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Prevention of venous thromboembolic disease in the critical patient: An assessment of clinical practice in the Community of Madrid
Profilaxis de la enfermedad tromboembólica venosa en el paciente crítico: aproximación a la práctica clínica en la Comunidad de Madrid
P. García-Olivares
, J.E. Guerrero, M.J. Tomey, A.M. Hernangómez, D.O. Stanescu
Corresponding author
Unidad de Cuidados Intensivos, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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García-Olivares, J.E. Guerrero, M.J. Tomey, A.M. Hernangómez, D.O. Stanescu" "autores" => array:5 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "García-Olivares" "email" => array:2 [ 0 => "garciaolivaresp@gmail.com" 1 => "pitiusas@terra.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.E." "apellidos" => "Guerrero" ] 2 => array:2 [ "nombre" => "M.J." "apellidos" => "Tomey" ] 3 => array:2 [ "nombre" => "A.M." "apellidos" => "Hernangómez" ] 4 => array:2 [ "nombre" => "D.O." "apellidos" => "Stanescu" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Profilaxis de la enfermedad tromboembólica venosa en el paciente crítico: aproximación a la práctica clínica en la Comunidad de Madrid" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2295 "Ancho" => 2335 "Tamanyo" => 195710 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Comparison of the venous thromboembolic disease prophylaxis modalities in different international registries.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Venous thromboembolic disease (VTED), which comprises both deep venous thrombosis (DVT) and pulmonary embolism, is one of the most common avoidable complications in hospitalized patients.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The association of multiple risk factors (previous chronic diseases, severity of the condition leading to admission, the use of mechanical ventilation, immobility, invasive procedures, etc.) causes critically ill patients to be particularly vulnerable to VTED.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In this respect, a number of studies have demonstrated a high incidence of VTED in patients admitted to Intensive Care Units (ICUs), with the observation of DVT in 10–28% of the individuals who do not receive prophylaxis,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> and of pulmonary embolism in 7–27% of the necropsy studies in patents who have died of any cause.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The use of both pharmacological and non-pharmacological prophylactic measures has been able to lower the incidence of DVT to 5–10%.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5,6</span></a> The utilization of such prophylactic measures is therefore regarded as a quality index of particular relevance in the critically ill.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The latest clinical practice guides of the American College of Chest Physicians (ACCP 2012) offer concrete recommendations for the prevention of VTED in different diseases and types of patients, including the critically ill.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–11</span></a> The heterogeneity and complexity of the patients admitted to the ICU (with multiple and different conditions leading to admission, previous chronic diseases predisposing to VTED, the presence of factors that increase the risk of bleeding, the use of medical apparatuses and devices, techniques and drugs routinely used in these Units, etc.) make the application of these recommendations complex and difficult, to say the least. To this problem we in turn must add the possible increase in mortality rate associated to a lack of prophylaxis or the use of inadequate prophylaxis, and which varies according to the type of disease involved, but can range from 8% in the septic patient to 15% in polytraumatized individuals.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A series of measures are currently available for the prevention of VTED in the critical patient (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Pharmacological (drug) prophylaxis with both unfractionated heparin (UFH) and low molecular weight heparin (LMWH) has been shown to be the most effective preventive measure in both medical disease (grade 2C recommendation) and in general surgical or traumatologic cases with a high risk of VTED (grade 1B recommendation). The utilization of other drugs administered via the oral route, such as direct thrombin and factor Xa inhibitors, has not been tested to date in critical patients–their only possible indication being patients with orthopedic trauma of the hip or knee (fundamentally the placing of prostheses), with good oral tolerance, and who require admission to the ICU for some reason. Mechanical prophylaxis involving both graduated compression stockings (GCS) and intermittent pneumatic compression systems (IPCS) would be indicated in the management of patients with medical diseases and contraindications to pharmacological prophylaxis, or with a high bleeding risk (grade 2C recommendation), as well as in patients with non-traumatic (grade 2C recommendation) or traumatic surgical disease (grade 1C recommendation). Mechanical prophylaxis is moreover recommended in addition to pharmacological prophylaxis (i.e., as combined prophylaxis) in surgical patients with a high risk of suffering VTED (grade 2B recommendation).<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–11,13</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The application of these recommendations in the critical patient setting is highly variable, as reflected by different international studies published over the last 10 years.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14–17</span></a> No descriptions of the situation in Spain are available to date.