Doppler Compression Ultrasound of the Lower Extremities in Icu Patients: An Inter-Rater Reliability Study

Cook, Deborah J.; Medic, Angie; Andrews, Joanne; Schiff, David; Dobranowski, Julian; Bates, S.K.; McDonald, Ellen; Landry, France; Crowther, Mark

doi:10.1097/00003246-200212001-00265

Cited by 4 publications

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“…The ICU team and research coordinators made comprehensive daily bleeding assessments with a validated tool [ 16 ] and were blinded to the anti-FXa levels. DVT was identified by twice-weekly screening venous ultrasound, which has been protocolized in previous studies [ 1 , 30 ] and has been shown to be reliable [ 12 ]. These design features made biased interpretation of clinical outcomes unlikely in this open-label study.…”

Section: Discussionmentioning

confidence: 99%

“…A standard technique was used to assess venous segments in six locations from the trifurcation to the common femoral vein. This technique, which has high inter-rater reliability in ICU patients [ 12 ], was performed by specifically trained study ultrasound technologists and radiologists. DVT was defined by a noncompressible vein segment [ 13 ], and was classified as catheter-related if it occurred within 24 hours of placement of a central venous (including dialysis) catheter in the same site.…”

Section: Methodsmentioning

confidence: 99%

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Venous thromboembolism and bleeding in critically ill patients with severe renal insufficiency receiving dalteparin thromboprophylaxis: prevalence, incidence and risk factors

et al. 2008

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BackgroundCritically ill patients with renal insufficiency are predisposed to both deep vein thrombosis (DVT) and bleeding. The objective of the present study was to evaluate the prevalence, incidence and predictors of DVT and the incidence of bleeding in intensive care unit (ICU) patients with estimated creatinine clearance <30 ml/min.MethodsIn a multicenter, open-label, prospective cohort study of critically ill patients with severe acute or chronic renal insufficiency or dialysis receiving subcutaneous dalteparin 5,000 IU once daily, we estimated the prevalence of proximal DVT by screening compression venous ultrasound of the lower limbs within 48 hours of ICU admission. DVT incidence was assessed on twice-weekly ultrasound testing. We estimated the incidence of major and minor bleeding by daily clinical assessments. We used Cox proportional hazards regression to identify independent predictors of both DVT and major bleeding.ResultsOf 156 patients with a mean (standard deviation) creatinine clearance of 18.9 (6.5) ml/min, 18 had DVT or pulmonary embolism within 48 hours of ICU admission, died or were discharged before ultrasound testing – leaving 138 evaluable patients who received at least one dose of dalteparin. The median duration of dalteparin administration was 7 days (interquartile range, 4 to 12 days). DVT developed in seven patients (5.1%; 95% confidence interval, 2.5 to 10.1). The only independent risk factor for DVT was an elevated baseline Acute Physiology and Chronic Health Evaluation II score (hazard ratio for 10-point increase, 2.25; 95% confidence interval, 1.03 to 4.91). Major bleeding developed in 10 patients (7.2%; 95% confidence interval, 4.0 to 12.8), all with trough anti-activated factor X levels ≤ 0.18 IU/ml. Independent risk factors for major bleeding were aspirin use (hazard ratio, 6.30; 95% confidence interval, 1.35 to 29.4) and a high International Normalized Ratio (hazard ratio for 0.5-unit increase, 1.68; 95% confidence interval, 1.07 to 2.66).ConclusionIn ICU patients with renal insufficiency, the incidence of DVT and major bleeding are considerable but appear related to patient comorbidities rather than to an inadequate or excessive anticoagulant from thromboprophylaxis with dalteparin.Clinical Trial RegistrationNumber NCT00138099.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Venous thromboembolism and bleeding in critically ill patients with severe renal insufficiency receiving dalteparin thromboprophylaxis: prevalence, incidence and risk factors

et al. 2008

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“…A previous inter-rater reliability study demonstrated perfect agreement between these two ultrasonographers at all six venous sites [16]. …”

Section: Methodsmentioning

confidence: 97%

“…To ensure uniformity of DVT screen ultrasounds, two trained ultrasonographers performed all tests independently of each other and were blinded to patient history and physical examinations. A previous inter-rater reliability study demonstrated perfect agreement between these two ultrasonographers at all six venous sites [ 16 ].…”

