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Neurocritical Care
Published in: Neurocritical Care 2/2010

01-04-2010 | Review

Prophylaxis for Venous Thrombo-Embolism in Neurocritical Care: A Critical Appraisal

Authors: Ahmed M. Raslan, Jeremy D. Fields, Anish Bhardwaj

Published in: Neurocritical Care | Issue 2/2010

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Abstract

Venous thrombo-embolism (VTE) is frequently encountered in critically ill neurological and neurosurgical patients admitted to intensive care units. This patient population includes those with brain neoplasm, intracranial hemorrhage, ischemic stroke, subarachnoid hemorrhage, pre- and post-operative patients undergoing neurosurgical procedures and those with traumatic brain injury, and acute spinal cord injury (SCI). There is a wide variability in clinical practice for thromboprophylaxis in these patients, in part due to paucity of data based on randomized clinical trials. Here, we review the current literature on the incidence of VTE in the critically ill neurological and neurosurgical patients as well as appraise available data to support particular practice paradigms for specific subsets of these patients. Data synthesis was conducted via search of Medline, Cochrane databases, and manual review of article bibliographies. Critically ill neurological and neurosurgical patients have higher susceptibility to VTE. Intermittent compression devices with or without anti-thrombotics is generally the method of choice for thromboprophylaxis. Low molecular weight heparin is the method of choice in certain patient subgroups such as those with SCI and ischemic stroke. Inferior vena cava filters may play a role in thromboprophylaxis in selected cases. Without clear guidelines that can be universally applied to this diverse group of patients, prophylaxis for VTE should be tailored to the individual patient with cautious assessment of benefits versus risks. There is a need for higher level evidence to guide VTE prophylaxis in certain subgroups of this patient population.
Literature
1.
Kearon C, Ginsberg J, Hirsh J. The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolisn. Ann Intern Med. 1998;129:1044–9.PubMed
2.
Wells P, Lensing A, Davidson B, et al. Accuracy of ultrasound for the diagnosis of deep venous thrombosis in asymptomatic patients after orthopedic surgery: a meta-analysis. Ann Intern Med. 1995;122:47–53.PubMed
3.
Pierce C, Haut E, Kardooni S, et al. Surveillance bias and deep venous thrombosis in the national trauma data bank: the more we look, the more we find. J Trauma. 2008;64:932–7.CrossRefPubMed
4.
Piotrowski JJ, Alexander JJ, Brandt CP, McHenry CR, Yuhas JP, Jacobs D. Is deep vein thrombosis surveillance warranted in high risk trauma patients? Am J Surg. 1996;172:210–3.CrossRefPubMed
5.
Velmahos GC, Nigro J, Tatevossian R, et al. Inability of an aggressive policy of thromboprophylaxsis to prevent deep vein thrombosis (DVT) in critically injured patients: are current methods of DVT prophylaxis insufficient? J Am Coll Surg. 1998;187:529–33.CrossRefPubMed
6.
Cipolle MD, Wojcik R, Seislove E, Wasser TE, Pasquale MD. The role of surveillance duplex scanning in preventing venous thromboembolism in trauma patients. J Trauma. 2002;52:453–62.CrossRefPubMed
7.
Misra M, Roitberg B, Ebersole K, Charbel F. Prevention of pulmonary embolism by combined modalities of thromboprophylaxis and intensive surveillance protocol. Neurosurgery. 2004;54:1099–102.PubMed
8.
Geerts W, Heit J, Clagett P, et al. Prevention of venous thromboembolism. Chest. 2001;119:132S–75S.CrossRefPubMed
9.
Hirsh J, Dalen J, Anderson D, et al. Oral anticoagulants: mechanism of action, clinical effectiveness, and optimal therapeutic range. Chest. 2001;119:8S–21S.CrossRefPubMed
10.
Hirsh J, Warkentin T, Shauhnessy S, et al. Heparin and low-molecular-weight heparin mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy and safety. Chest. 2001;119:64S–94S.CrossRefPubMed
11.
12.
Fleming T. Red book: pharmacy’s fundamental reference (Red Book Drug Topics), 111 ed. Montvale, NJ: Thomson Healthcare; 2007.
13.
14.
Crowther MA, Cook DJ. Thrombophrophylaxis in medical-surgical critically ill patients. Curr Opin Crit Care. 2008;14:520–3.CrossRefPubMed
15.
