assessment of deep vein thromboses for therapeutic trials. Angiology. 2003;54:19–24.
    1. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW. Prevention of venous thromboembolism. Chest. 2004.
    1. Fraisse F, Holzapfel L, Couland JM, Simonneau G, Bedock B, Feissel H, Herbecq P, Pordes R, Poussel JF, Roux L, for the Association of Non-University Affiliated Intensive Care Specialist Physicians in France Nadroparin in the prevention of deep vein thrombosis in acute decompensated COPD. Am Rev Resp Crit Care Med. 2000;161:1109–1114.
    1. Eikelboom JW, Quinlan DJ, Douketis JD. Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials. Lancet. 2001;358:9–15. doi: 10.1016/S0140-6736(00)05249-1.
    1. Robinson SK, Anderson DR, Gross M, Petrie D, Leighton R, Stanish W, Alexander D, Mitchell M, Flemming B, Gent M. Ultrasonographic screening before hospital discharge for deep venous thrombosis after arthroplasty. Ann Intern Med. 1997;127:439–445.

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