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The present study aims to analyze the frequency of use of the different measures for the prevention of VTED in patients admitted to ICUs in the Community of Madrid (Spain), and to compare the findings with the quality indexes of the Spanish Society of Intensive Care Medicine (SEMICYUC),<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> the clinical practice guides of the ACCP 2012,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–11</span></a> and the data found in the different international studies.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14–17</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Patients and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A multicenter, cross-sectional epidemiological study was made involving a sample composed of all the patients admitted to different ICUs in the Community of Madrid, with the purpose of analyzing the frequency of use of the different VTED prophylactic measures proposed for application in critical patients. To this effect a prevalence cut was made of the prophylactic measures employed, performed on a single day of a concrete week.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A list was prepared of the hospitals belonging to the public health system of Madrid, with the addition of private hospital centers with polyvalent ICUs of similar characteristics. The heads of the different Units were contacted by telephone and invited to participate. In the case of those centers that agreed to take part in the study, a physician in charge of conducting the survey was assigned, and a contact e-mail address was established. Each physician in charge of conducting the survey received a first e-mail with information on the most relevant aspects of the study. The definitive electronic survey was then sent, with instructions to return it to us via e-mail once completed. The survey was considered adequate for collecting the required data, since an instrument of similar characteristics had been used in a recent study,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and it had moreover been adopted without problems by physicians belonging to our Department and who did not participate in the project. The collected information was entered in a Microsoft Excel spreadsheet and subsequently analyzed using the SPSS version 18 statistical package.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In accordance with the clinical practice guides of the ACCP of the year 2008 and revised in 2012,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,8–11</span></a> all the patients admitted to the ICU were considered to be at risk of developing VTED, and were thus candidates for some type of prophylaxis (specific recommendation 2C for the critical patient or recommendation 1B considering the critical patient as an acute patient with a moderate or high risk of developing VTED). Likewise, all the Units were considered to require a specific VTED prevention protocol (grade 1A recommendation of the clinical practice guides of the ACCP 2008 and 100% proposition according to the critical patient quality indexes of the SEMICYUC), including assessment and risk stratification for the appropriate adjustment of prophylaxis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The prevalence cut was performed in the week from 16 to 23 March 2012. We included all the patients admitted in each Unit on the concrete day on which the survey was carried out.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The main data included in the survey were the following:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0055" class="elsevierStylePara elsevierViewall">Unit size and occupation: number of available beds and number of admitted patients.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0060" class="elsevierStylePara elsevierViewall">Type of patient according to the disease leading to admission:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">a.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Medical disease: no surgery was required to resolve the condition.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">b.</span><p id="par0070" class="elsevierStylePara elsevierViewall">Surgical disease: non-traumatologic surgical measures were required to resolve the condition (both emergency and programmed surgery with posterior complications).</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">c.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Polytraumatism: high-energy multiple trauma conditions. Major burn cases were also included.</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3.</span><p id="par0080" class="elsevierStylePara elsevierViewall">Information on the VTED prophylactic measures used:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">a.</span><p id="par0085" class="elsevierStylePara elsevierViewall">Use or not of some type of prophylaxis.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">b.</span><p id="par0090" class="elsevierStylePara elsevierViewall">Type of prophylaxis used:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Pharmacological prophylaxis: UFH or LMWH (direct thrombin and factor Xa inhibitors were excluded, since they currently have no indications in the critical patient).</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Mechanical prophylaxis: GCS or IPCS.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Combined prophylaxis: UFH or LMWH added to some mechanical prophylactic system.</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">c.</span><p id="par0110" class="elsevierStylePara elsevierViewall">Existence of contraindications to pharmacological prophylaxis and the reasons for contraindication: thrombocytopenia, coagulopathy, recent major surgery, high bleeding risk, or others. Each Unit cataloged the contraindications of their patients according to their own criteria.