Introduction

The threat of pulmonary embolism (PE) is a daily concern for patients in the intensive care unit (ICU), who typically have one or more risk factors for venous thromboembolism (VTE), the precursor of pulmonary embolism.

Risk factors for VTE

See Table 24.1 .

Prevalence of VTE

See Fig. 24.1 .

Prevalence of Venous Thromboembolism (VTE) in Hospitalized Patients. *

In the past 3 months.

From Spencer FA, Emery C, Lessard D, et al. The Worcester Venous Thromboembolism Study: a population-based study of the clinical epidemiology of venous thromboembolism. J Gen Intern Med. 2006;21:722–727.

Thromboprophylaxis

• •
  

  Thromboprophylaxis for specific conditions ( Table 24.2 )

  
  
  
  

  Table 24.2

  
  

  Thromboprophylaxis for Specific Conditions

  
  

  Data from Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients. Chest . 2012;141(2 suppl):e278S–e325S; and Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients. Chest . 2012;141(2 suppl):e227S–e277S.

  
  

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  CONDITIONS	REGIMENS (ANY DRUG OR MECHANICAL DEVICE)
  	UFH	LMWH	FONDAPARINUX	ASA	APIXABAN	DABIGATRAN	RIVAROXABAN	WARFARIN	IPC
  Acute medical illness	+	+	+
  General and abdominal-pelvic surgery Low risk Moderate risk High risk	+ +	+ +	+ a	+ a					+ + + b
  Abdominal-pelvic surgery for cancer		+
  Thoracic Surgery Moderate risk High risk	+ +	+ +							+ + b
  Cardiac surgery with complications	+	+							+ b
  Craniotomy									+
  Spinal surgery	+	+							+
  Hip or knee surgery	+ c	+	+ c	+ c	+ c	+ c	+ c	+ c	+ c
  Major orthopedic surgery					+	+	+ d	+ d	+ e
  Major trauma	+	+							+
  Head or spinal cord injury	+	+							+ b
  Any of the above + active bleeding or high risk of bleeding									+

   

  
  

  ASA , Aspirin; IPC , Intermittent pneumatic compression; LMWH , Low-molecular-weight heparin; UFH , Unfractionated heparin

  
  

  a If contraindicated to UFH or LMWH

  
  

  b Combined with UFH or LMWH

  
  

  c Alternative ( LMWH , Preferred)

  
  

  d Second-line agent

  
  

  e Combined with apixaban or dabigatran

  
  
  
  
• •
  

  Pharmacotherapy according to specific conditions ( Table 24.3 )

  
  
  
  

  Table 24.3

  
  

  Pharmacotherapy for Thromboprophylaxis According to Specific Conditions ^a

  
  

  From Guyatt GH, Akl EA, Crowther M, et al. Executive summary antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest . 2012;141(2 suppl):7S–47S.

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  ANTICOAGULANT	USUAL DOSE	DOSE ADJUSTMENT	COMMENTS
  Unfractionated Heparin
  UFH	5000 units SubQ q8–12h	BMI ≥50: 7000 units q8h	LWMH has a lower risk of HIT compared to UFH LMWH is equivalent to UFH for most conditions in ICU except for orthopedic procedures involving the hip and knee (LMWH is superior to UFH) First dose of LMWH should not be given <12 h after surgery
  Low-Molecular-Weight Heparins
  Enoxaparin	40 mg SubQ q24h or 30 mg SubQ q12h	BMI >40: 0.5 mg/kg q24h CrCl <30: 30 mg q24h
  Dalteparin	2500–5000 units SubQ q24h	No adjustment
  Factor Xa Inhibitors
  Fondaparinux	2.5 mg SubQ q24h	CI: <50 kg or CrCl <30: avoid	Useful for patients with history of HIT
  Betrixaban (Bevyxxa)	160 mg ×1 then 80 mg PO daily with food ×35–42 days	CrCl 15–29 or strong P-gp inhibitors (e.g., amiodarone, azithromycin, clarithromycin, ketoconazole, verapamil): 80 mg ×1 then 40 mg PO daily with food ×35–42 days CrCl <15 or dialysis: not studied	New prophylactic anticoagulant for acute medical illness
  Antiplatelet
  Aspirin	160 mg PO daily	Caution in CrCl <10	N/A
  Direct Oral Anticoagulants
  Apixaban	2.5 mg PO BID	CrCl <30: excluded from studies	Apixaban, dabigatran, and rivaroxaban can elevate the INR
  Dabigatran	150 mg–220 mg PO daily	CrCl ≤30: excluded from studies
  Rivaroxaban	10 mg PO daily	CrCl <30: avoid
  Vitamin K Antagonist
  Warfarin	5–10 mg PO daily for 2 days, then titrate to INR 2–3	Monitor INR closely	Monitor INR closely

   
  

  BID , Twice daily; BMI , Body mass index; CI , Contraindicated; CrCl , Creatinine clearance; HIT , Heparin-induced thrombocytopenia; ICU , Intensive care unit; INR , International normalized ratio; LMWH , Low-molecular-weight heparin; P-gp , P-glycoprotein; PO , Orally; SubQ , Subcutaneous; UFH, Unfractionated heparin

  
  

  a Refer to specific conditions in Table 24.2

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