Background: Venous thromboembolism is a complication that is commonly seen among critically ill patients admitted at both surgical and medical ICUs. Prophylaxis for deep venous thrombosis (DVT), early recognition and appropriate treatment can save many lives. Recommendations for use of prophylaxis are available. However, there are different practices among different subspecialties in its use and applications. In general, physicians have different approaches to DVT prophylaxis, and usually this is influenced by the subsets of patients seen and encountered in the practice as well as the availability of the medications used for prophylaxis. The use of standard criteria for stratification of patients for VTE prophylaxis use is sometimes under-utilized. Many patients who might benefit from the routine use of these medications are sometimes not properly identified. Thus, this study was conducted to assess the practices and attitudes of physicians on venous thromboembolism (VTE) among critically ill patients admitted at the medical and neurologic ICU.
Methods: This was a multi-centered cohort study involving critically ill patients, 18 years old and above, admitted for a minimum of 4 days at the medical and neurology ICU of PHC, MMC and PGH. Patients who were included were evaluated for their demographic characteristics, use of DVT prophylaxis, type, doses and timing of medication used, indications and/or use of mechanical prophylaxis, and techniques for screening and surveillance of DVT and/or pulmonary embolism. Chart review was done and admitting data were collated to answer a standard DVT "risk assessment questionnaire. Interviewer-administered questionnaires for physicians who managed the patients, regarding their attitudes and practices were also used (including a risk-grading sheet to double check their knowledge of the factors that contribute to DVT). Patients enrolled were followed up for an addition of at least 1 more week (or until discharge from ICU) by the investigators to assess clinically for development of DVT/PE and if necessary to recommend either d-dimer, V/Q Scan or venous duplex ultrasound of the lower extremities.
Results: A total of 106 consecutive patients who were either admitted in the medical or neurologic ICU for at least 4 were studied and followed up for 4 weeks. A total of 27 physician's questionnaire was also distributed to investigate their practices and attitudes. Only 57% of patients received VTE prophylaxis. Out of the 57% who received VTE prophylaxis only 62% (37/60) were deemed appropriate for risk stratification. Around 2.8% developed proven VTE (pulmonary embolism or deep venous thrombosis). Well's score was found to be associated with development of VTE. Seventy four percent believed that the primary indication for using DVT prophylaxis was history of previous DVT/PE. Seventy one percent used prophylaxis only selectively due to fear of bleeding and cost despite seventy percent reporting seeing morbidity due to VTE.
Conclusion: The use of VTE prophylaxis in the said institutions is insufficient and not matched to the level of risk. There is a need to establish a common standardized approach to ensure that patients will receive adequate prophylaxis among medical and neurologic ICU patients.