Thromboprophylaxis patterns and determinants in critically ill patients: a multicenter audit

Area of Science:

• Critical Care Medicine
• Pharmacology
• Evidence-Based Medicine

Background:

• Heparin is a standard for preventing venous thromboembolism in critically ill patients.
• Low molecular weight heparin (LMWH) may offer advantages over unfractionated heparin (UFH) in reducing pulmonary embolism and heparin-induced thrombocytopenia risks without increasing bleeding.
• Assessing guideline adherence and LMWH utilization is crucial for optimizing patient care.

Purpose of the Study:

• To evaluate guideline concordance for thromboprophylaxis in North American intensive care units (ICUs).
• To identify predictors of thromboprophylaxis guideline adherence.
• To analyze factors influencing the use of low molecular weight heparin (LMWH) versus unfractionated heparin (UFH).

Main Methods:

• A retrospective audit of 1,935 medical-surgical patients across 28 North American ICUs in November 2011.
• Calculation of guideline concordance based on days with appropriate or inappropriate omission/administration of thromboprophylaxis.
• Multilevel logistic regression analysis to identify predictors of concordance and LMWH use, incorporating patient and center-level covariates.

Main Results:

• Guideline concordance for thromboprophylaxis was high at 95.5% patient-days.
• Concordance was associated with higher illness severity (APACHE II score), higher BMI, cancer, prior venous thromboembolism, and mechanical ventilation.
• Low molecular weight heparin (LMWH) was underutilized, especially in sicker patients, surgical patients, and those on vasoactive drugs or renal replacement therapy.

Conclusions:

• High guideline concordance for thromboprophylaxis in ICUs was observed.
• Low molecular weight heparin (LMWH) was less frequently used than recommended, particularly in high-risk patient subgroups.
• Optimizing LMWH use in critically ill patients represents a significant quality improvement target.