Chest

Chest

Volume 146, Issue 1, July 2014, Pages 51-57
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Original Research
Critical Care
Thrombosis Prophylaxis and Mortality Risk Among Critically Ill Adults

https://doi.org/10.1378/chest.13-2160Get rights and content

BACKGROUND

The optimal approach for managing increased risk of VTE among critically ill adults is unknown.

METHODS

An observational study of 294,896 episodes of critical illness among adults was conducted in 271 geographically dispersed US adult ICUs. The primary outcomes were all-cause ICU and in-hospital mortality after adjustment for acuity and other factors among groups of patients assigned, based on clinical judgment, to prophylactic anticoagulation, mechanical devices, both, or neither. Outcomes of those managed with prophylactic anticoagulation or mechanical devices were compared in a separate paired, propensity-matched cohort.

RESULTS

After adjustment for propensity to receive VTE prophylaxis, APACHE (Acute Physiology and Chronic Health Evaluation) IV scores, and management with mechanical ventilation, the group treated with prophylactic anticoagulation was the only one with significantly lower risk of dying than those not provided VTE prophylaxis (ICU, 0.81 [95% CI, 0.79-0.84]; hospital, 0.84 [95% CI, 0.82-0.86; P < .0001). The mortality risk of those receiving mechanical device prophylaxis was not lower than that of patients without VTE prophylaxis. A study of 87,107 pairs of patients matched for propensity to receive VTE prophylaxis found that those managed with prophylactic anticoagulation therapy had significantly lower risk of death (ICU subhazard ratio, 0.82 [95% CI, 0.78-0.85]; hospital subhazard ratio, 0.82 [95% CI, 0.79-0.85]; P < .001) than those receiving only mechanical device prophylaxis.

CONCLUSIONS

These findings support a recommendation for prophylactic anticoagulation therapy in preference to mechanical device prophylaxis for critically ill adult patients who do not have a contraindication to anticoagulation.

Section snippets

Materials and Methods

The primary outcomes of this cohort study were adjusted ICU and hospital mortality among groups of critically ill adults managed with prophylactic anticoagulation therapy, thromboprophylaxis with a mechanical device, both, or neither, as assigned by clinical judgment. The study included all adult patients discharged alive or dead from participating ICUs from January 1, 2008, to September 30, 2010. Data were derived from patient information contained in the Philips eICU Research Institute data

Patient Characteristics

This study included records from 294,896 hospital discharge events from 5,321 adult ICU beds in 271 ICUs located in 188 hospitals and 32 health-care systems from 31 states. Patients who failed to meet age, date, or validity criteria or were not at risk for VTE were excluded from the study (Fig 1). Patient demographic characteristics by VTE prophylaxis group are presented in Table 1. Almost all patients (93%) were treated with some form of VTE prophylaxis; a combination of prophylactic

Discussion

The main finding of this large observational study is that adult patients in the ICU who are managed with prophylactic anticoagulation have lower adjusted mortality than those managed with mechanical devices or not provided thrombosis prophylaxis. The risks of ICU and in-hospital mortality in patients managed without VTE prophylaxis were lower than in those managed with VTE prophylaxis based on analyses that did not adjust for differences in acuity (Table 2). Analyses that adjusted for acuity,

Acknowledgments

Author contributions: C. M. L. had full access to the data and takes responsibility for its integrity and the accuracy of the analyses. C. M. L., O. B., and I. H. Z. contributed to the study concept; C. M. L., X. L., O. B., C. S. F., and I. H. Z. contributed to the study design; C. M. L. and O. B. contributed to data acquisition; C. M. L., X. L., O. B., C. S. F., and I. H. Z. contributed to data interpretation; X. L., O. B., C. S. F., and I. H. Z. contributed to data analysis; X. L. and C. S.

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FUNDING/SUPPORT: The database and support for analyses performed by Drs Liu and Zuckerman and Ms Franey were provided by the eICU Research Institute.

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