Limpus A, Chaboyer W, McDonald E, et al. Mechanical thrombophrophylaxis in critically ill patients: a systematic review and meta-analysis. Am J Crit Care. 2006;15:402–10.PubMed
16.
Agnelli G, Piovella F, Buincristiani P, et al. Enoxaparin plus compression stockings compared with compression stockings alone in the prevention of venous thromboembolism after elective neurosurgery. N Engl J Med. 1998;339:80–5.CrossRefPubMed
17.
Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004;126:338S–400S.CrossRefPubMed
18.
Greets WH, Bergvist D, Pineo GF, et al. Prevention of venous thromboembolism. American College of Chest Physicians Evidence Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133:381S–453S.CrossRef
19.
Committee for Standards in Hematology: Writing Group: Baglin TP, Brush J, Streiff M. Guidelines on use of vena cava filters. Br J Haematol. 2006; 134: 590–5.
20.
McMurtry AL, et al. Increased use of prophylactic vena cava filters in trauma patients failed to decrease overall incidence of PE. J Am Coll Surg. 1995;189(3):314–20.CrossRef
21.
Karmy-Jones R, Jurkovich GJ, Velmahos GC, et al. Practice patterns and outcomes of retrievable vena cava filters in trauma patients: an AAST multi-center study. J Trauma. 2007;62:17–24.CrossRefPubMed
22.
Marras LC, Greets WH, Perry JR. The risk of venous thromboembolism is increased throughout the course of malignant glioma. Cancer. 2000;89:640–6.CrossRefPubMed
23.
Chiocca EA, Schwartzbaum JA. Gliomas and venous thromboembolism: how common? Editor J Neurosurg. 2007;106:599–600.CrossRef
24.
Brandes AA, Scelzi E, Salmistraro E, et al. Incidence and risk of thromboembolism during treatment of high-grade gliomas: a prospective study. Eur J Cancer. 1997;33:1592–6.CrossRefPubMed
25.
Semrad TJ, O’Donnell R, Wun T, et al. Epidemiology of venous thromboembolism in 9489 patients with malignant glioma. J Neurosurg. 2007;106:601–8.CrossRefPubMed
26.
Turpie AG, Hirsh J, Gent M, et al. Prevention of deep vein thrombosis in potential neurosurgical patients. A randomized trial comparing graduated compression stockings alone or graduated compression stockings plus intermittent pneumatic compression with control. Arch Intern Med. 1989;149:679–81.CrossRefPubMed
27.
Bucci MN, Papadopoulos SM, Chen JC, et al. Mechanical prophylaxis of venous thrombosis in patients undergoing craniotomy: a randomized trial. Surg Neurol. 1989;32:285–8.CrossRefPubMed
28.
Wautrecht JC, Macquaire V, Vandesteene A, et al. Prevention of deep vein thrombosis in neurosurgical patients with brain tumors: a controlled, randomized study comparing graded compression stockings alone and with intermittent sequential compression. Correlation with pre- and postoperative fibrinolysis. Preliminary results. Int Angiol. 1996;15(3 Suppl 1):5–10.
29.
Dickinson L, Miller L, Patel C, et al. Enoxaparin increases the incidence of postoperative intracranial hemorrhage when initiated preoperatively for deep venous thrombosis prophylaxis in patients with brain tumors. Neurosurgery. 1998;43:1074–9.CrossRefPubMed
30.
Carmen T, Kanner A, Barnett G, et al. Prevention of thromboembolism after neurosurgery for brain and spinal tumors. South Med J. 2003;96:17–22.CrossRef
31.
Iorio A, Agnelli G. Low-molecular-weight and unfractionated heparin for prevention of venous thromboembolism in neurosurgery: a meta-analysis. Arch Intern Med. 2000;160:2327–32.CrossRefPubMed
32.
Constantini S, Kornowski R, Pomeranz S, et al. Thromboembolic phenomena in neurosurgical patients operated upon for primary and metastatic brain tumors. Acta Neurochir (Wien). 1991;109(3–4):93–7.CrossRef
33.
Goldhaber S, Dunn K, Gerhard-Herman M, et al. Low rate of venous thromboembolism after craniotomy for brain tumor using multimodality prophylaxis. Chest. 2002;122:1933–7.CrossRefPubMed
35.
McCarthy ST, Turner J. Low-dose subcutaneous heparin in the prevention of deep-vein thrombosis and pulmonary emboli following acute stroke. Age Ageing. 1986;15:84–8.CrossRefPubMed
36.
