Thromboembolism Occurrence and Diagnosis in the Medical Intensive Care Unit

Abstract

Venous thromboembolism (VTE) represents an unrelenting and formidable challenge in the critical care setting even for the most experienced clinician. The morbidity and mortality attributed to untreated VTE have been substantiated by increasing series of epidemiologic and postmortem studies. As a larger group of the general population grows older, with increasing requirements for critical care services, challenges for the intensivist in the diagnosis and management of VTE are expected to grow. Moreover, despite the tremendous development of many critical care technologies, complexities of medical conditions commonly encountered in the critically ill have detracted from suspicion of VTE and made prompt recognition difficult. The approach to diagnosis of VTE should optimize diagnostic yield and outcomes with responsible use of resources. Key to an appropriate approach of VTE diagnosis in the intensive care unit is an understanding of the predisposing risk factors--pretest probability and the strengths and weaknesses of available diagnostic tools. Rational use of ultrasound, impedance plethysmography, computed tomography (CT), echocardiography, contrast venography, angiography, and D-dimer assays have provided the clinicians with a more substantial armamentarium, albeit incomplete, to facilitate diagnosis of VTE. The best use of these diagnostic tests often are dependent on local availability and expertise as part of a multidisciplinary team. With application of sound clinical principles in identifying select patients at risk and disciplined use of diagnostic technologies using simple algorithms, improvements in the diagnosis and management of VTE in the intensive care unit may be expected.

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“…This pool, however, should not be considered a biomarker of intravascular fibrin deposition and thrombus formation. It can be speculated that this might be one of the reasons why D-dimer is a useful biomarker in healthy ambulatory subjects suspected of VTE [ 5 ] and is of little value in those who are hospitalized and/or critically ill [ 6 ]. In the latter, such comorbidities as pneumonia, malignancy, congestive heart failure, etc., may increase D-dimer even in the absence of VTE.…”