Cook Deborah, Douketis James, Meade Maureen, Guyatt Gordon, Zytaruk Nicole, Granton John, Skrobik Yoanna, Albert Martin, Fowler Robert, Hebert Paul, Pagliarello Guiseppe, Friedrich Jan, Freitag Andreas, Karachi Tim, Rabbat Christian, Heels-Ansdell Diane, Geerts William, Crowther Mark
Department of Medicine, 1200 Main Street, McMaster University, Hamilton, Canada.
Crit Care. 2008;12(2):R32. doi: 10.1186/cc6810. Epub 2008 Mar 3.
Critically ill patients with renal insufficiency are predisposed to both deep vein thrombosis (DVT) and bleeding. The objective of the present study was to evaluate the prevalence, incidence and predictors of DVT and the incidence of bleeding in intensive care unit (ICU) patients with estimated creatinine clearance <30 ml/min.
In a multicenter, open-label, prospective cohort study of critically ill patients with severe acute or chronic renal insufficiency or dialysis receiving subcutaneous dalteparin 5,000 IU once daily, we estimated the prevalence of proximal DVT by screening compression venous ultrasound of the lower limbs within 48 hours of ICU admission. DVT incidence was assessed on twice-weekly ultrasound testing. We estimated the incidence of major and minor bleeding by daily clinical assessments. We used Cox proportional hazards regression to identify independent predictors of both DVT and major bleeding.
Of 156 patients with a mean (standard deviation) creatinine clearance of 18.9 (6.5) ml/min, 18 had DVT or pulmonary embolism within 48 hours of ICU admission, died or were discharged before ultrasound testing - leaving 138 evaluable patients who received at least one dose of dalteparin. The median duration of dalteparin administration was 7 days (interquartile range, 4 to 12 days). DVT developed in seven patients (5.1%; 95% confidence interval, 2.5 to 10.1). The only independent risk factor for DVT was an elevated baseline Acute Physiology and Chronic Health Evaluation II score (hazard ratio for 10-point increase, 2.25; 95% confidence interval, 1.03 to 4.91). Major bleeding developed in 10 patients (7.2%; 95% confidence interval, 4.0 to 12.8), all with trough anti-activated factor X levels </= 0.18 IU/ml. Independent risk factors for major bleeding were aspirin use (hazard ratio, 6.30; 95% confidence interval, 1.35 to 29.4) and a high International Normalized Ratio (hazard ratio for 0.5-unit increase, 1.68; 95% confidence interval, 1.07 to 2.66).
In ICU patients with renal insufficiency, the incidence of DVT and major bleeding are considerable but appear related to patient comorbidities rather than to an inadequate or excessive anticoagulant from thromboprophylaxis with dalteparin.
肾功能不全的重症患者易发生深静脉血栓形成(DVT)和出血。本研究的目的是评估估计肌酐清除率<30 ml/min的重症监护病房(ICU)患者中DVT的患病率、发病率及预测因素,以及出血的发生率。
在一项多中心、开放标签、前瞻性队列研究中,对患有严重急性或慢性肾功能不全或正在接受透析的重症患者每日皮下注射达肝素5000 IU,我们通过在ICU入院后48小时内对下肢进行加压静脉超声筛查来估计近端DVT的患病率。通过每周两次的超声检查评估DVT的发病率。我们通过每日临床评估来估计严重出血和轻微出血的发生率。我们使用Cox比例风险回归来确定DVT和严重出血的独立预测因素。
156例患者的平均(标准差)肌酐清除率为18.9(6.5)ml/min,其中18例在ICU入院后48小时内发生DVT或肺栓塞、死亡或在超声检查前出院,其余138例患者可进行评估,他们至少接受了一剂达肝素。达肝素给药的中位持续时间为7天(四分位间距,4至12天)。7例患者发生DVT(5.1%;95%置信区间,2.5至10.1)。DVT的唯一独立危险因素是基线急性生理与慢性健康状况评分II升高(每增加10分的风险比,2.25;95%置信区间,1.03至4.91)。10例患者发生严重出血(7.2%;95%置信区间,4.0至12.8),所有患者的谷值抗活化因子X水平≤0.18 IU/ml。严重出血的独立危险因素是使用阿司匹林(风险比,6.30;95%置信区间,1.35至29.4)和国际标准化比值升高(每增加0.5单位的风险比,1.68;95%置信区间,1.07至2.66)。
在肾功能不全的ICU患者中,DVT和严重出血的发生率相当,但似乎与患者的合并症有关,而非与达肝素进行血栓预防时抗凝不足或过量有关。