McCarthy ST, Turner JJ, Robertson D, et al. Low-dose heparin as a prophylaxis against deep-vein thrombosis after acute stroke. Lancet. 1977;310:800–901.CrossRef
37.
Kelly J, Rudd A, Lewis R, et al. Venous thromboembolism after acute stroke. Stroke. 2001;32:262–7.PubMed
38.
Prasad BK, Banerjee AK, Howard H. Incidence of deep vein thrombosis and the effect of pneumatic compression of the calf in elderly hemiplegics. Age Ageing. 1982;11:42–4.CrossRefPubMed
39.
Muir KW, Watt A, Baxter G, et al. Randomized trial of graded compression stockings for prevention of deep-vein thrombosis after acute stroke. Q J Med. 2000;93:359–64.
41.
The CLOTS Trials Collaboration. Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep venous thrombosis after stroke (CLOTS trial 1): a multicentre, randomized controlled trial. Lancet. 2009;373:1958–65.CrossRef
42.
Gubitz G, Sandercock P, Counsell C. Anticoagulants for acute ischaemic stroke. Cochrane Database Syst Rev. 2004;3:CD000024.
43.
Hillbom M, Erila T, Sotaniemi K, et al. Enoxaparin vs. heparin for prevention of deep-vein thrombosis in acute ischemic stroke: a randomized, double-blind study. Acta Neurol Scand. 2002;106:84–92.CrossRefPubMed
44.
Diener HC, Ringelstein E, Kummer RV, et al. Prophylaxis of thrombotic and embolic events in acute ischemic stroke with low-molecular weight heparin certoparin. Results of the PROTECT trial. Stroke. 2006;37:139–44.CrossRefPubMed
45.
Sherman D, Albers G, Bladin C, et al. The efficacy and safety of enoxaparin versus unfractionated heparin for the prevention of venous thromboembolism after acute ischemic stroke (PREVAIL Study): an open label randomized comparison. Lancet. 2007;369:1347–55.CrossRefPubMed
46.
Gould MK, Dembitzer AD, Doyle RL, et al. Low molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis: a meta-analysis of randomized, controlled trials. Ann Intern Med. 1999;130:800–9.PubMed
47.
Adams H, Adams R, Brott T, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the stroke council of the American stroke association. Stroke. 2003;34:1056–83.CrossRefPubMed
48.
Adams HP, et al. AHA/ASA guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655–711.CrossRefPubMed
49.
Albers GW, Amarenco P, Easton JD, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):630S–69S.CrossRefPubMed
50.
Gregory PC, Kuhlemeier KV. Prevalence of venous thromboembolism in acute hemorrhagic and thromboembolic stroke. Am J Phys Med Rehabil. 2003;82:384–9.CrossRef
51.
Skaf E, Stein P, Beemath A, et al. Venous thromboembolism in patients with ischemic and hemorrhagic stroke. Am J Card. 2005;96:1731–3.CrossRefPubMed
52.
Goldstein JN, Fazen LE, Wendell L, et al. Risk of thromboembolism following acute intracerebral hemorrhage. Neurocrit Care. 2009;10:28–34.CrossRefPubMed
53.
Lacut K, Bressollette L, Le Gal G, et al. Prevention of venous thrombosis in patients with acute intracereberal hemorrhage. Neurology. 2005;65:865–9.CrossRefPubMed
54.
Tetri S, Hakala J, Juvela S, et al. Safety of low-dose subcutaneous enoxaparin for the prevention of venous thromboembolism after primary intracerebral haemorrhage. Thromb Res. 2008;123(2):206–12.CrossRefPubMed
55.
Boeer A, Voth E, Henze T, et al. Early heparin therapy in patients with spontaneous intracerebral haemorrhage. J Neurol Neurosurg Psychiatry. 1991;54:466–7.CrossRefPubMed
56.
Dickmann U, Voth E, Schicha H, et al. Heparin therapy, deep-vein thrombosis and pulmonary embolism after intracerebral hemorrhage. Klin Wochenschr. 1988;66:1182–3.CrossRefPubMed
57.
Broderick J, Connolly S, Feldmann E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007;38:2001–23.CrossRefPubMed
58.
