Advances in management of venous thromboembolism in critically ill patients

Deep venous thrombosis (DVT) is common in the critically ill patients as they are immobile ,sedated and exposed to thrombin generating procedures (e.g., central venous catheterization and surgery). The diagnosis of DVT in the critically ill presents specific challenges because many patients are not able to communicate their symptoms (such as leg pain or shortness of breath), and they may lack typical examination findings seen in outpatients with DVT (such as unilateral leg oedema). Furthermore, laboratory markers shown to predict DVT in symptomatic outpatients (such as d-dimer or factor V Leiden) do not have predictive value in the critically ill. Finally, tests commonly used to diagnose venous thromboembolism (VTE) (such as compression ultrasonography), which have been shown reliable in symptomatic outpatients have not been adequately evaluated in critically ill patients (Oudega et al., 2005).The timing and incidence of hypercoagulability, which predisposes to these events is unknown,nevertheless, with institutional screening programs serving primarily to establish a diagnosis after an event has occurred.Moreover, emerging evidence suggests that rapid thrombelastography (r-TEG) provides a real-time analysis of comprehensive thrombostatic function, which represents an analysis of both enzymatic and platelet components of thrombus formation. It was hypothesized that r-TEG can be used as a screening tool to identify hypercoagulable states in surgical patients and would predict subsequent thromboembolic events (Kashuk et al., 2009).In addition to aggressive mobilization, which should be a part of routine postoperative care, mechanical methods of prophylaxis include graduated elastic stockings, sequential compression devices and foot pumps