Key result
Novel thromboprophylaxis strategies, including weight-based or continuous infusions, have yet to demonstrate superiority compared to standard-of-care in high-risk critically ill patients.
Why the study?
Do novel thromboprophylaxis strategies prevent venous thromboembolism better than standard-of-care in high-risk critically ill patients?
Do novel thromboprophylaxis strategies prevent venous thromboembolism better than standard-of-care in high-risk critically ill patients?
While critically ill patients, especially those obese or on vasopressors, are at high risk for VTE prophylaxis failure, novel dosing strategies have not yet demonstrated superiority over standard care.
Standard dosing remains appropriate for VTE prophylaxis in high-risk ICU patients; leaves open whether novel strategies benefit specific subgroups.
Venous thromboembolism (VTE) is a major health concern associated with significant morbidity and mortality. Critically ill patients are at an increased risk of VTE compared to general medical patients due to unique risk factors: prolonged immobilization, invasive lines and devices, certain medications, and acquired thrombophilia. Furthermore, VTE in the critically ill is associated with increased duration of mechanical ventilation, increased length of intensive care unit and hospital stay, and a trend toward increased mortality. Clinical practice guidelines therefore recommend VTE prophylaxis with either subcutaneous heparin or low-molecular-weight heparin for all critically ill patients without contraindication. Yet, many patients will develop VTE despite appropriate pharmacologic prophylaxis, which has led to interest in risk-stratifying critically ill patients for more aggressive prophylaxis strategies. Recent research identified patients at highest risk of failure of thromboprophylaxis and provided insight into the pathophysiologic mechanisms. Obesity and the receipt of vasopressors are 2 risk factors consistently identified in observational studies; further clinical data support decreased absorption of anticoagulant administered via the subcutaneous route as the likely mechanism behind thromboprophylaxis failure in these patient populations. Several studies have investigated novel thromboprophylaxis strategies to circumvent pharmacokinetic limitations in patients who are obese or on vasopressors: increased fixed-dose, weight-based subcutaneous, or continuous intravenous infusion of a prophylactic dose of anticoagulant has shown promise in limited studies; however, the results have yet to demonstrate superiority compared to current standard-of-care. This review discusses observational studies identifying patients at risk of thromboprophylaxis failure and critiques clinical studies evaluating novel thromboprophylaxis strategies in high-risk, critically ill patients with a focus on their limitations. Future studies are currently being conducted that will provide further guidance into the appropriate use of individualized thromboprophylaxis.
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Lewis et al. (2018) conducted a review in Venous thromboembolism. Novel thromboprophylaxis strategies (increased fixed-dose, weight-based subcutaneous, or continuous intravenous infusion) vs. Standard-of-care (subcutaneous heparin or low-molecular-weight heparin) was evaluated. Novel thromboprophylaxis strategies, including weight-based or continuous infusions, have yet to demonstrate superiority compared to standard-of-care in high-risk critically ill patients.
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