Prophylaxis of Venous Thrombosis in NeurocriticalCare

Authors:

Rizwan Raheem MD,

Junaid Kalia MD

Introduction

• Risk of DVT in at-risk medical patients without anticoagulant prophylaxis is10–15%.

• 10–20% of calf thrombi extend to the proximal veins.

• PE occurs in up to 50% of patients with DVT.

• Central venous catheter-associated thrombosis risk is ~5%.

• Despite a relatively low incidence of VTE in medical patients, most deaths due to PE occur in medical patients.

Methods

• Pharmacological Agents
• Low-molecular-weight heparin:
• Enoxaparin,1 mg/kg subcutaneously once daily
• Dalteparin, 5000 units subcutaneously once daily
• Unfractionated heparin: 5000 units subcutaneously every 8 to 12 hours
• Fondaparinux: 2.5 mg subcutaneously daily

• Mechanical Techniques
• Intermittent pneumatic compressions (IPC).
• Graduated compression stockings (GCS).

Contraindication

• Pharmacological prophylaxis
• Active bleeding or recent bleeding or high risk for bleeding (active PUD)
• Patients with coagulopathy (INR greater than 1.5)
• A planned surgical procedure in the next 6 to 12 hours
• Thrombocytopenia (Less than 50,000, sometimes less than 100,000)
• Bleeding disorders

• Mechanical prophylaxis
• Limb ischemia due to peripheral vascular disease
• Skin breakdown

Specific Uses

• LMWH
• Preferred to use UFH due to ease of administration (once daily versus 2 to 3 times per day)
• Higher level of evidence in prevention in Acute Ischemic Stroke

• UFH
• Preferred in patients with CKD and or on Dialysis

• Mechanical methods [only]
• Used in patients with a high risk of bleeding e.g. liver disorder, bleeding diathesis

• Graduated compression devices
• Used in long-distance travelers with risk factors for VTE
• Properly fitted below-knee graduated compression devices at 15 to 30 mm Hg of pressure along with frequent ambulation and calf muscle exercises.
• Chemical prophylaxis is not indicated simultaneously.

Neurocritical Care Society Guideline Recommendation by Pathology

Ischemic Stroke

• Society recommends initiating VTE pharmacoprophylaxis as soon as is possible in patients with acute ischemic stroke. (Strong recommendation and high-quality evidence)

• In patients with acute ischemic stroke and restricted mobility, we recommend prophylactic-dose LMWH over prophylactic-dose UFH in combination with IPC. (Strong recommendation and high-quality evidence)

• Due to insufficient evidence, the panel could not issue a recommendation regarding the use of Compression Stockings for VTE prophylaxis although their use does not appear to be harmful.

• In stroke patients undergoing hemicraniotomy or endovascular procedures, we suggest the use of UFH, LMWH, and/or IPC for VTE prophylaxis in the immediate postsurgical or endovascular approach, except when patients have received rTPA, in which scenario prophylaxis should be delayed 24 h. (Weak recommendation and low-quality evidence).

Intracranial Hemorrhage

• We recommend the use of IPC and/or GCS for VTE prophylaxis over no prophylaxis at admission. (Strong recommendation and high-quality evidence)

• We suggest using prophylactic doses of subcutaneous UFH or LMWH to prevent VTE in patients with stable hematomas and no ongoing coagulopathy beginning within 48 h of hospital admission. (Weak recommendation and low-quality evidence)

• We suggest continuing mechanical VTE prophylaxis with IPCs in patients started on pharmacologic prophylaxis. (Weak recommendation low-quality evidence

Aneurysmal Subarachnoid Hemorrhage

• Society recommends VTE prophylaxis with UFH in all patients with aSAH (Strong recommendation and high quality evidence) except in those with unsecured ruptured aneurysms expected to undergo surgery. (Strong recommendation and low-quality evidence)

• We recommend initiating IPCs as VTE prophylaxis as soon as patients with aSAH are admitted to the hospital. (Strong recommendation and moderate-quality evidence)

• We recommend VTE prophylaxis with UFH at least 24 h after an aneurysm has been secured by surgical approach or by coiling. (Strong recommendation and moderate-quality evidence.

