Chest
Volume 148, Issue 5, November 2015, Pages 1224-1230
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Original Research
Critical Care
VTE Incidence and Risk Factors in Patients With Severe Sepsis and Septic Shock

https://doi.org/10.1378/chest.15-0287Get rights and content

BACKGROUND

Prospective studies on the incidence of VTE during severe sepsis and septic shock remain absent, hindering efficacy assessments regarding VTE prevention strategies in sepsis.

METHODS

We prospectively studied 113 consecutively enrolled patients in the ICU with severe sepsis and septic shock at three hospitals. All patients provided informed consent. VTE thromboprophylaxis was recorded for all patients. Patients underwent ultrasonography and were followed for VTE prior to ICU discharge. All-cause 28-day mortality was recorded. Variables from univariate analyses that were associated with VTE (including central venous catheter [CVC] insertion, age, length of stay, and mechanical ventilation) were included in a multivariable logistic regression analysis using backward stepwise elimination to determine VTE predictors.

RESULTS

Mean APACHE (Acute Physiology and Chronic Health Evaluation) II score was 18.2 ± 7.0, and age was 50 ± 18 years. Despite all patients receiving guideline-recommended thromboprophylaxis, the incidence of VTE was 37.2% (95% CI, 28.3-46.8). Most VTE events were clinically significant (defined as pulmonary embolism, proximal DVT, and/or symptomatic distal DVT) and associated with an increased length of stay (18.2 ± 9.9 days vs 13.4 ± 11.5 days, P < .05). Mortality was higher in patients with acute VTE but did not reach statistical significance. Insertion of a CVC and longer mechanical ventilation duration were significant VTE risk factors. VTE incidence did not differ by thromboprophylaxis type.

CONCLUSIONS

To our knowledge this is the first multicenter prospective study to identify a high incidence of VTE in patients with severe sepsis and septic shock, despite the use of universal, guideline-recommended thromboprophylaxis. Our findings suggest that the systemic inflammatory milieu of sepsis may uniquely predispose patients with sepsis to VTE. More effective VTE prevention strategies are necessary in patients with sepsis.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02353910; URL: www.clinicaltrials.gov

Section snippets

Results

We prospectively enrolled 113 consecutively identified patients in the ICU with severe sepsis or septic shock (Fig 1, Table 1). Upon study entry, the mean APACHE II score was 18.2, > 50% of patients had shock requiring vasopressors, and > 75% required mechanical ventilation (Table 1). Overall, 61.1% of patients (69 of 113) had a CVC placed as part of their ICU care. More than 50% of patients had obesity, a known risk factor for VTE (Table 1). All-cause 28-day mortality was 21.2% (95% CI,

Discussion

To our knowledge, this is the first prospective, multicenter study to investigate VTE incidence, outcomes, and risk factors in patients admitted to the ICU with severe sepsis and septic shock. We identified a high incidence of VTE (37.2%) in patients with sepsis despite the use of universal, guideline-recommended thromboprophylaxis. The majority of patients (88%) had clinically significant VTE (symptomatic PE, proximal DVT, or symptomatic distal DVT) that influenced clinical management and was

Conclusions

In conclusion, patients with severe sepsis and septic shock have a high incidence of VTE, despite the use of universal, guideline-recommended thromboprophylaxis. More effective VTE prevention strategies are necessary in patients with sepsis, and future research in this population is urgently needed. Among these high-risk patients, removing CVCs when no longer necessary, minimizing the size of CVCs or avoiding their use when feasible, and strategies for early extubation may reduce the incidence

Acknowledgments

Author contributions: M. T. R. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis, including and especially any adverse effects. D. K. contributed to data analysis, critical writing, and intellectual content; T. C. C. contributed to statistical analysis and intellectual content; C. G. E., S. M., and R. C. P. contributed to critical writing and intellectual content; L. W. K., A. S. W., C. K. G., G. A. Z., and

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originally published Online First June 25, 2015.

FUNDING/SUPPORT: This work was supported by the National Institutes of Health [Grants HL092161 to M. T. R. and HL112311 to A. S. W.) and the National Institute on Aging [Grants AG040631 and AG048022 to M. T. R.]. This work was also supported by the University of Utah Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health [Grant 8UL1TR000105 (formerly UL1RR025764)].

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