Lauzier François, Muscedere John, Deland Eric, Kutsogiannis Demetrios Jim, Jacka Michael, Heels-Ansdell Diane, Crowther Mark, Cartin-Ceba Rodrigo, Cox Michael J, Zytaruk Nicole, Foster Denise, Sinuff Tasnim, Clarke France, Thompson Patrica, Hanna Steven, Cook Deborah
Crit Care. 2014 Apr 25;18(2):R82. doi: 10.1186/cc13844.
Heparin is safe and prevents venous thromboembolism in critical illness. We aimed to determine the guideline concordance for thromboprophylaxis in critically ill patients and its predictors, and to analyze factors associated with the use of low molecular weight heparin (LMWH), as it may be associated with a lower risk of pulmonary embolism and heparin-induced thrombocytopenia without increasing the bleeding risk.
We performed a retrospective audit in 28 North American intensive care units (ICUs), including all consecutive medical-surgical patients admitted in November 2011. We documented ICU thromboprophylaxis and reasons for omission. Guideline concordance was determined by adding days in which patients without contraindications received thromboprophylaxis to days in which patients with contraindications did not receive it, divided by the total number of patient-days. We used multilevel logistic regression including time-varying, center and patient-level covariates to determine the predictors of guideline concordance and use of LMWH.
We enrolled 1,935 patients (62.3 ± 16.7 years, Acute Physiology and Chronic Health Evaluation [APACHE] II score 19.1 ± 8.3). Patients received thromboprophylaxis with unfractionated heparin (UFH) (54.0%) or LMWH (27.6%). Guideline concordance occurred for 95.5% patient-days and was more likely in patients who were sicker (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.17, 1.75 per 10-point increase in APACHE II), heavier (OR 1.32, 95% CI 1.05, 1.65 per 10-m/kg2 increase in body mass index), had cancer (OR 3.22, 95% CI 1.81, 5.72), previous venous thromboembolism (OR 3.94, 95% CI 1.46,10.66), and received mechanical ventilation (OR 1.83, 95% CI 1.32,2.52). Reasons for not receiving thromboprophylaxis were high risk of bleeding (44.5%), current bleeding (16.3%), no reason (12.9%), recent or upcoming invasive procedure (10.2%), nighttime admission or discharge (9.7%), and life-support limitation (6.9%). LMWH was less often administered to sicker patients (OR 0.65, 95% CI 0.48, 0.89 per 10-point increase in APACHE II), surgical patients (OR 0.41, 95% CI 0.24, 0.72), those receiving vasoactive drugs (OR 0.47, 95% CI 0.35, 0.64) or renal replacement therapy (OR 0.10, 95% CI 0.05, 0.23).
Guideline concordance for thromboprophylaxis was high, but LMWH was less commonly used, especially in patients who were sicker, had surgery, or received vasopressors or renal replacement therapy, representing a potential quality improvement target.
肝素在危重症患者中使用安全且可预防静脉血栓栓塞。我们旨在确定危重症患者血栓预防的指南依从性及其预测因素，并分析与低分子量肝素（LMWH）使用相关的因素，因为LMWH可能与较低的肺栓塞风险和肝素诱导的血小板减少症相关，且不会增加出血风险。
我们在28个北美重症监护病房（ICU）进行了一项回顾性审计，纳入了2011年11月收治的所有连续的内科和外科患者。我们记录了ICU的血栓预防情况及未进行预防的原因。指南依从性通过将无禁忌证患者接受血栓预防的天数与有禁忌证患者未接受预防的天数相加，再除以患者总住院天数来确定。我们使用包括随时间变化、中心和患者水平协变量的多水平逻辑回归来确定指南依从性和LMWH使用的预测因素。
我们纳入了1935例患者（年龄62.3±16.7岁，急性生理与慢性健康状况评分[APACHE]II为19.1±8.3）。患者接受普通肝素（UFH）（54.0%）或LMWH（27.6%）进行血栓预防。95.5%的患者住院天数符合指南，病情较重的患者（APACHE II评分每增加10分，比值比[OR]1.49，95%置信区间[CI]1.17，1.75）、体重较重的患者（体重指数每增加10 kg/m²，OR 1.32，95% CI 1.05，1.65）、患有癌症的患者（OR 3.22，95% CI 1.81，5.72）、既往有静脉血栓栓塞史的患者（OR 3.94，95% CI 1.46，10.66）以及接受机械通气的患者（OR 1.83，95% CI 1.32，2.52）更易符合指南。未接受血栓预防的原因包括出血风险高（44.5%）、当前出血（16.3%）、无理由（12.9%）、近期或即将进行侵入性操作（10.2%）、夜间入院或出院（9.7%）以及生命支持受限（6.9%）。病情较重的患者（APACHE II评分每增加10分，OR 0.65，95% CI 0.48，0.89）、外科患者（OR 0.41，95% CI 0.24，0.72）、接受血管活性药物治疗的患者（OR 0.47，95% CI 0.35，0.64）或接受肾脏替代治疗的患者（OR 0.10，95% CI 0.05，0.23）使用LMWH的频率较低。
血栓预防的指南依从性较高，但LMWH的使用较少，尤其是在病情较重、接受手术、使用血管升压药或接受肾脏替代治疗的患者中，这是一个潜在的质量改进目标。