Bertram M, Bonsanto M, Hacke W, et al. Managing the therapeutic dilemma: patients with spontaneous intracerebral hemorrhage and urgent need for anticoagulation. J Neurol. 2000;247:209–14.CrossRefPubMed
59.
Streiff MB. Vena caval filters: a comprehensive review. Blood. 2000;95:3669–77.PubMed
60.
Sironen J, Juvela S, Varis J, et al. No effect of enoxaparin on outcome of aneurysmal subarachnoid hemorrhage: a randomized, double-blind, placebo-controlled clinical trial. J Neurosurg. 2003;99:953–9.CrossRef
61.
Collen JF, Jackson JL, Shorr AF, Moores LK. Prevention of venous thromboembolism in neurosurgery: a metaanalysis. Chest. 2008;134:237–49.CrossRefPubMed
62.
Browd SR, Ragel BT, Davis GE, et al. Prophylaxis for deep venous thrombosis in neurosurgery: a review of the literature. Neurosurg Focus. 2004;17(4):E1.CrossRefPubMed
63.
Danish S, Burnett M, Ong J, et al. Prophylaxis for deep venous thrombosis in craniotomy patients: a decision analysis. Neurosurgery. 2005;56:1286–94.CrossRefPubMed
64.
Jacobs DG, Piotrowski JJ, Hoppensteadt DA, et al. Hemodynamicand fibrinolytic consequences of intermittent pneumaticcompression: preliminary results. J Trauma. 1996;40:710–7.CrossRefPubMed
65.
Ting A, Cheng S, Cheung G, et al. Perioperative deep vein thrombosis in Chinese patients undergoing craniotomy. Surg Neurol. 2002;58:274–9.CrossRefPubMed
66.
Stephens PH, Healy MT, Smith M, et al. Prophylaxis against thromboembolism in neurosurgical patients: a survey of current practice in the United Kingdom. Br J Neurosurg. 1995;9:159–63.CrossRefPubMed
67.
Nurmohamed MT, van Riel AM, Henkens CM, et al. Low molecular weight heparin and compression stockings in the prevention of venous thromboembolism in neurosurgery. Thromb Haemost. 1996;75:233–8.PubMed
68.
Kurtoglu M, Yanar H, Bilsel Y, et al. Venous thromboembolism prophylaxis after head and spinal trauma: intermittent pneumatic compression devices versus low molecular weight heparin. World J Surg. 2004;28:807–11.CrossRefPubMed
69.
Cerrato D, Ariano C, Fiacchino F. Deep vein thrombosis and low-dose heparin prophylaxis in neurosurgical patients. J Neurosurg. 1978;49:378–81.CrossRefPubMed
70.
Goldhaber SZ, Dunn K, Gerhard-Herman M, et al. Low rate of venous thromboembolism after craniotomy for brain tumor using multimodality prophylaxis. Chest. 2002;122(6):1933–7.CrossRefPubMed
71.
Macdonald RL, Amidei C, Baron J, et al. Randomized, pilot study of intermittent pneumatic compression devices plus dalteparin versus intermittent pneumatic compression devices plus heparin for prevention of venous thromboembolism in patients undergoing craniotomy. Surg Neurol. 2003;59:363–72. discussion 372-4.CrossRefPubMed
72.
Prestar FJ. Prevention of thromboembolism complications with low molecular weight heparin in microneurosurgical lumbar intervertebral disk operations. Neurochirurgia (Stuttg). 1992;35:1–4.
73.
Voth D, Schwarz M, Hahn K, et al. Prevention of deep vein thrombosis in neurosurgical patients: a prospective double-blind comparison of two prophylactic regimen. Neurosurg Rev. 1992;15:289–94.PubMed
74.
Knudson MM, Ikossi DG, Khaw L, et al. Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank. Ann Surg. 2004;240:490–6. discussion 496–8.CrossRefPubMed
75.
Knudson MM, Lewis FR, Clinton A, et al. Prevention of venous thromboembolism in trauma patients. J Trauma. 1994;37:480–7.CrossRefPubMed
76.
Geerts WH, Jay RM, Code KI, et al. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med. 1996;335:701–7.CrossRefPubMed
77.
Attia J, Ray JG, Cook DJ, et al. Deep vein thrombosis and its prevention in critically ill adults. Arch Intern Med. 2001;161:1268–79.CrossRefPubMed
78.
