Medscape Medical News 2009. © 2009 Medscape
Patients in the intensive care unit (ICU) may have a higher risk for upper-extremity deep vein thrombosis (DVT) than for lower-extremity DVT, yet the focus tends to be only on the legs, according to a study presented here at the Society of Critical Care Medicine 38th Critical Care Congress.
“Upper-extremity assessment is not routinely done and it’s not considered as important as assessment of the lower extremities,” Loay Kabbani, MD, from the Department of Surgical Critical Care at the University of Michigan, in Ann Arbor, told Medscape Critical Care during the conference.
Dr. Kabbani and colleagues prospectively reviewed the records of 1275 patients admitted to the surgical ICU over a 12-month period (July 2007 to June 2008). Patients with documented DVT before ICU admission were excluded.
Of the total, 204 patients underwent venous duplex scans for clinical suspicion of DVT. About half (103 patients) had both upper- and lower-extremity scans, 24 patients had upper-extremity scans, and 77 had lower-extremity scans.
Demographic data, admitting diagnosis, and APACHE III scores were evaluated. Central venous catheter presence, DVT prophylaxis and treatments, and mortality were also included in the analysis.
DVT was confirmed in 39 patients. The incidence of upper-extremity DVT was higher than that of lower-extremity DVT (17% vs 11%; P = .11). Four-extremity scans diagnosed more DVT than 2-extremity scans (33% vs 7%; P < .001).
“Upper-extremity DVT was as common as, if not more common than, lower-extremity DVT in surgical ICU patients,” Dr. Kabbani told Medscape Critical Care.
“There was a significantly higher incidence of upper-extremity DVT in patients with sepsis or central lines. They had higher APACHE III scores on admission to the ICU, longer hospital stays, and higher in-hospital mortality rates than patients with DVTs.”
Sepsis was present in 72% of patients with upper-extremity DVT, compared with 53% of patients with lower-extremity DVT (P < 0.001), and 86% of upper-extremity DVT was associated with central venous catheters.
“Although studies for upper-extremity DVT are commonly performed in ICU patients, these patients are not routinely monitored,” said Robert Duncan Hite, MD, director of Medical Intensive Care and Critical Care Research at Wake Forest University Health Sciences, in Winston-Salem, North Carolina, in an interview with Medscape Critical Care.
“It is more common that upper-extremity studies are performed in patients with clinical signs or symptoms that might suggest upper-extremity DVT. This study suggests that may not be enough,” he said.
“The treatment for upper-extremity DVT is the same as for lower-extremity DVT, and that is with anticoagulants,” Dr. Hite commented. “One key difference is that most upper-extremity DVT is associated with the placement of a central venous catheter, so management should include removal of the line when possible, and the duration of therapy might not need to be as long as in lower-extremity DVT.
“A limitation of this study is [not knowing] whether all of the additional upper-extremity DVTs that were identified required treatment, or if removal of the central venous catheter was enough,” Dr. Hite added.
“Since anticoagulant therapy in the critically ill is associated with much higher risk and morbidity, clinicians should be cautious about aggressively treating all upper-extremity DVTs until more data are available,” he concluded.
Dr. Kabbani told Medscape Critical Care that a prospective cohort study to address these issues is being designed.
Drs. Hite and Dr. Kabbani have disclosed no relevant financial relationships.
Society of Critical Care Medicine (SCCM) 38th Critical Care Congress: Abstract 305. Presented February 2, 2009.