Prevention of thrombosis Massimo Lamperti MD, MBA Chief of General Anaesthesia Department Anaesthesiology Institute Cleveland Clinic Abu Dhabi Clinical Professor of Anaesthesiology Cleveland Clinic Lerner College of Medicine of Case Western Reserve
Disclosures Member of the Cochrane Review for A&E and Critical Care Advisor for Masimo, Draeger 3
Topics of this presentation Thrombosis: location, diagnosis, treatment Literature Prevention: SDI 4
Catheter-related thrombosis: location Upper body Lower body Location of thrombus: 5
Catheter-related thrombosis: Diagnosis Compressive ultrasound Doppler ultrasound Phlebography CT angio 6
Catheter-related thrombosis: Diagnosis/Treatment 7
Catheter-related thrombosis: Treatment Use of anticoagulant treatment for routine prophylaxis of CRT is not recommended A CVC should be inserted on the right side, in the IJV, and the distal tip of the CVC should be located at the junction of the superior vena cava and the right atrium 8
Catheter-related thrombosis: Treatment 9
Catheter-related thrombosis: Treatment 10
Literature Big biases for heterogeneity and selection Related more on DVT(5-29%) than asymptomatic thrombosis (40-66%) Higher risk in ICU? oncological patients? 11
12
A 1-year prospective observational study of PICC insertions was conducted A total of 2014 PICCs for a total of 15115 days of PICC placement 57 pts PICC associated DVT 11 pts pulmonary embolism Chest 2010;138(4):803-810 13
21 putative risk factors for DVT were examined: PICC size, length duration final tip location reason for PICC insertion accessed arm and vein patient sex and age insertion nurse insertion division previous DVT previous cancer hypercoagulability surgery duration>1 h bed rest; BMI 29 kg/m2 receiving hormone replacement or oral contraception admission diagnosis use of anticoagulants use of pressors Chest 2010;138(4):803-810 14
DVT 3% Chest 2010;138(4):803-810 15
A 3-year, prospective, observational study of all PICC insertions by a specially trained a CHEST 2013; 143(3):627 633 16
DVT from 3% (2008) to 1.9% (2010) Cost and LOS attributable to PICC-associated DVT were $15973 and 4.6 days CHEST 2013; 143(3):627 633 17
18
19
20
21
22
Prospective study performed on a large cohort (n = 400) of patients with cancer aged >18 requiring long-term CVC implantation for chemotherapy infusion Patients underwent ultrasound examination at 1 and 6 months after CVC implantation to detect 'early' (1 month) and 'late' (6 months) asymptomatic DVT or fibrin sheaths incidence. Sixty-nine patients underwent US examination also 12 months after CVC implantation Incidence of CVC-related thrombosis was 0.10 events per 1000 catheter days. Anticoagulation therapy with LWMH resolved 50% of DVT, but no CVC needed removing. Incidence of new onset fibrin sheaths was 0.71 events per 1000 catheter days. Fibrin sheaths resolution occurred independently of LWMH therapy. 23
retrospective study on 89 patients ICU patients average indwelling times: 22±12 days one episode of symptomatic thrombosis 8 cases of partial obstruction solved with NS flush 24
Catheter-related thrombosis: prevention S: Selection D: Detection I: Intervention 25
Selection of the vein and catheter Catheter-related thrombosis due to incorrect catheter/vein Nifong et al., Chest 2011 26
Selection of the vein and catheter Prospective cohort; n=136, 1 site, Australia Association between catheter#vein#vte Patients with a C:V ratio > 45% RR 13.0 (1.44-122.7) for DVT compared to those <45% (adjusted for co-morbidities, meds) Sharp R, et al. Int J Nursing Studies 2014 27
Detection Incidence of internal jugular vein CRT was 26.7%, corresponding to 70.5 cases per 1,000 catheter days. Incidence of "fibrin sleeve" was 28.4% Incidence of CRT was not associated with duration of the placement of the introducer catheter (average 3.9±2 days) or the SGC (average of 2.4±1.7 days Infusion of total parenteral nutrition and dextran showed a significantly increased risk of thrombosis 28
Intervention Lock of the catheter 29
Intervention HS is not superior to NS in reducing CVCs occlusion In the short term, the use of HS is slightly superior to NS for flushing catheters from a statistical point of view 30
Keynotes Selection of catheter and vein is the key Big heterogeneity in the definition of catheterrelated thrombosis Use of a bundle can help reducing the risk of thrombosis 31
The risk exists if we don t prevent 32
33
For any questions or if you want a copy of these slides: LamperM@clevelandclinicabudhabi.ae