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">d.</span><p id="par0115" class="elsevierStylePara elsevierViewall">Patients subjected to systemic anticoagulation therapy.</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">4.</span><p id="par0120" class="elsevierStylePara elsevierViewall">Information on the use of a specific VTED protocol by the Unit.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">5.</span><p id="par0125" class="elsevierStylePara elsevierViewall">Information on the adjustment of VTED prophylaxis according to risk scales.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">6.</span><p id="par0130" class="elsevierStylePara elsevierViewall">Information on the use of deep venous system ultrasound as a VTED screening method.</p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">The only exclusion criterion for the definitive analysis was established after the data from each Unit had been obtained, and consisted of the exclusion of those patients receiving treatment with heparin at anticoagulation doses.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Following review of the project and protocol, the Clinical Research Ethics Committee of Hospital General Universitario Gregorio Marañón approved conduction of the study.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Due to the characteristics of the study, only a descriptive analysis of the patients was carried out. Quantitative variables were reported as the mean (standard deviation) in the case of a normal distribution, and as the median (interquartile range) in the case of a non-normal distribution. Qualitative variables in turn were reported as a proportion or percentage.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0150" class="elsevierStylePara elsevierViewall">A total of 26 of the ICUs contacted by telephone agreed to participate in the study. Of these, 18 (17 public and one private center) finally completed the survey (69.2%) (<a class="elsevierStyleCrossRef" href="#sec0040">see Annex</a>). Out of a total of 302 critical patient beds, with a median of 14 beds per Unit (8–20), we collected data on 252 patients (10 patients per Unit; 7–17), representing an occupation rate of 83% of the total available beds. Sixty percent of the patients presented medical diseases (153/252), 32% surgical diseases (81/252), and 8% polytraumatisms (18/252). A total of 234 patients were included in the definitive analysis, since 18 were excluded because systemic anticoagulation had been used (7%).</p><p id="par0155" class="elsevierStylePara elsevierViewall">On the day of their inclusion in the study, 82% of the patients (192/234) were receiving some type of VTED prophylaxis: pharmacological prophylaxis in 84% of the cases (161/192), mechanical prophylaxis in 14% (27/192), and both types of prophylaxis (combined prophylaxis) in only four patients (2%) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">In the 165 patients receiving pharmacological prophylaxis, including the four with combined prophylaxis, LMWHs were the only drugs used – particularly enoxaparin, which was administered in 17 of the 18 Units (94%). One of the Units used nadroparin in addition to enoxaparin. In the remaining Unit, dalteparin was the LMWH used.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Of the different mechanical prophylactic measures (including the measures used in the 4 patients with combined prophylaxis), GCS were the most commonly used option (58% of the patients; 18/31). IPCS were used in only 13 patients.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Contraindications to the use of pharmacological prophylaxis were documented in 20% of the patients (46/234), with a median of one patient per Unit (0–4). More than one reason for not providing drug prophylaxis was recorded in 19 patients (41%). Of the patients with contraindications to heparin, 27 (58%) were subjected to mechanical prophylaxis, while the rest of the patients received no prophylactic measures. The causes of contraindication to pharmacological prophylaxis were the following (in decreasing order of frequency): thrombocytopenia 28% (18/65), recent bleeding 26% (17/65), high bleeding risk 21% (14/65), recent major surgery 14% (9/65), and coagulopathy 11% (7/65).</p><p id="par0175" class="elsevierStylePara elsevierViewall">Eighteen percent of the analyzed patients (42/234) received no prophylactic measures. Of these individuals, 19 (45%) belonged to the group of patients with contraindications to pharmacological prophylaxis, while 23 patients had no contraindications. More than one patient received no prophylactic measures in 11 of the 18 Units (61%), with a median of two patients per Unit (0–4).</p><p id="par0180" class="elsevierStylePara elsevierViewall">Lastly, it should be mentioned that one-half of the Units (9/18) had no specific VTED prophylaxis protocol, and in only one of them were VTED risk scales used to adjust prophylaxis. Four of the total ICUs (22%) used clinical ultrasound to screen for DVT in patients at a high risk of developing VTED.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0185" class="elsevierStylePara elsevierViewall">This study included 15 of the 20 ICUs belonging to the public health network (75%)(3 critical patient Units of the same hospital center responded independently), together with the polyvalent ICU of a private center, in the Community of Madrid. Considering both the number of participating Units and the number of patients studied (252 subjects), the results obtained can give us a good idea of the prevalence of VTED prophylactic measures among the critical patients of our Community, and the findings can probably be extrapolated to the situation found in the rest of the country.