Boddi Maria, Peris Adriano
Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
Trauma Emergency ICU, ECMO Referral Center, Careggi Teaching Hospital, Florence, Italy.
Adv Exp Med Biol. 2017;906:167-181. doi: 10.1007/5584_2016_114.
Venous thromboembolism (VTE) which includes deep vein thrombosis (DVT) and pulmonary embolism (PE) is a severe complication in critically ill patients generally affected by multiorgan disfunction associated with immobilization also prolonged.Nowadays, VTE prophylaxis is included in the requirements of hospital accreditation and evaluation of the maintenance of standards of quality of care. ICU patients are characterized by a dynamic day-to-day variation both of thromboembolic that bleeding risk and DVT incidence in presence of thromboprophylaxis ranges between 5 and 15 %.Patient-centered methods for the assessment of both thrombotic and bleeding risk are recommended because pre-existent factors to ICU admission, diagnosis, emerging syndromes, invasive procedures and pharmacological treatments daily induce important changes in clinical condition.General consensus currently establishes use of heparin in pharmacological prophylaxis at the time of admission to the ICU and the temporary suspension of heparin in patients with active bleeding or severe (<50,000/cc) thrombocytopenia. Individualized thromboprophylaxis regimens were proposed but there is still no consensus based on evidence.DVT diagnosis is not clinical but imaging-based and in each ICU data on DVT incidence (DVT diagnosed 72 h after ICU admission) should be obtained by weekly ultrasound screening standardized for the anatomical sites of compression used, taking into account the persistence of DVT-risk throughout ICU stay. A role for mechanical thromboprophylaxis by elastic stockings or pneumatic compression was reported but no general consensus was reached about its use at the best. Much work has to be done but ICU remain the last frontier for VTE prophylaxis.
静脉血栓栓塞症（VTE）包括深静脉血栓形成（DVT）和肺栓塞（PE），是危重症患者的一种严重并发症，这类患者通常会受到与长期制动相关的多器官功能障碍影响。如今，VTE预防已纳入医院评审要求以及护理质量标准维持情况的评估之中。ICU患者的特点是，血栓栓塞和出血风险以及在进行血栓预防情况下DVT发生率每天都有动态变化，范围在5%至15%之间。建议采用以患者为中心的方法来评估血栓形成和出血风险，因为入住ICU前存在的因素、诊断、新出现的综合征、侵入性操作和药物治疗每天都会使临床状况发生重大变化。目前普遍的共识是，在入住ICU时采用肝素进行药物预防，对于有活动性出血或严重血小板减少（<50,000/cc）的患者应暂时停用肝素。虽然有人提出了个体化的血栓预防方案，但基于证据的共识仍未达成。DVT的诊断并非基于临床，而是基于影像学，在每个ICU中，关于DVT发生率（入住ICU 72小时后诊断出的DVT）的数据应通过对用于压迫的解剖部位进行标准化的每周超声筛查来获取，同时要考虑到在整个ICU住院期间DVT风险的持续性。有报道称弹性袜或气动压迫在机械性血栓预防中发挥了作用，但对于其最佳使用方式尚未达成普遍共识。仍有许多工作要做，但ICU仍是VTE预防的最后一道防线。
