This document discusses thromboprophylaxis in ICU patients. It provides information on: - The risk of venous thromboembolism (VTE) in hospitalized patients and the potential for prophylaxis to reduce this risk - Common prophylactic options like enoxaparin, fondaparinux, and unfractionated heparin - Tools to assess patient risk like the PADUA and IMPROVE scores - Factors to consider when selecting a prophylactic method, including duration of prophylaxis The document aims to review best practices for preventing VTE in high-risk hospitalized populations through appropriate thromboprophylaxis.

1. DR SANTOSH KUMAR BHASKAR
Thromboprophylaxis in ICU

2. Q
 Which of the following has not been shown to
prevent VTE in high risk hospitalized
patients?
 A.Enoxaparin 40 mg subcutaneously daily
 B.Fondapariux 2.5 mg subcutaneously daily.
 C.4 factor PCC 50U/kg intravenously daily
 D.An electronic alert notifying providers that
the patients is at increased risk for VTE and is
not ordered for any prophylactic measures.

3. Answer
 Which of the following has not been shown to
prevent VTE in high risk hospitalized
patients?
 A.Enoxaparin 40 mg subcutaneously daily
 B.Fondapariux 2.5 mg subcutaneously daily.
 C.4 factor PCC 50U/kg intravenously daily
 D.An electronic alert notifying providers that
the patients is at increased risk for VTE and is
not ordered for any prophylactic measures.

4. “If a man will begin with
certainties, he shall end in
doubts: but if he will be content
to begin with doubts, he shall
end in certainties.”
Francis Bacon

5. Dictionary meaning of
thromboprophylaxis
 (Thrombo +prophylaxis)
 Any preventive measure or medication that
reduces the likelihood of the formation of blood
clots.

6. INTRODUCTION
 VTE= DVT + EMBOLISM
 It is estimated that over half of hospitalized
medical patients are at risk for venous
thromboembolism (VTE, ie, deep vein thrombosis
[DVT] and/or pulmonary embolus [PE])
Anderson FA Jr, Zayaruzny M, Heit JA, et al.
Estimated annual numbers of US acute-care
hospital patients at risk for venous
thromboembolism. Am J Hematol 2007; 82:777.

7.  PE is identified as the most preventable cause of
death among hospitalized patients.
 Lindblad B, Eriksson A, Bergqvist D. Autopsy-verified pulmonary embolism in a surgical department:
analysis of the period from 1951 to 1988. Br J Surg 1991; 78:849.
 Stein PD, Henry JW. Prevalence of acute pulmonary embolism among patients in a general hospital
and at autopsy. Chest 1995; 108:978.
 White RH, Zhou H, Romano PS. Incidence of symptomatic venous thromboembolism after different
elective or urgent surgical procedures. Thromb Haemost 2003; 90:446.
 Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting
enough deep vein thrombosis? J R Soc Med 1989; 82:203.
 Martino MA, Borges E, Williamson E, et al. Pulmonary embolism after major abdominal surgery in
gynecologic oncology. Obstet Gynecol 2006; 107:666.
 Dismuke SE, Wagner EH. Pulmonary embolism as a cause of death. The changing mortality in
hospitalized patients. JAMA 1986; 255:2039.
 Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979-
1998: an analysis using multiple-cause mortality data. Arch Intern Med 2003; 163:1711.
 Quality Improvement Initiatives including DS Based
strategies have the potential to improve
thromboprophylaxis utilization and reduce the
incidence of VTE during hospitalization.

8. EPIDEMIOLOGY
 While many epidemiologic studies report venous
thromboembolism (VTE) rates, in the absence of
prophylaxis, that range from 10 to 80 percent, these
rates are likely overestimated .
 Thromboprophylaxis has been shown to reduce the
risk of VTE in hospitalized medical and surgical
patients. While thromboprophylaxis has been reported
to reduce the risk of death in surgical patients .
 Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary
embolism and venous thrombosis by perioperative administration of
subcutaneous heparin. Overview of results of randomized trials in
general, orthopedic, and urologic surgery. N Engl J Med 1988; 318:1162.
 Prevention of fatal postoperative pulmonary embolism by low doses of
heparin. An international multicentre trial. Lancet 1975; 2:45.

9.  Most studies and a meta-analysis have not been able
to show a consistent beneficial effect of
thromboprophylaxis on mortality in hospitalized
medical patients .
 Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the
prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical
Patients with Enoxaparin Study Group. N Engl J Med 1999; 341:793.
 Hull RD, Schellong SM, Tapson VF, et al. Extended-duration venous thromboembolism prophylaxis in
acutely ill medical patients with recently reduced mobility: a randomized trial. Ann Intern Med 2010;
153:8.
 Halkin H, Goldberg J, Modan M, Modan B. Reduction of mortality in general medical in-patients by
low-dose heparin prophylaxis. Ann Intern Med 1982; 96:561.
 Gärdlund B. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary
embolism in patients with infectious diseases. The Heparin Prophylaxis Study Group. Lancet 1996;
347:1357.
 Mahé I, Bergmann JF, d'Azémar P, et al. Lack of effect of a low-molecular-weight heparin (nadroparin)
on mortality in bedridden medical in-patients: a prospective randomised double-blind study. Eur J
Clin Pharmacol 2005; 61:347.
 Kakkar AK, Cimminiello C, Goldhaber SZ, et al. Low-molecular-weight heparin and mortality in acutely
ill medical patients. N Engl J Med 2011; 365:2463.
 Lederle FA, Zylla D, MacDonald R, Wilt TJ. Venous thromboembolism prophylaxis in hospitalized
medical patients and those with stroke: a background review for an American College of Physicians
Clinical Practice Guideline. Ann Intern Med 2011; 155:602.
 Lester W, Freemantle N, Begaj I, et al. Fatal venous thromboembolism associated with hospital
admission: a cohort study to assess the impact of a national risk assessment target. Heart 2013;
99:1734.

