Venous Thromboembolism Prophylaxis in Neurocritical Care Patients: Are Current Practices, Best Practices?

• Published in: Neurocritical care 2019-04, Vol.30 (2), p.355-363
• Main Authors: Sauro, K. M., Soo, A., Kramer, A., Couillard, P., Kromm, J., Zygun, D., Niven, D. J., Bagshaw, S. M., Stelfox, H. T.
• Format: Article
• Language: English
• Subjects: Adult; Aged; Alberta; Algorithms; Brain research; Clinical Audit; Clinical outcomes; Codes; Comorbidity; Compression therapy; Contraindications; Critical Care - methods; Critical Care - standards; Critical Care - statistics & numerical data; Critical Care Medicine; Disease prevention; Evidence-Based Medicine; Female; Guideline Adherence - standards; Guideline Adherence - statistics & numerical data; Hemoglobin; Hospitals; Humans; Intensive; Intensive care; Internal Medicine; Ischemia; Male; Medicine; Medicine & Public Health; Middle Aged; Mortality; Neurology; Original Article; Patients; Population; Practice Guidelines as Topic - standards; Retrospective Studies; Thoracic surgery; Thromboembolism; Thrombosis; Trauma; Traumatic brain injury; Variables; Venous Thromboembolism - therapy
• ISSN: 1541-6933; 1556-0961
• DOI: 10.1007/s12028-018-0614-9

Background/Objectives Venous thromboembolism (VTE) is a leading cause of preventable, in-hospital deaths; critically ill patients have a higher risk. Effective and efficient strategies to prevent VTE exist; however, neurocritical care patients present unique challenges due to competing risk of bleeding. The objective of this study was to examine current VTE prophylaxis practices among neurocritical care patients, concordance with guideline-recommended care, and the association with clinical outcomes. Methods This retrospective cohort study of patients admitted to ten adult, medical–surgical and neurological intensive care units (ICUs) in nine hospitals between 2014 and 2017 using administrative and clinical data. Neurocritical care patients were classified based on the primary admission diagnosis. Concordance with guideline-recommended care was evaluated using recommendations from recent guidelines. Results 20.0% of 23,191 patients were classified as neurocritical care. Among neurocritical care patients, pharmacological VTE prophylaxis was administered on 60.9% of all ICU days, mechanical VTE prophylaxis on 46.9%, and no VTE prophylaxis on 12.2% of all ICU days. Type of VTE prophylaxis was associated with sex, neurological diagnosis, and invasive neurological monitoring. Fifty-six percentage of ICU days were guideline concordant but concordance varied by recommendation (range 6–100%) and by type of VTE prophylaxis recommended ( p  = 0.05); among patients where guidelines recommended use of pharmacologic prophylaxis, care was concordant 26.6% of ICU days, whereas for mechanical prophylaxis it was concordant 80.5% of ICU days. There was an overall improvement in guideline concordance on 2.3% of ICU days after the publication of the Society of Neurocritical Care guideline ( p  = 0.005). Conclusions Neurocritical care patients commonly receive mechanical VTE prophylaxis despite guidelines recommending the use of pharmacological VTE prophylaxis. Our findings suggest uncertainty around best VTE prophylaxis practices for neurocritical care patients remains.