Incidence of venous thromboembolic disease and risk of bleeding in critically ill patients with hematologic malignancies: A retrospective study.

OBJECTIVE: Our objectives were to describe the use of thromboprophylaxis and the incidence of VTE/bleeding in critically ill patients with hematologic malignancies (HM). DESIGN: Retrospective cohort study (2014-2022). SETTING: Medic-Surgical Intensive Care Unit (ICU) in a tertiary care academic center. PATIENTS: Adult patients admitted to ICU with a concomitant diagnosis of a hematological malignancy. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: We analyzed demographic data, use of thromboprophylaxis and secondary outcomes that included incidence of VTE (venous thromboembolism), bleeding, mortality, severity scores and organ support. We applied a multivariable logistic regression model to examine the risk of thrombosis in the ICU. RESULTS: We included 862 ICU admissions (813 unique patients). Thromboprophylaxis was given during 65% of admissions (LMWH 14%, UFH 8%, and SCDs 43%); in 21% it was contraindicated due to thrombocytopenia; 14% of cases lacked documentation on prophylaxis. There were 38 unique incident cases of VTE (27 DVT, 11 PE), constituting 4.4% of ICU episodes. Most of VTE cases happened in patients with various degrees of thrombocytopenia. In the multivariable analysis, SOFA score on the first ICU day was independently associated (OR 0.85, 95% CI 0.76-0.96) with the risk of VTE. Bleeding occurred in 7.2% (minor) and 14.4% (major) of episodes; most frequent sites being CNS, abdomen/GI and pulmonary. CONCLUSIONS: In this cohort of critically ill patients with HM, there was considerable variability in the utilization of DVT prophylaxis, with predominant use of SCDs. The incidence of VTE was 4.4% and major bleeding 14%. CLINICAL TRIAL REGISTRATION: NCT05396157. Venous Thromboembolism in Hematologic Malignancy and Hematopoietic Cell Transplant Patients: a Retrospective Study (https://clinicaltrials.gov/).

Recomendaciones para el uso de tromboprofilaxis en pacientes hospitalizados por COVID-19 en la Argentina / Recommendations for the use of thromboprophylaxis in hospitalized patients with COVID-19 in Argentina

Si bien la incidencia es incierta, algunos reportes de caso sugieren que la infección por COVID 19 se asocia con un aumento del riesgo de tromboembolismo venoso. Sugerimos iniciar tromboprofilaxis a todos los pacientes hospitalizados por síntomas asociados con una infección por COVID-19, a menos que esté contraindicado, con enoxaparina 40 mg SC diariamente si el clearance de creatinina es mayor a 30 ml/min.

Although the incidence is uncertain, some case reports suggest that COVID 19 infection is associated with an increased risk of venous thromboembolism. We suggest starting prophylactic anticoagulant therapy for all patients hospitalized with a symptomatic infection with COVID-19, unless contraindicated, with enoxaparin 40 mg SC daily if creatinine clearance is greater than 30 ml/min.

Tromboembolismo de pulmón: Sospecha clínica y correlación anatomopatológica / Pulmonary embolism. Clinical suspicion and anatomopathological correlation

Las discrepancias entre la sospecha clínica y los hallazgos patológicos en el tromboembolismo pulmonar (TEP) son frecuentes. El objetivo de este estudio fue analizar la prevalencia de TEP en una serie de necropsias de fallecidos en un hospital general de agudos entre 1998 y 2017, su relación con la sospecha clínica y su importancia como causa de muerte. Es un estudio retrospectivo y observacional de 350 autopsias realizadas en el Servicio de Patología; analiza características demográficas, principales diagnósticos clínicos informados en la solicitud de autopsia (sospecha clínica de muerte), incidencia anatomopatológica de TEP, diagnósticos primarios de autopsia relacionados con la muerte y concordancia entre sospecha clínica y diagnósticos de autopsia. En solo el 8% de las autopsias (n = 28), el TEP fue el diagnóstico clínico informado. En las autopsias, se encontró TEP en 127 casos (36.3%). Afectó arterias pulmonares grandes en 33 casos (25.9%), vasos medianos en 75 (59.1%) y vasos pequeños en 19 casos. El TEP se consideró el principal contribuyente o la causa principal de muerte en un 30.9% (n = 108) de los casos. Sin embargo, solo en el 15.7% de los casos confirmados había una sospecha clínica previa de TEP. Esta serie muestra que el TEP es un hallazgo de alta prevalencia y una causa importante de muerte en autopsias realizadas en un hospital de agudos. La evidencia de la baja concordancia entre los diagnósticos anatomopatológicos y clínicos del TEP alerta sobre la importancia de la sospecha clínica para lograr un tratamiento temprano de la enfermedad.

Discrepancies between clinical suspicion and pathological findings in pulmonary embolism (PE) appear to be frequent. The aim of this study was to analyze the prevalence of PE in a necropsy series of patients who have died in an acute care hospital between 1998-2017, its relationship with previous clinical suspicion, and its importance as a cause of death. It is a retrospective observational study of 350 autopsies done at the Department of Pathology. We analyzed the demographic characteristics, main clinical diagnoses stated in the autopsy request form, incidence of PE diagnosed, main autopsy findings related with the cause of death, as well as the concordance between clinical suspicion and autopsy diagnosis. In only 8% of the cases (n = 28) the clinical diagnosis of autopsy request was PE. An autopsy diagnosis of PE was done in 127 cases (36.3%); in 33 cases (25.9%) affected large pulmonary vessels; medium caliber vessels were affected in 75 cases (59.1%), and in 19 cases small vessels. The PE was considered as a contributor or cause of death in 30.9% (n = 108). However, only 15.7% of the confirmed PE cases had previous clinical suspicion. This series of necropsies shows that PE is a high prevalence finding in autopsies at an acute care hospital, and an important cause of death in a 20 years period. The finding of a low concordance with clinical diagnosis should alert the medical community on the importance of clinical suspicion in order to achieve an early diagnosis and treatment of this disease.