</p><p id="par0190" class="elsevierStylePara elsevierViewall">As a first appraisal of the results obtained, it should be mentioned that while the percentage of patients with some VTED prophylactic measure is apparently high (82%), it falls short of the 90% rate proposed by the SEMICYUC quality indexes for the management of critical patients in Spain,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> or the levels proposed by the clinical practice guides of the ACCP 2012.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Although the level of evidence 2C (grade 1B recommendation when regarding critical patients as acute patients with a high risk of VTED) and 1B is meant for surgical patients (general or traumatologic), these guidelines advise the use of prophylactic measures in the critical patient. On examining the situation by Units, over one-half (60%) presented percentage prophylaxis rates lower than those recommended. This was more apparent in the larger Units (88% in the case of ICUs with more than 10 beds versus only 25% of the Units with fewer than 10 beds). The described panorama is not very different from that reported in other countries referred to the use of VTED prevention measures. In effect, with the exception of the study conducted in Austria in the year 2012,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> which included 52 ICUs with 502 patients and reported a compliance rate of 95% (though the authors described a large percentage of inadequate prophylaxis, taking into account the lack of anti-Xa factor monitoring), the rest have all reported compliance rates that fall short of the recommendations of both the SEMICYUC and the ACCP: 87% in the French-Canadian registry of 2003,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> 77% in the international IMPROVE registry of 2007,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and 86% in the Australian-New Zealand ANZICS-CTG registry of 2010<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">In concordance with the current recommendations on preventive measures in the critical patient, pharmacological prophylaxis–in the absence of contraindications–was the most widely used strategy.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–11,13</span></a> The great variability in the use of the different heparins (UFH and LMWH) described in the literature reflects the lack of scientific evidence of the superiority of one type of heparin over the rest,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> except as refers to the greater reduction in the incidence of pulmonary embolism following prophylaxis with LMWH (dalteparin) versus UFH described in a recent clinical trial.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In our Units the exclusive use of LMWH could be related to simpler administration (once a day) and the fact that in most cases routine testing is not needed to adjust the drug. This practice is consistent with the way things are commonly done in other European countries such as France and Austria–in contraposition to the more frequent use of UFH in countries such as the United States, Canada, New Zealand and Australia. The recent publication of the results of the PROTECT multicenter trial<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> has not been able to clarify the situation, since after randomizing almost 4000 patients to either LMWH (5000<span class="elsevierStyleHsp" style=""></span>IU s.c. of dalteparin once a day) or UFH (5000<span class="elsevierStyleHsp" style=""></span>IU s.c. twice day), the incidence of DVT (as assessed by ultrasound) was found to be similar in both groups (5.1% and 5.8%, respectively). Although as mentioned above it is true that there appears to be a decrease in the incidence of pulmonary embolism in the group treated with dalteparin (1.3% versus 2.3%; HR 0.51; 95%CI 0.30–0.88), this reduction was not associated to a decrease in mortality. Little can be commented on the more frequent use in our study of enoxaparin as LMWH (16 of the 18 Units), since to date no clinical trials have compared the efficacy of the different types of LMWH, and there are no concrete recommendations in this respect.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–11,13</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">In relation to this subject, an important limitation of our study is the fact that the enoxaparin dose administered was not recorded, its activity was not monitored, and the type of patient receiving the drug was not documented–specifically as refers to the subgroup of patients with impaired renal function (creatinine clearance<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml/min). The utilization of repeated enoxaparin doses for prophylaxis in this subgroup of patients (which is the practice found in most of the Units in our study) could lead to drug accumulation over a number of days, and although this does not seem to increase the risk of bleeding episodes, it would oblige us to reduce the usual dose. In contrast, the administration of two daily doses for anticoagulation purposes does increase bleeding risk. There appears to be no such accumulation in the case of nadroparin, dalteparin and tinzaparin, and dose adjustment therefore would not be needed when using these agents.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a> However, both in patients with renal failure and in other patient subgroups such as neurocritical cases, patients requiring vasopressor drugs, or individuals with generalized edema or anasarca, the need to measure the anti-factor Xa levels in order to assess the correct LMWH dosage remains subject to discussion, due to the lack of evidence of a correlation between such levels and the development of symptomatic or asymptomatic VTED.