Gerlach R, Scheuer T, Beck J, et al. Risk of postoperative hemorrhage after intracranial surgery after early nadroparin administration: results of a prospective study. Neurosurgery. 2003;53:1028–34. discussion 1034–5.CrossRefPubMed
79.
Kleindienst A, Harvey H, Mater E, et al. Early antithrombotic prophylaxis with low molecular weight heparin in neurosurgery. Acta Neurochir (Wien). 2003;145:1085–91.CrossRef
80.
Norwood SH, McAuley CE, Berne JD, et al. Prospective evaluation of the safety of enoxaparin prophylaxis for venous thromboembolism in patients with intracranial hemorrhagic injuries. Arch Surg. 2002;137:696–701. discussion 701–2.CrossRefPubMed
81.
Kim J, Gearhart MM, Zurick A, et al. Preliminary report on the safety of heparin for deep venous thrombosis prophylaxis after severe head injury. J Trauma. 2002;53:38–42.CrossRefPubMed
82.
Cothren CC, Smith WR, Moore EE, Morgan SJ. Utility of once-daily dose of low-molecular-weight heparin to prevent venous thromboembolism in multisystem trauma patients. World J Surg. 2007;31:98–104.CrossRefPubMed
83.
Vergouwen MD, Roos YB, Kamphuisen PW. Venous thromboembolism prophylaxis and treatment in patients with acute stroke and traumatic brain injury. Curr Opin Crit Care. 2008;14:149–55.CrossRefPubMed
84.
Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. V. Deep vein thrombosis prophylaxis. J Neurotrauma. 2007;24 Suppl 1:S32–6.
85.
Yao JST. Deep vein thrombosis in spinal cord-injured patients: evaluation and assessment. Chest. 1992;102(suppl):645S–8S.CrossRefPubMed
86.
Geerts WH, Code KI, Jay RM, et al. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;331:1601–6.CrossRefPubMed
87.
Gunduz S, Ogur E, Mohur H, et al. Deep vein thrombosis in spinal cord injured patients. Paraplegia. 1993;31:606–10.PubMed
88.
Waring WP, Karunas RS. Acute spinal cord injuries and the incidence of clinically occurring thromboembolic. Paraplegia. 1991;29:8–16.PubMed
89.
Kim SW, Charalles JT, Park KW, et al. Prevalence of deep vein thrombosis in patients with chronic spinal cord injury. Arch Physical Med Rehabil. 1994;75:965–8.
90.
Jones T, Ugalde V, Franks P, et al. Venous thromboembolism after spinal cord injury: incidence, time course, and associated risk factors in 16,240 adults and children. Arch Phys Med Rehabil. 2005;86:2240–7.CrossRefPubMed
91.
Spinal Cord Medicine Consortium. Clinical practice guidelines. J Spinal Cord Med. 1998;21:248–93.
92.
Wade W, Chisholm M. Venous thrombosis after acute spinal cord injury. Am J Phys Med Rehabil. 2000;97:504–8.CrossRef
93.
Deep K, Jigajinni MV, McLean A, Fraser M. Prophylaxis of thromboembolism in spinal injuries-results of enoxaparin used in 276 patients. Spinal Cord. 2001;39:88–91.CrossRefPubMed
94.
Thumikat P, Poonnoose P, Balasubrahmaniam P, et al. A comparison of heparin/warfarin and enoxaparin thromboprophylaxis in spinal cord injury: the Sheffield experience. Spinal Cord. 2002;40:416–20.CrossRef
95.
Slavik R, Chan E, Gorman S, et al. Dalteparin versus enoxaparin for venous thromboembolism prophylaxis in acute spinal cord injury and major orthopedic trauma patients: ‘DETECT’ trial. J Trauma. 2007;62:1075–81.CrossRefPubMed
96.
Maxwell RA, Chavarria-Aguilar M, Cockerham WT, et al. Routine prophylactic vena cava filtration is not indicated after acute spinal cord injury. J Trauma. 2002;52:902–6.CrossRefPubMed
Metadata
Title
Prophylaxis for Venous Thrombo-Embolism in Neurocritical Care: A Critical Appraisal
Authors
Ahmed M. Raslan
Jeremy D. Fields
Anish Bhardwaj
Publication date
01-04-2010
Publisher
Humana Press Inc
Published in
Neurocritical Care / Issue 2/2010
Print ISSN: 1541-6933
Electronic ISSN: 1556-0961
DOI
https://doi.org/10.1007/s12028-009-9316-7

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