Some thought about DVT prophylaxis in ICU.
Part of my presentation on the same topic.

Question 1: What is the incidence of DVT and PE in current era of widespread thrombo-prophylaxis?
#FOAMed

Question 2: How do you diagnose DVT in ICU?
I think, the best evidence is available for CUS with limited scope for Venography.
And no role of D-Dimer.
#FOAMed

Question 3: Is there any evidence supporting Heparin thrombo-prophylaxis in ICU?
#FOAMed

Yes.
Number needed to prophylax to prevent 1 DVT - 20
Number needed to prophylax to prevent 1 PE - 52
Overall no major bleeding. But bleeding risk need to be individualised.

Question 4: Is there any evidence of LMWH over UFH in VTE Prophylaxis?
#FOAMeYes.
LMWH decreases DVT. But no difference in Proximal DVT.
No difference in PE.
No difference in major bleeding.
Lower incidence of HIT in LMWH (PROTECT Trial).
Overall advantage LMWH.

Question 5: Is there any role of Mechanical Thromboprophylaxis?
#FOAMed

Question 6: What is the evidence for Pharmacological Thromboprophylaxis in patients with low CrCL?

Maximum evidence is for Dabigatran.
But unfortunately even on Dabigtran with adequate Anti-factor Xa level maintained both DVT and bleeding risk remains high.
#FOAMed

Question 7: Any evidence in TBI?
#FOAMed
Suggestions.
GCS 13-15. No bleed expansion at 48-H. Start.
GCS 13-15. Some expansion at 48-H. Start only after 72-H.
GCS 3-12. Not before 72 H. But before 7-days.
For DAI. No bleeding. Start after 72-H.
Consult Neurosurgery.

Question 8: How to treat DVT in ICU?
#FOAMed
Standard anticoagulation.
Limited role for Catheter Directed Thrombolysis.

Question 9: How do I provide DVT prophylaxis in my ICU?
#FOAMed

All ICU patients need DVT prophylaxis.
Pharmacological preferred over Mechanical.
If DVT prophylaxis not given for some reason, the reason must be documented.

Question 10: Is there any evidence for DOACs?
#FOAMed
Yes. For several of them.
APEX supports Betrixaban for prophylaxis.
Xalia supports Rivaroxaban for treatment.
But will be cautious in using them in my patients. Limited evidence in ICU patients. Limited reversal agent.