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21–26</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Mechanical prophylaxis as recommended in patients with a high bleeding risk or contraindications to pharmacological prophylaxis (grade 2C recommendation in medical or general surgical patients and grade 1C recommendation in traumatologic surgery patients) was little used in our study, representing about 14% of the total patients receiving some type of prophylaxis and a little over 50% of those with a concrete indication for the use of mechanical prophylaxis.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–11,13</span></a> The use of this type of prophylaxis, as reported in the different international registries, varies from 14% of all patients (31% among those with a specific indication for such measures) in the French-Canadian study of 2003, with a higher utilization rate in Canada,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> to 36% of all patients (70% among those with a specific indication for such measures) in the ANZICS-CTG study of 2010.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The poor acceptance of this type of prophylactic strategy could be related to the lack of clinical trials in critical patients supporting its use, and to the absence of cost-effectiveness analyses. We consider it important to underscore the great variability in the use of the different mechanical prophylactic devices, with a predominance of GCS over IPCS–though the latter might be more effective in preventing DVT in certain patient subgroups such as neurocritical cases, polytraumatized patients or high-risk surgical patients.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–11,27,28</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">On the other hand, the use of combined prophylaxis (drugs and mechanical measures simultaneously) has been indicated in critical patients with a high risk of suffering VTED.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,10,11</span></a> Although our study did not require specification of the risk factors for DVT among the patients, and we therefore were unable to stratify them according to risk, the use of this form of prophylaxis was infrequent (2%). On examining the literature, the use of combined prophylaxis in critical patients is seen to have varied over the last 10 years, increasing from a little over 10% in the French-Canadian study of 2003 to about 40% in the Australian-New Zealand study of 2010 and the Austrian publication of 2012.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,16,17</span></a> Two recent metaanalyses by Kakkos et al.,<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29,30</span></a> with results that appear favorable to the use of combined prophylaxis versus single-mode prophylaxis (pharmacological or mechanical) in patients with a high risk of developing VTED–fundamentally surgical patients (OR 0.16; 95%CI 0.07–0.34 for DVT in the former, and OR 0.31; 95%CI 0.23–0.43 for DVT with OR 0.34; 95%CI 0.23–0.50 for pulmonary embolism in the latter)–appear to offer a reasonable argument for increased use of combined prophylaxis while in wait of clinical trials specifically centered on critical patients. Furthermore, according to the clinical practice guides of the ACCP 2012,<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> the recommendation in surgical patients (traumatologic or otherwise) with a high risk of suffering VTED is to combine pharmacological prophylaxis with intermittent pneumatic compression for the duration of hospital stay, based on 2C level of evidence. In our study, up to 40% of the patients were surgical or polytraumatized subjects; such a recommendation therefore may have been applicable to a considerable proportion of them once the bleeding risk phase was left behind.</p><p id="par0215" class="elsevierStylePara elsevierViewall">The formalization and implementation of a specific protocol in each Unit, based both on the general recommendations of the clinical practice guides and on the specific characteristics of the patients admitted to the Unit (risk stratification), could improve the prevention of VTED in the critical patient.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7,31,32</span></a> Our study showed only one-half of the participating Units to have a prophylaxis protocol–this proportion falling well short of the recommended quality index of 100% in the critical patient proposed by the SEMICYUC.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Furthermore, only one of the Units included VTED risk stratification in their protocol, with a view to optimizing prophylaxis.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31,33</span></a> This situation means that our clinical practice is not in line with that recommended by the guides which propose routine assessment of VTED risk in the critical patient (grade 1A recommendation).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Lastly, mention should be made of the growing use of clinical ultrasound by intensivists in the critical care setting.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34,35</span></a> The fact that VTED, and more specifically DVT, is often asymptomatic and silent in our patients, suggests that deep venous system ultrasound using the simplified compression technique (a simple and rapid procedure) may be very useful in screening for VTED in the ICU. In our case, only four of the participating Units routinely used ultrasound screening for VTED. In line with the recommendation of the current guides not to routinely screen for DVT (grade 2C recommendation),<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,10,11</span></a> we consider that the technique should be reserved for those patients with an increased risk of suffering VTED, or in which adequate prophylaxis is not possible for some reason.