10. BURDEN OF THE VTE
 Which of the following statements about the
epidemiology of venous thromboembolism (VTE)
is false?
 A.Pulmonary embolism is the most preventable
cause of death among hopitalized medical
patients.
 B.VTE is the third most common cardiovascular
disorder after myocardial infarction and stroke.
 C.Long term mortality in patients who have
suffered an initial VTE is similar to that of age
matched individuals from the general population.
 D.Recurrent PE is an important cause of
mortality in patients who have suffered an initial
VTE.

11. BURDEN OF THE VTE
 Which of the following statements about the
epidemiology of venous thromboembolism (VTE)
is false?
 A.Pulmonary embolism is the most preventable
cause of death among hopitalized medical
patients.
 B.VTE is the third most common cardiovascular
disorder after myocardial infarction and stroke.
 C.Long term mortality in patients who have
suffered an initial VTE is similar to that of age
matched individuals from the general
population.
 D.Recurrent PE is an important cause of
mortality in patients who have suffered an initial

12. THROMBOSIS RISK SCORE
 PADUA PREDICTION SCORE
 IMPROVE RISK SCORE
 GENEVA RISK SCORE

13. THROMBOSIS RISK SCORE

14. THROMBOSIS RISK SCORE
 PADUA PREDICTION SCORE
 Low risk patients (score <4): 0.3 percent
 High risk patients (score ≥4): 2.2 (receiving
adequate in-hospital thromboprophylaxis) and 11
percent (not receiving adequate in-hospital
thromboprophylaxis)

15. IMPROVE BLEEDING RISK
MODEL

16. IMPROVE BLEEDING RISK
MODEL
 Risk scores of 1: 0.5 percent
 Risk scores of 4: 1.6 percent
 Risk scores of 7: 4.1 percent
 Risk scores of 15: 14 percent

17. SELECTION OF METHOD OF
PROPHYLAXIS
Selecting a method of thromboprophylaxis is
dependent upon many factors including
 the nature of the acute medical illness,
 the risk of hemorrhage and thrombosis,
 preferences and values of the patient,
 institutional policy, and
 cost.

18. DURATION OF PROPHYLAXIS
 VTE prophylaxis should ideally continue until the
patient is ambulatory or discharged from the
hospital. Although data do not support routinely
extending the duration of thromboprophylaxis in
acutely ill medical patients beyond admission, in
our experience select populations should
probably receive extended thromboprophylaxis
(eg, non ambulatory patients, patients unable to
ambulate independently or mechanically
ventilated patients admitted to acute rehabilitation
for physical therapy or ventilator weaning).

19. OPTIONS FOR
THROMBOPROPHYLAXIS
 MECHANICAL THROMBPROPHYLAXIS
 PHARMACOLOGIC THROMBOPROPHYLAXIS

20. MECHANICAL
THROMBPROPHYLAXIS

21. PHARMACOLOGICAL
THROMBOPROPHYLAXIS
In randomized trials, pharmacologic prophylaxis
with low molecular weight (LMW) heparin,
unfractionated heparin (UFH), or fondaparinux
have all been shown to be superior to placebo or
mechanical devices in preventing VTE.
 Dentali F, Douketis JD, Gianni M, et al. Meta-analysis: anticoagulant prophylaxis to
prevent symptomatic venous thromboembolism in hospitalized medical patients.
Ann Intern Med 2007; 146:278.
 Wein L, Wein S, Haas SJ, et al. Pharmacological venous thromboembolism
prophylaxis in hospitalized medical patients: a meta-analysis of randomized
controlled trials. Arch Intern Med 2007; 167:1476.
 Själander A, Jansson JH, Bergqvist D, et al. Efficacy and safety of anticoagulant
prophylaxis to prevent venous thromboembolism in acutely ill medical inpatients: a
meta-analysis. J Intern Med 2008; 263:52.

22. PHARMACOLOGICAL
THROMBOPROPHYLAXIS
 LMW heparin because meta-analyses suggest it
is superior to UFH (twice daily or three times daily
dosing regimens), particularly in high risk
populations

23. UFH LMWH FONDAPARINUX
EFFICACY Thromboprophylactic
doses of UFH are
effective at preventing
VTE when compared
with placebo or
mechanical devices
When compared with
UFH, LMWH appears
to be marginally
superior for the
prevention of VTE
Fondapariux is superior to
placebo and probably as
effective as LMW heparin for
patients who are not critically
ill, although compared to
LMW heparin
DOSE 5000 units
subcutaneously twice
daily.
Enoxaparin 40 mg s/c
once daily
Dalteparin 5000 units
s/c once daily
Tinzaparin 4500 anti-
Xa s/c once daily
Nadroparin 3800 anti-
Xa units/day in
patients ≤70 kg and
5700 units per day in
patients >70 kg once
daily
2.5 mg subcutaneously once
daily
Cr
clearance
<30ml/mi
n
preferred Dose to be adjusted Should not be used.

25. THANK
S