Nonleg venous thromboses associated with PE, longer ICU stay

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1. Venous thrombosis in the critically ill tended to be incident, proximal, and in the deeper veins of the upper extremities with the majority located in the internal jugular vein.

2. Nonleg DVTs (NLDVTs) were associated with higher risk of pulmonary embolization (PE), longer ICU and hospital stays, but not with overall ICU mortality.

Evidence Rating Level: 1 (Excellent)

Study Rundown:  Prophylaxis against thromboembolic events is recommended in the critically ill patient population. Little is known in the way of risk and predisposing factors for NLDVTs and the association between them and PEs.  Nonleg venous thrombosis in the study tended to be incident, proximal, and deep as opposed to prevalent, distal, and superficial. Consistent with prior findings, cancer was the only independent risk factor for NLDVT in the study. NLDVTs were associated with a higher risk of developing a PE but not death.

The strengths of this study include the large database from which the study results were drawn, and the randomized, blinded, and duplicated assessment of patient data. The study protocol did not actively screen for NLDVTs and only included patients who had signs and symptoms warranting further investigation as determined by intensivists. This design underestimates the actual number of NLDVTs. Given the lack of NLDVT screening for all patients, the association between PE and NLDVT is susceptible to detection bias. Studying NLDVTs in this population is an important endeavor as they occur with some frequency despite adequate thromboprophylaxis but further studies are needed to confirm these findings.

Click to read the study in JAMA Internal Medicine

Relevant Reading: Prophylaxis and treatment of venous thromboembolism in the critically ill.

In-Depth [nested prospective cohort study]: The data for this study was collected as part of the Prophylaxis for Thromboembolism in Critical Care Trial (PROTECT) which was a multicenter (6 countries, 76 ICUs), randomized, blinded, and concealed trail of unfractionated heparin vs. low-molecular weight heparin dalteparin for thromboprophylaxis of 3746 medical-surgical ICU patients. A NLDVT was defined as non-compressible venous segment on venous ultrasonography. PEs were diagnosed with CT angiograms or V/Q scans.

Of 3746 patients, 84 (2.2%) were diagnosed with at least one nonleg venous thrombosis (deep or superficial). Patients were more likely to have incident vs. prevalent (75 vs. 9, P < 0.001), proximal vs. distal (76 vs. 15, P < 0.001), and deep vs. superficial (67 vs. 31, P < 0.8%) thrombosis. 40 patients had catheter associated DVTs. Of the 145 NLDVT segments, 137 were in the upper extremity and the internal jugular vein was the most frequent site (70 of these were classified as catheter-related). Cancer arose as an independent risk factor for NLDVTs in both univariate and multivariate analyses. Patients with NLDVTs were more likely to develop PEs (14.9% & vs. 1/9%, P < 0.001), have longer ICU and hospital stays, but did not have increased mortality.

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