</p><p id="par0225" class="elsevierStylePara elsevierViewall">As commented above, the main limitation of our study was the impossibility of conducting a thorough and detailed analysis of the suitability of the prophylactic measures used. The initial aim of the study was fundamentally to assess the prevalence of prophylaxis and its different types; however, on posteriorly analyzing the results, we would have liked to have more information in order to adequately assess the suitability of the prophylactic measures adopted. Despite the large number of participating Units and the acceptable number of patients recruited, which could offer an impression of the routine results obtained in the ICUs of the Community of Madrid, the fact of having collected the data on a single day means that generalizations are not possible. Furthermore, performing the survey by e-mail implied possible errors both in forming and interpreting the questions, and even in answering them.</p><p id="par0230" class="elsevierStylePara elsevierViewall">It seems obvious that a larger study is needed to correctly establish the situation of VTED prophylaxis in Spain. A prevalence cut at national level, with a more exhaustive and rigorous survey, could offer a more reliable idea of the current situation. The creation of a specific VTED working group probably could lead to studies designed to clarify the doubts on different aspects referred to the prevention of VTED: the true incidence of VTED in our Units, the most appropriate LMWH and its optimum dose, monitoring and dose adjustments based on anti-factor Xa levels, the efficacy of combined prophylaxis in high-risk critical patients, or the role of clinical ultrasound in prophylaxis, among other issues.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0235" class="elsevierStylePara elsevierViewall">In our study, pharmacological prophylaxis with LMWH was the most widely used VTED prevention measure. Mechanical prophylaxis was little used in patients with contraindications to pharmacological prophylaxis, and the use of combined prophylaxis was merely anecdotal. Many of the Units lacked specific prophylaxis protocols.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Financial support</span><p id="par0240" class="elsevierStylePara elsevierViewall">This study has received no financial support from public or private institutions.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0245" class="elsevierStylePara elsevierViewall">Pablo Garcia-Olivares, Jose Eugenio Guerrero-Sanz and Ana Maria Hernangomez have participated in different symposia on venous thromboembolic disease in the critical patient organized by the company Covidien Spain, S.L.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres360703" "titulo" => array:8 [ 0 => "Abstract" 1 => "Objective" 2 => "Design" 3 => "Setting" 4 => "Patients" 5 => "Variables of interest" 6 => "Results" 7 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec340555" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres360704" "titulo" => array:8 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Diseño" 3 => "Ámbito" 4 => "Pacientes" 5 => "Variables de interés" 6 => "Resultados" 7 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec340554" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Financial support" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack89087" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-02-01" "fechaAceptado" => "2013-07-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec340555" "palabras" => array:5 [ 0 => "Venous thromboembolic disease" 1 => "Deep venous thrombosis" 2 => "Thromboprophylaxis" 3 => "Intensive care unit" 4 => "Critical patient" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec340554" "palabras" => array:5 [ 0 => "Enfermedad tromboembólica venosa" 1 => "Trombosis venosa profunda" 2 => "Tromboprofilaxis" 3 => "Unidad de cuidados Intensivos" 4 => "Paciente crítico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze measures referred to venous thromboembolic prophylaxis in critically ill patients.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An epidemiological, cross-sectional (prevalence cut), multicenter study was performed using an electronic survey. Comparison of results with quality indexes of the Spanish Society of Intensive Care Medicine, the American College of Chest Physician guidelines and international studies.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Intensive Care Units (ICUs) in the Community of Madrid (Spain).</p> <span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">All patients admitted to the ICU on the day of the survey.</p> <span class="elsevierStyleSectionTitle" id="sect0030">Variables of interest</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">General aspects of venous thromboembolic prophylaxis and protocols used (risk stratification and ultrasound screening). A descriptive analysis was performed, continuous data being expressed as the mean or median, and categorical data as percentages.</p> <span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A total of 234 patients in 18 ICUs were included. Eighteen percent (42/234) received no prophylaxis, and 55% had no contraindication to pharmacological prophylaxis. Of the 192 patients receiving prophylaxis, 84% received pharmacological prophylaxis, 14% mechanical prophylaxis and 2% combined prophylaxis. Low molecular weight heparin was the only pharmacological prophylaxis used, with a majority use of enoxaparin (17 of 18 ICUs). In patients with mechanical prophylaxis (31/192), antiembolic stockings were the most commonly used option (58%). Pharmacological prophylaxis contraindications were reported in 20% of the patients (46/234), the most frequent cause being thrombocytopenia (28% of the cases). Fifty percent of the ICUs used no specific venous thromboembolic prophylaxis protocol.