Section: Methodsmentioning

confidence: 97%

Red blood cell transfusion and increased length of storage are not associated with deep vein thrombosis in medical and surgical critically ill patients: a prospective observational cohort study

et al. 2011

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IntroductionWith prolonged storage times, cell membranes of red blood cells (RBCs) undergo morphologic and biochemical changes, termed 'RBC storage lesions'. Storage lesions may promote inflammation and thrombophilia when transfused. In trauma patients, RBC transfusion was an independent risk factor for deep vein thrombosis (DVT), specifically when RBC units were stored > 21 days or when 5 or more units were transfused. The objective of this study was to determine if RBC transfusions or RBC storage age predicts incident DVT in medical or surgical intensive care unit (ICU) patients.MethodsUsing a database which prospectively enrolled 261 patients over the course of 1 year with an ICU stay of at least 3 days, we analyzed DVT and RBC transfusions using Cox proportional hazards regression. Transfusions were analyzed with 4 thresholds, and storage age using 3 thresholds. DVTs were identified by twice-weekly proximal leg ultrasounds. Multivariable analyses were adjusted for 4 significant DVT predictors in this population (venous thrombosis history, chronic dialysis, platelet transfusion and inotropes).ResultsOf 261 patients, 126 (48.3%) had at least 1 RBC transfusion; 46.8% of those transfused had ≥ 5 units in ICU. Patients receiving RBCs were older (68.8 vs 64.1 years), more likely to be female (47.0 vs 30.7), sicker (APACHEII 26.8 vs 24.4), and more likely to be surgical (21.4 vs 8.9) (P < 0.05). The total number of RBCs per patient was 1-64, mean was 6.3 (SD 7.5), median was 4 (IQR 2,8). In univariate analyses, there was no association between DVT and RBC exposure (1 day earlier, 3 days earlier, 7 days earlier, or ever) or RBC storage (≤ 7 or > 7 days, ≤ 14 or > 14 days, ≤ 21 or > 21 days). Among patients transfused, no multivariable analyses showed that RBC transfusion or storage age predicted DVT. Trends were counter to the hypothesis (e.g., RBC storage for ≤ 7 days suggested a higher DVT risk compared to > 7 days (HR 5.3; 95% CI 1.3-22.1).ConclusionsWe were unable to detect any association between RBC transfusions or prolonged red cell storage and increased risk of DVT in medical or surgical ICU patients. Alternate explanations include a lack of sufficient events or patients' interaction, between patient groups, a mixing of red cell storage times creating differential effects on DVT risk, and unmeasured confounders.

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“…A standard technique was used to assess for noncompressible vein segments that has high interrater reliability in ICU patients. 21 Screening for pulmonary embolism was not done, and if embolism was diagnosed, it was based on the results from objective diagnostic tests. 22,23…”

Section: Deep Vein Thrombosismentioning

confidence: 99%

Prophylaxis Against Deep Vein Thrombosis in Critically Ill Patients With Severe Renal Insufficiency With the Low-Molecular-Weight Heparin Dalteparin<subtitle>An Assessment of Safety and Pharmacodynamics: The DIRECT Study</subtitle>

Douketis

Cook²,

Meade³

et al. 2008

Arch Intern Med

139

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Background: Use of low-molecular-weight heparins is avoided in patients with renal insufficiency because of concerns about an excessive anticoagulant effect and increased bleeding risk. To challenge this premise, we evaluated if deep vein thrombosis (DVT) prophylaxis with dalteparin sodium confers an excessive anticoagulant effect in critically ill patients with severe renal insufficiency. Methods: We conducted a multicenter, single-arm clinical trial of DVT prophylaxis with dalteparin sodium, 5000 IU once daily in critically ill patients with a creatinine clearance lower than 30 mL/min (to convert to milliliters per second, multiply by 0.0167). Bioaccumulation was defined by a trough anti-Xa level higher than 0.40 IU/mL, measured twice weekly. The pharmacodynamic properties of dalteparin were assessed by serial anti-Xa levels measured on days 3, 10, and 17. Author Affiliations are listed at the end of this article. Group Information: Members of the committees and participating centers of the Canadian Critical Care Trials Group are listed on page 1811.

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Doppler Compression Ultrasound of the Lower Extremities in Icu Patients: An Inter-Rater Reliability Study

Cited by 4 publications

References 0 publications

Venous thromboembolism and bleeding in critically ill patients with severe renal insufficiency receiving dalteparin thromboprophylaxis: prevalence, incidence and risk factors

Venous thromboembolism and bleeding in critically ill patients with severe renal insufficiency receiving dalteparin thromboprophylaxis: prevalence, incidence and risk factors

Red blood cell transfusion and increased length of storage are not associated with deep vein thrombosis in medical and surgical critically ill patients: a prospective observational cohort study

Prophylaxis Against Deep Vein Thrombosis in Critically Ill Patients With Severe Renal Insufficiency With the Low-Molecular-Weight Heparin Dalteparin<subtitle>An Assessment of Safety and Pharmacodynamics: The DIRECT Study</subtitle>

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