Nonleg venous thrombosis in critically Ill adults a nested prospective cohort study

Francois Lamontagne, Lauralyn McIntyre, Peter Dodek, Diane Heels-Ansdell, Maureen Meade, Julia Pemberton, Yoanna Skrobik, Ian Seppelt, Nicholas E. Vlahakis, John Muscedere, Graham Reece, Marlies Ostermann, Soundrie Padayachee, Jamal Alhashemi, Michael Walsh, Bradley Lewis, David Schiff, Alan Moody, Nicole Zytaruk, Martine LeBlancDeborah J. Cook*, Olivier Lesur, Sandra Proulx, Sylvie Cloutier, Brigitte Bolduc, Marie Pierre Rousseau, Julie Leblond, Gérard Schmutz, Paul Hebert, Irene Watpool, Tracy McArdle, Claude Gaudert, Paule Marchand, Carson Davidson, Anne Marie Dugal, Susan Fetzer, Wael Shabana, Marc Castonguay, Sohail Anwar, Valentina Kozarenko, Shahina Mohammad, Svitlana Sikalska, Suzanne Gauthier, Arif Mustafa, Betty Jean Ashley, Sheilagh Mans, Mara Pavan, Jonathon Leipsic, Sam Meiersdorf, Adrian Yoong, Francisco Avila Flores, Hina Mumtaz, Patrick Ng, Cathy Fix, Lori Hand, Maya Biljan, Michael Patlas, Lianne Broughton, Lucy Degrow, Dianna Connor, Maggie Tuhy, Dawn Whyte, Meaghan Jefferson, Kaitlyn Aarts, Lindsay Vooys, Michael Anzovino, Johanne Harvey, Stefania Chitu, Marceline Quach, Linda Pinet, Susan Fleury, Nicole Godfrey, Sharlene Hammond, Elizabeth Mann, Monica Myers, Amber Robinson, Chris Grey, Eric Saurbrei, Jennifer Cox, Angela Nugent, Julie Kolesar, Amy Fisher, Amy Northrup-St-Onge, Marshaw Paterson-Skeete, Wendy Schlottke, Wendy Bertrim, Cathy Marshall, Ellen McDonald, Andrea Tkaczyk, France Clarke, Christine Wallace, Jennifer McDonald, Sarah Todd, Patty Harkness, Angela Medic, Joanna Andrews, Moira Sands, Iwona Hall, Tanya Boniakowski, Kim Lichty, Leonie Weisbrodt, Robyn Bond, Stella Suen, Jason Trinh, Roger Hall, Richard Huang, Helen Chow, Treena Sara, Kiran Nand, Rabsima Ibrahim, James Jarrett, Jagdish Seehra, Gill Stringer, Sanaa Shalabi, Randa Ainosah, Julie Ann Sonbul, Rustico Gloriani, Rosalinda Huertazuela, Ibrahim Abbas, Judy Chavez, Nahid El Toum, David Treacher, Tony Sherry, John Smith, Barnaby Sanderson, Josephine Ng, John Brooks, Ling Lim, Katie Lei, Paul Tunstell, Cathy McKenzie, Francesco Cicirello, T. S. Padayachee, Nicholas Thomas, Andrew J. Arnold, Laurie Meade, Debbie Bauer, Nora Harer

*Corresponding author for this work

    Research output: Contribution to journalReview articlepeer-review

    42 Citations (Scopus)


    IMPORTANCE: Critically ill patients are at risk of venous thrombosis, and therefore guidelines recommend daily thromboprophylaxis. Deep vein thrombosis (DVT) commonly occurs in the lower extremities but can occur in other sites including the head and neck, trunk, and upper extremities. The risk of nonleg deep venous thromboses (NLDVTs), predisposing factors, and the association between NLDVTs and pulmonary embolism (PE) or death are unclear.

    OBJECTIVE: To describe the frequency, anatomical location, risk factors, management, and consequences of NLDVTs in a large cohort of medical-surgical critically ill adults.

    DESIGN, SETTING, AND PARTICIPANTS: A nested prospective cohort study in the setting of secondary and tertiary care intensive care units (ICUs). The study population comprised 3746 patients, who were expected to remain in the ICU for at least 3 days and were enrolled in a randomized clinical trial of dalteparin vs standard heparin for thromboprophylaxis.

    MAIN OUTCOMES AND MEASURES: The proportion of patients who had NLDVTs, the mean number per patient, and the anatomical location. We characterized NLDVTs as prevalent or incident (identified within 72 hours of ICU admission or thereafter) and whether they were catheter related or not. We used multivariable regression models to evaluate risk factors for NLDVT and to examine subsequent anticoagulant therapy, associated PE, and death. RESULTS Of 3746 trial patients, 84 (2.2%) developed 1 or more non-leg vein thromboses (superficial or deep, proximal or distal). Thromboses were more commonly incident (n = 75 [2.0%]) than prevalent (n = 9 [0.2%]) (P < .001) and more often deep (n = 67 [1.8%]) than superficial (n = 31 [0.8%]) (P < .001). Cancer was the only independent predictor of incident NLDVT (hazard ratio [HR], 2.22; 95% CI, 1.06-4.65). After adjusting for Acute Physiology and Chronic Health Evaluation (APACHE) II scores, personal or family history of venous thromboembolism, body mass index, vasopressor use, type of thromboprophylaxis, and presence of leg DVT, NLDVTs were associated with an increased risk of PE (HR, 11.83; 95% CI, 4.80-29.18). Nonleg DVTs were not associated with ICU mortality (HR, 1.09; 95% CI, 0.62-1.92) in a model adjusting for age, APACHE II, vasopressor use, mechanical ventilation, renal replacement therapy, and platelet count below 50 × 10(9)/L. CONCLUSIONS AND RELEVANCE Despite universal heparin thromboprophylaxis, nonleg thromboses are found in 2.2% of medical-surgical critically ill patients, primarily in deep veins and proximal veins. Patients who have a malignant condition may have a significantly higher risk of developing NLDVT, and patients with NLDVT, compared with those without, appeared to be at higher risk of PE but not higher risk of death.

    TRIAL REGISTRATION: Identifier: NCT00182143.

    Original languageEnglish
    Pages (from-to)689-696
    Number of pages8
    JournalJAMA Internal Medicine
    Issue number5
    Publication statusPublished - May 2014


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