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Pharmacological prophylaxis with low molecular weight heparin was the most frequently used venous thromboembolic prophylactic measure. In patients with contraindications to pharmacological prophylaxis, mechanical measures were little used. The use of combined prophylaxis was anecdotal. Many of our ICUs lack specific prophylaxis protocols.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0050">Objetivo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Analizar la utilización de medidas de profilaxis de enfermedad tromboembólica venosa en el paciente crítico.</p> <span class="elsevierStyleSectionTitle" id="sect0055">Diseño</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudio epidemiológico, transversal (corte de prevalencia) y multicéntrico realizado mediante encuesta electrónica. Comparación de resultados con índices de calidad de la Sociedad Española de Medicina Intensiva, guías del American College of Chest Physicians y registros internacionales.</p> <span class="elsevierStyleSectionTitle" id="sect0060">Ámbito</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Unidades de Cuidados Intensivos (UCI) de la Comunidad de Madrid.</p> <span class="elsevierStyleSectionTitle" id="sect0065">Pacientes</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Todos los pacientes ingresados en UCI el día de la realización de la encuesta.</p> <span class="elsevierStyleSectionTitle" id="sect0070">Variables de interés</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Aspectos generales de profilaxis de enfermedad tromboembólica venosa y utilización de protocolos. Análisis descriptivo expresado como media o mediana para variables cuantitativas y porcentajes para variables cualitativas.</p> <span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 234 pacientes de 18 UCI. El 18% (42/234) no recibía ninguna profilaxis; un 55% de ellos no tenía contraindicación para profilaxis farmacológica. De los 192 pacientes con profilaxis, en el 84% fue farmacológica, en el 14% mecánica y en el 2% combinada. Las heparinas de bajo peso molecular fueron los únicos fármacos usados (enoxaparina en 17 de 18 UCI). En pacientes con profilaxis mecánica (31/192) las medias de compresión graduada fueron las más utilizadas (58%). El 20% de los pacientes (46/234) presentaba contraindicación para profilaxis farmacológica, con trombocitopenia como causa más frecuente (28%). La mitad de las UCI no utilizaba un protocolo específico de profilaxis.</p> <span class="elsevierStyleSectionTitle" id="sect0080">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La profilaxis farmacológica con heparinas de bajo peso molecular fue la medida preventiva de enfermedad tromboembólica venosa más utilizada. Considerando los pacientes con contraindicación para profilaxis farmacológica, los sistemas mecánicos de profilaxis fueron poco utilizados. El uso de profilaxis combinada fue anecdótico. Hubo ausencia de protocolos específicos de profilaxis en muchas de nuestras UCI.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García-Olivares P, Guerrero JE, Tomey MJ, Hernangómez AM, Stanescu DO. Profilaxis de la enfermedad tromboembólica venosa en el paciente crítico: aproximación a la práctica clínica en la Comunidad de Madrid. Med Intensiva. 2014;38:347–355.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:3 [ "apendice" => "<p id="par0255" class="elsevierStylePara elsevierViewall">Intensive Care Units of: Hospital La Paz, Hospital Clínico San Carlos, Hospital Puerta de Hierro, Hospital Infanta Sofía, Hospital Infanta Elena, Hospital Infanta Cristina, Hospital de Henares, Hospital de Getafe, Hospital de La Princesa, Hospital de Torrejón de Ardoz, Hospital del Sureste, Hospital Infanta Leonor, Hospital del Tajo, Hospital Doce de Octubre, Hospital Severo Ochoa, Hospital Madrid Norte San Chinarro.</p>" "titulo" => "Annex" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2093 "Ancho" => 2310 "Tamanyo" => 195285 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Prevention of venous thromboembolic disease in the Community of Madrid (Spain).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2295 "Ancho" => 2335 "Tamanyo" => 195710 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Comparison of the venous thromboembolic disease prophylaxis modalities in different international registries.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Adapted from the 2012 guides of the American College of Chest Physicians." "tabla" => array:2 [ "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">VTED, venous thromboembolic disease; LMWH, low molecular weight heparin; UFH, unfractionated heparin; GCS, graduated compression stockings; IPCS, intermittent pneumatic compression system.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Prophylaxis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Considerations \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient with medical disease</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LMWH or UFH</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade 2C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">or Grade 1B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Considering critical patient as acute case with high risk of VTED \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient with medical disease and high bleeding risk or contraindication to pharmacological prophylaxis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GCS or IPCS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade 2C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Switch to pharmacological prophylaxis once bleeding risk is resolved \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient with general surgical disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LMWH or UFH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade 1B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider associating GCS or IPCS in case of high risk