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David Kaplan, MD; Matthew T. Rondina, MD
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FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest.

CORRESPONDENCE TO: Matthew T. Rondina, MD, Department of Internal Medicine, University of Utah, 50 N Medical Dr, Room 4B120, Salt Lake City, UT 84132


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(4):1107-1108. doi:10.1016/j.chest.2016.01.016
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We appreciate the thoughtful questions raised by Drs Sorenson and McCurdy and the support of our article investigating the incidence of VTE in severe sepsis and septic shock. Our finding of a VTE incidence of 37.2% is higher than in prior reports, perhaps owing in part to our study design in which all patients were evaluated with ultrasound imaging.

We agree that strategies to reduce VTE risk in sepsis might include weight-based dosing of heparinoids, which may prevent VTE in patients who are obese more effectively compared with fixed-dosing regimens., Although we were unable to detect a significant correlation between BMI and VTE in our study, this may be a result of the markedly prothrombotic state in severe sepsis and septic shock. Critically ill patients who are septic are also at increased risk of bleeding, partly because of sepsis-associated coagulopathy. Thus, increased anticoagulant dosing may cause excess bleeding in this population. Prospective, randomized, controlled trials are needed to optimize anticoagulant selection and dosing to prevent VTE severe sepsis and septic shock.

The timing of VTE development in sepsis also intrigues us, and we appreciate this insightful comment. Cook et al performed serial ultrasound examinations on 817 critically ill patients (5.4% of whom had sepsis) and found that the median time to VTE diagnosis was 8 days (interquartile range, 4-14 days). Since only a small minority of patients in this cohort had sepsis, however, additional prospective studies are needed to determine the timing of VTE in septic patients. This information would potentially lead to earlier VTE diagnosis and treatment, and more favorable clinical outcomes. Meanwhile, providers should maintain a low threshold for evaluating the possibility of VTE in sepsis.

In our opinion, whether VTE is an unavoidable consequence is not yet known. Whereas thromboprophylaxis reduces VTE in hospitalized medically ill and surgical patients, current guideline-supported VTE prevention strategies may be less effective among critically ill patients who have sepsis. Higher-intensity anticoagulation (perhaps regardless of BMI) combining thromboprophylaxis with mechanical devices or using recently approved anticoagulants may reduce VTE risk but requires further investigation.

References

Kaplan D. .Casper T.C. .Elliott C.G. .et al VTE incidence and risk factors in patients with severe sepsis and septic shock. Chest. 2015;148:1224-1230 [PubMed]journal. [CrossRef] [PubMed]
 
Wang T.F. .Milligan P.E. .Wong C.A. .Deal E.N. .Thoelke M.S. .Gage B.F. . Efficacy and safety of high-dose thromboprophylaxis in morbidly obese inpatients. Thromb Haemost. 2014;111:88-93 [PubMed]journal. [PubMed]
 
Rondina M.T. .Wheeler M. .Rodgers G.M. .Draper L. .Pendleton R.C. . Weight-based dosing of enoxaparin for VTE prophylaxis in morbidly obese, medically-Ill patients. Thromb Res. 2010;125:220-223 [PubMed]journal. [CrossRef] [PubMed]
 
Semeraro N. .Ammollo C.T. .Semeraro F. .Colucci M. . Coagulopathy of acute sepsis. Semin Thromb Hemost. 2015;41:650-658 [PubMed]journal. [CrossRef] [PubMed]
 
Cook D. .Crowther M. .Meade M. .et al Deep venous thrombosis in medical-surgical critically ill patients: prevalence, incidence, and risk factors. Crit Care Med. 2005;33:1565-1571 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Kaplan D. .Casper T.C. .Elliott C.G. .et al VTE incidence and risk factors in patients with severe sepsis and septic shock. Chest. 2015;148:1224-1230 [PubMed]journal. [CrossRef] [PubMed]
 
Wang T.F. .Milligan P.E. .Wong C.A. .Deal E.N. .Thoelke M.S. .Gage B.F. . Efficacy and safety of high-dose thromboprophylaxis in morbidly obese inpatients. Thromb Haemost. 2014;111:88-93 [PubMed]journal. [PubMed]
 
Rondina M.T. .Wheeler M. .Rodgers G.M. .Draper L. .Pendleton R.C. . Weight-based dosing of enoxaparin for VTE prophylaxis in morbidly obese, medically-Ill patients. Thromb Res. 2010;125:220-223 [PubMed]journal. [CrossRef] [PubMed]
 
Semeraro N. .Ammollo C.T. .Semeraro F. .Colucci M. . Coagulopathy of acute sepsis. Semin Thromb Hemost. 2015;41:650-658 [PubMed]journal. [CrossRef] [PubMed]
 
Cook D. .Crowther M. .Meade M. .et al Deep venous thrombosis in medical-surgical critically ill patients: prevalence, incidence, and risk factors. Crit Care Med. 2005;33:1565-1571 [PubMed]journal. [CrossRef] [PubMed]
 
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