Recomendaciones actualizadas para profilaxis de la enfermedad tromboembólica venosa en Argentina / Updated recommendations for venous thromboembolic prophylaxis in Argentina

La enfermedad tromboembólica venosa (ETV) en adultos hospitalizados posee elevada morbimortalidad, es origen de complicaciones crónicas y determina incrementos de costos para el sistema de salud. Desde la publicación de recomendaciones de tromboprofilaxis en pacientes internados en 2013, han surgido nuevas alternativas y estrategias, que nos motivaron a actualizar nuestras recomendaciones. A pesar de que existen diferentes consensos y guías de práctica clínica la adherencia a las mismas es subóptima. Se han actualizado las diferentes alternativas terapéuticas para los adultos hospitalizados (clínicos no quirúrgicos, quirúrgicos no ortopédicos, con y sin cáncer, ortopédicos y embarazadas), poniendo particular atención en los fármacos disponibles en Argentina.

Venous thromboembolic disease (VTE) in hospitalized adults has high morbidity and mortality, is the origin of chronic complications and increased cost for the health system. Since the publication of recommendations for thromboprophylaxis in hospitalized patients in 2013, new alternatives and strategies have emerged, which motivated us to update our recommendations. Although there are different consensus and clinical practice guidelines, adherence to them is suboptimal. The different therapeutic alternatives for hospitalized adult patients (non-surgical, surgical non-orthopedic, with and without cancer, orthopedic an d pregnant) have been updated, paying particular attention to the drugs available in Argentina.

Guía de recomendaciones para la profilaxis de la enfermedad tromboembólica venosa en adultos en la Argentina / Venous thromboembolic prophylaxis: Guidelines for adults in Argentina

La enfermedad tromboembólica venosa (ETV) en adultos posee elevada morbimortalidad y puede asociarse a complicaciones crónicas invalidantes. Sin embargo, la adherencia a estándares de cuidado no es óptima. Se analizó la evidencia disponible en tromboprofilaxis y se generaron recomendaciones (1) o sugerencias (2) con diferentes grados de evidencia (A, B o C) para diferentes escenarios y métodos de tromboprofilaxis. En cirugías ortopédicas mayores se recomienda la profilaxis farmacológica con heparinas de bajo peso molecular, HBPM (1B), fondaparinux, dabigatrán y rivaroxaban (1B) que deben iniciarse durante la internación y mantenerse hasta 35 días después de la cirugía de cadera y hasta 10 días posteriores a la artroplastia de rodilla. La artroscopia de rodilla y la cirugía de columna programada no requieren profilaxis farmacológica (2B) salvo que posean factores de riesgo adicionales, en cuyo caso se recomiendan las HBPM. En pacientes con internación clínica y movilidad reducida esperable mayor a tres días, que posean factores de riesgo adicionales, se recomienda tromboprofilaxis con HBPM, HNF o fondaparinux (1B) hasta el alta. Aquellos pacientes neuroquirúrgicos o con HIC deberán recibir inicialmente tromboprofilaxis mecánica (2C) y dependiendo del caso, iniciar HBPM o HNF entre las 24-72 horas posteriores (2C). Estas últimas dos drogas son recomendadas para pacientes críticos. Los pacientes sometidos a cirugías no ortopédicas con bajo riesgo de ETV deberán realizar deambulación precoz (2C) y tromboprofilaxis mecánica (2C), mientras que aquellos en los que el riesgo de ETV sea elevado deberán recibir HBPM y HNF (1B o 2C según su riesgo de sangrado).(AU)

The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).(AU)

Guía de recomendaciones para la profilaxis de la enfermedad tromboembólica venosa en adultos en la Argentina / Venous thromboembolic prophylaxis: Guidelines for adults in Argentina

La enfermedad tromboembólica venosa (ETV) en adultos posee elevada morbimortalidad y puede asociarse a complicaciones crónicas invalidantes. Sin embargo, la adherencia a estándares de cuidado no es óptima. Se analizó la evidencia disponible en tromboprofilaxis y se generaron recomendaciones (1) o sugerencias (2) con diferentes grados de evidencia (A, B o C) para diferentes escenarios y métodos de tromboprofilaxis. En cirugías ortopédicas mayores se recomienda la profilaxis farmacológica con heparinas de bajo peso molecular, HBPM (1B), fondaparinux, dabigatrán y rivaroxaban (1B) que deben iniciarse durante la internación y mantenerse hasta 35 días después de la cirugía de cadera y hasta 10 días posteriores a la artroplastia de rodilla. La artroscopia de rodilla y la cirugía de columna programada no requieren profilaxis farmacológica (2B) salvo que posean factores de riesgo adicionales, en cuyo caso se recomiendan las HBPM. En pacientes con internación clínica y movilidad reducida esperable mayor a tres días, que posean factores de riesgo adicionales, se recomienda tromboprofilaxis con HBPM, HNF o fondaparinux (1B) hasta el alta. Aquellos pacientes neuroquirúrgicos o con HIC deberán recibir inicialmente tromboprofilaxis mecánica (2C) y dependiendo del caso, iniciar HBPM o HNF entre las 24-72 horas posteriores (2C). Estas últimas dos drogas son recomendadas para pacientes críticos. Los pacientes sometidos a cirugías no ortopédicas con bajo riesgo de ETV deberán realizar deambulación precoz (2C) y tromboprofilaxis mecánica (2C), mientras que aquellos en los que el riesgo de ETV sea elevado deberán recibir HBPM y HNF (1B o 2C según su riesgo de sangrado).

The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).