of VTED. Grade 2B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient with surgical disease and high bleeding risk or contraindication to pharmacological prophylaxis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GCS or IPCS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade 2C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Switch to pharmacological prophylaxis once bleeding risk is resolved \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient with traumatologic surgical disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LMWH or UFHor IPCS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade 1Bor Grade 1C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider associating GCS or IPCS in case of high risk of VTED. Grade 2B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient with traumatologic surgical disease and high bleeding risk and/or contraindication to pharmacological prophylaxis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IPCS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade 2C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Switch to pharmacological prophylaxis once bleeding risk is resolved \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab539286.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Recommendations referred to venous thromboembolic disease prophylaxis in the critical patient.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8<span class="elsevierStyleHsp" style=""></span>th edition)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W.H. 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Koenig" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.10-1479" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2011" "volumen" => "139" "paginaInicial" => "538" "paginaFinal" => "542" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21030490" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack89087" "titulo" => "Acknowledgements" "texto" => "<p id="par0250" class="elsevierStylePara elsevierViewall">The authors wish to express their most sincere gratitude to the physicians of the different Intensive Care Units for their collaboration in this study.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000003800000006/v1_201408130221/S2173572714000460/v1_201408130221/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/21735727/0000003800000006/v1_201408130221/S2173572714000460/v1_201408130221/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572714000460?idApp=WMIE" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 11 | 19 |
| 2024 October | 51 | 58 | 109 |
| 2024 September | 45 | 26 | 71 |
| 2024 August | 65 | 36 | 101 |
| 2024 July | 32 | 27 | 59 |
| 2024 June | 41 | 46 | 87 |
| 2024 May | 43 | 28 | 71 |
| 2024 April | 49 | 32 | 81 |
| 2024 March | 43 | 26 | 69 |
| 2024 February | 35 | 34 | 69 |
| 2024 January | 28 | 29 | 57 |
| 2023 December | 34 | 44 | 78 |
| 2023 November | 51 | 40 | 91 |
| 2023 October | 24 | 41 | 65 |
| 2023 September | 31 | 36 | 67 |
| 2023 August | 43 | 17 | 60 |
| 2023 July | 49 | 32 | 81 |
| 2023 June | 41 | 18 | 59 |
| 2023 May | 44 | 37 | 81 |
| 2023 April | 48 | 29 | 77 |
| 2023 March | 33 | 30 | 63 |
| 2023 February | 34 | 31 | 65 |
| 2023 January | 43 | 26 | 69 |
| 2022 December | 54 | 30 | 84 |
| 2022 November | 74 | 47 | 121 |
| 2022 October | 91 | 41 | 132 |
| 2022 September | 99 | 42 | 141 |
| 2022 August | 62 | 52 | 114 |
| 2022 July | 38 | 28 | 66 |
| 2022 June | 23 | 31 | 54 |
| 2022 May | 50 | 50 | 100 |
| 2022 April | 25 | 33 | 58 |
| 2022 March | 39 | 55 | 94 |
| 2022 February | 44 | 29 | 73 |
| 2022 January | 28 | 25 | 53 |
| 2021 December | 50 | 51 | 101 |
| 2021 November | 30 | 46 | 76 |
| 2021 October | 53 | 70 | 123 |
| 2021 September | 52 | 41 | 93 |
| 2021 August | 40 | 33 | 73 |
| 2021 July | 29 | 34 | 63 |
| 2021 June | 54 | 22 | 76 |
| 2021 May | 46 | 55 | 101 |
| 2021 April | 136 | 89 | 225 |
| 2021 March | 52 | 35 | 87 |
| 2021 February | 47 | 28 | 75 |
| 2021 January | 57 | 23 | 80 |
| 2020 December | 35 | 16 | 51 |
| 2020 November | 24 | 14 | 38 |
| 2020 October | 47 | 25 | 72 |
| 2020 September | 60 | 15 | 75 |
| 2020 August | 19 | 13 | 32 |
| 2020 July | 24 | 10 | 34 |
| 2020 June | 50 | 19 | 69 |
| 2020 May | 34 | 12 | 46 |
| 2020 April | 41 | 21 | 62 |
| 2020 March | 16 | 14 | 30 |
| 2020 February | 56 | 22 | 78 |
| 2020 January | 61 | 24 | 85 |
| 2019 December | 32 | 25 | 57 |
| 2019 November | 35 | 34 | 69 |
| 2019 October | 60 | 22 | 82 |
| 2019 September | 29 | 22 | 51 |
| 2019 August | 49 | 23 | 72 |
| 2019 July | 35 | 20 | 55 |
| 2019 June | 33 | 22 | 55 |
| 2019 May | 46 | 26 | 72 |
| 2019 April | 28 | 11 | 39 |
| 2019 March | 27 | 24 | 51 |
| 2019 February | 35 | 37 | 72 |
| 2019 January | 29 | 37 | 66 |
| 2018 December | 43 | 71 | 114 |
| 2018 November | 76 | 90 | 166 |
| 2018 October | 88 | 17 | 105 |
| 2018 September | 29 | 9 | 38 |
| 2018 August | 21 | 7 | 28 |
| 2018 July | 28 | 6 | 34 |
| 2018 June | 41 | 6 | 47 |
| 2018 May | 30 | 5 | 35 |
| 2018 April | 58 | 6 | 64 |
| 2018 March | 24 | 3 | 27 |
| 2018 February | 17 | 7 | 24 |
| 2018 January | 33 | 12 | 45 |
| 2017 December | 21 | 8 | 29 |
| 2017 November | 30 | 8 | 38 |
| 2017 October | 28 | 5 | 33 |
| 2017 September | 23 | 10 | 33 |
| 2017 August | 14 | 7 | 21 |
| 2017 July | 17 | 3 | 20 |
| 2017 June | 32 | 9 | 41 |
| 2017 May | 30 | 7 | 37 |
| 2017 April | 23 | 10 | 33 |
| 2017 March | 20 | 2 | 22 |
| 2017 February | 17 | 5 | 22 |
| 2017 January | 14 | 6 | 20 |
| 2016 December | 19 | 13 | 32 |
| 2016 November | 42 | 19 | 61 |
| 2016 October | 49 | 23 | 72 |
| 2016 September | 34 | 12 | 46 |
| 2016 August | 49 | 20 | 69 |
| 2016 July | 23 | 10 | 33 |
| 2016 June | 2 | 0 | 2 |
| 2016 May | 1 | 0 | 1 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 September | 0 | 23 | 23 |
| 2014 December | 3 | 0 | 3 |
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