title: Nonleg venous thrombosis in critically ill adults: a nested prospective cohort study.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00182143.
authors.affiliation: Centre de recherche Clinique Étienne-Le Bel, Université de Sherbrooke, Sherbrooke, Quebec, Canada.
authors.forename: Francois
authors.initials: F
authors.lastname: Lamontagne
authors.affiliation: Department of Medicine (Division of Critical Care), The Ottawa Hospital, Ottawa, Ontario, Canada.
authors.forename: Lauralyn
authors.initials: L
authors.lastname: McIntyre
authors.affiliation: Center for Health Evaluation and Outcome Sciences and Department of Medicine, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Dodek
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Diane
authors.initials: D
authors.lastname: Heels-Ansdell
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada5Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Maureen
authors.initials: M
authors.lastname: Meade
authors.affiliation: Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Julia
authors.initials: J
authors.lastname: Pemberton
authors.affiliation: Department of Medicine, Hôpital Maisonneuve Rosemont, Montreal, Quebec, Canada.
authors.forename: Yoanna
authors.initials: Y
authors.lastname: Skrobik
authors.affiliation: Department of Intensive Care Medicine, Nepean Hospital, University of Sydney, Sydney, Australia.
authors.forename: Ian
authors.initials: I
authors.lastname: Seppelt
authors.affiliation: Department of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota.
authors.forename: Nicholas E
authors.initials: NE
authors.lastname: Vlahakis
authors.affiliation: Department of Critical Care, Queen's University, Kingston, Ontario, Canada.
authors.forename: John
authors.initials: J
authors.lastname: Muscedere
authors.affiliation: Department of Intensive Care Medicine, Blacktown Hospital, Sydney, Australia.
authors.forename: Graham
authors.initials: G
authors.lastname: Reece
authors.affiliation: Department of Critical Care, Guys and St Thomas Hospital, London, England.
authors.forename: Marlies
authors.initials: M
authors.lastname: Ostermann
authors.affiliation: Department of Ultrasonic Angiology, Guys and St Thomas Hospital, London, England.
authors.forename: Soundrie
authors.initials: S
authors.lastname: Padayachee
authors.affiliation: Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia.
authors.forename: Jamal
authors.initials: J
authors.lastname: Alhashemi
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada5Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Walsh
authors.affiliation: Department of Radiology, Mayo Clinic, Rochester, Minnesota.
authors.forename: Bradley
authors.initials: B
authors.lastname: Lewis
authors.affiliation: Department of Radiology, McMaster University, Hamilton, Ontario, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Schiff
authors.affiliation: Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Alan
authors.initials: A
authors.lastname: Moody
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Nicole
authors.initials: N
authors.lastname: Zytaruk
authors.affiliation: Department of Medicine, Hôpital Maisonneuve Rosemont, Montreal, Quebec, Canada.
authors.forename: Martine
authors.initials: M
authors.lastname: Leblanc
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada5Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Cook
mesh_terms: D018806:APACHE; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D015331:Cohort Studies; D016638:Critical Illness; D005260:Female; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units; D008168:Lung / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000209:etiology*; D012307:Risk Factors; D034941:Upper Extremity / Q000503:physiopathology*; D054556:Venous Thromboembolism / Q000209:etiology*; D020246:Venous Thrombosis / Q000145:classification / Q000150:complications* / Q000401:mortality
chemical_list: D000925:Anticoagulants; D006493:Heparin