Traumatic Brain Injury

• We recommend initiating IPC for VTE prophylaxis within 24 h of presentation of TBI or within 24 h after completion of craniotomy as supported by evidence in ischemic stroke and postoperative craniotomy. (Weak recommendation and low-quality evidence)

• We recommend initiating LMWH or UFH for VTE prophylaxis within 24–48 h of presentation in patients with TBI and ICH, or 24 h after craniotomy. (Weak recommendation and low-quality evidence).

• We recommend using mechanical devices such as IPC for VTE prophylaxis in patients with TBI, based on data from other Neurological injuries such as ischemic stroke. (Weak recommendation and low-quality evidence).

Brain Tumors

• We recommend VTE prophylaxis with either LMWH or UFH upon hospitalization for patients with brain tumors with low risk for major bleeding and who lack signs of hemorrhagic conversion. (Strong recommendation and moderate-quality evidence)

Spinal Cord Injury

• We recommend initiating VTE prophylaxis as early as possible, within 72 h of injury. (Strong recommendation and high-quality evidence)

• We recommend against using mechanical measures alone for VTE prophylaxis. (Weak recommendation and low-quality evidence)

• We recommend LMWH or adjusted dose UFH for VTE prophylaxis as soon as bleeding is controlled. (Strong recommendation and moderate-quality evidence)

• If VTE prophylaxis with LMWH or UFH is not possible, we suggest mechanical prophylaxis with IPC. (Weak recommendation and low-quality evidence)

Neuromuscular Disease

• We recommend using prophylactic doses of UFH (bid or tid) LMWH, or fondaparinux as the preferred method . (Strong recommendation and moderate-quality evidence)

• We recommend using IPC for VTE prophylaxis for patients in whom the bleeding risk is high. (Strong recommendation and moderate-quality evidence)

• We suggest combining pharmacologic and mechanical VTE prophylaxis (with IPC) in patients with neuromuscular disease. (Weak recommendation and low quality evidence)

• We suggest using GCS only for VTE prophylaxis in patients in whom pharmacologic prophylaxis or IPC use is contraindicated. (Weak recommendation and low-quality evidence)

• We suggest continuing VTE prophylaxis for an extended period of time, till hospitalization, or until the ability to ambulate returns. (Weak recommendation and very low-quality evidence)

Neurosurgical and Neurovascular Interventions

Elective Spine Surgery

• Ambulatory back surgery with unique positioning strategies such as prone or kneeling has been associated with zero rates of VTE, and we suggest considering the use of IPC only for VTE prophylaxis in this surgical population. (Weak recommendation and low-quality evidence)

• In standard elective spine surgery, we recommend using ambulation with mechanical VTE prophylaxis (GCS or IPC) alone, or combined with LMWH. In patients with increased risk for VTE, we recommend combined therapy with ambulation, GCS or IPC, and LMWH. (Strong recommendation and moderate-quality evidence).

• Because of the increased risk of bleeding, we recommend using UFH only as an alternative. (Strong recommendation and moderate-quality evidence)

Complicated Spinal Surgery

• We recommend using IPC with LMWH or UFH. (Strong recommendation and moderate-quality evidence)

• We recommend against the routine use of IVC filters in the setting of severe spinal cord injury or complicated spine surgery. (Weak recommendation and low-quality evidence)

• We suggest considering a removable prophylactic IVC filter as a temporary measure only in patients with PE and DVT or those with DVT at risk for PE who cannot be anticoagulated. (Weak recommendation and low quality evidence).

Elective Craniotomy

• We recommend using IPC with either LMWH or UFH within 24 h after craniotomy. (Strong recommendation and moderate-quality evidence)

• We recommend the use of IPC with LMWH or UFH within 24 h after standard craniotomy in the setting of glioma resection. (Strong recommendation and moderate-quality evidence)

Elective Intracranial/Intra-arterial Procedures

• Society suggests the use of CS and IPC until the patient is ambulatory. (Weak recommendation and low-quality evidence)

• We suggest immediate prophylactic anticoagulation with LWMH or UFH. (Weak recommendation and low-quality evidence)

Table 1: Timing of Chemical Prophylaxis

Further Readings

• Nyquist, P., Bautista, C., Jichici, D. et al. Prophylaxis of Venous Thrombosis in Neurocritical Care Patients: An Evidence-Based Guideline: A Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocrit Care 24, 47–60 (2016). https://doi.org/10.1007/s12028-015-0221-y

• Badireddy M, Mudipalli VR. Deep Venous Thrombosis Prophylaxis. [Updated 2021 Apr 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534865/

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