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Correspondence |

Increased Incidence of VTE in Septic Shock: Is this Preventable? FREE TO VIEW

Carina A. Sorenson, MD; Michael T. McCurdy, MD
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FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

CORRESPONDENCE TO: Carina A. Sorenson, MD, University of Maryland School of Medicine, Division of Pulmonary and Critical Care Medicine, 110 South Paca St, 2nd Floor, Baltimore, MD 21201


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


Chest. 2016;149(4):1107. doi:10.1016/j.chest.2015.12.040
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We read with great interest the article entitled, “VTE Incidence and Risk Factors in Patients With Severe Sepsis and Septic Shock,” published a recent issue of CHEST (November 2015). This well-conducted prospective study investigated the incidence of VTE in 113 patients presenting to three academic ICUs with severe sepsis or septic shock. Despite all patients receiving guideline-recommended thromboprophylaxis, the incidence of VTE at ICU discharge was 37.2%, a marked increase in VTE compared with previous studies that did not focus specifically on patients with sepsis.,, This interesting outcome raises three questions for us.

First, although the authors note that future studies should address the use of higher doses of heparinoids or combination prophylaxis with both heparinoids and mechanical devices, we instead wonder if greater attention to proper dosing of such medications should first be warranted. For example, the mean BMI in this study was 31.7 kg/m2, suggesting that weight-based dosing of heparinoids may be a more efficacious approach. In addition, patients with sepsis often develop significant subcutaneous edema as a result of volume resuscitation, confounding the degree of absorption of subcutaneously delivered heparin products.

Second, all patients were screened at ICU discharge for VTE by using compression ultrasonography, but we wonder when exactly the clots developed during the illness. Given the high incidence of VTE in this study and the high cost associated with VTE, future studies addressing the actual timing of VTE onset in patients with sepsis may elucidate the optimal timing for screening ultrasonography, leading to more cost-effective ICU management in this population.

Third, VTE development during hospitalization is often considered a preventable complication. The high incidence of VTE in patients with sepsis despite 100% compliance with prophylactic guidelines suggests that VTE may actually be an unavoidable consequence of the proinflammatory and prothrombotic state of sepsis.

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]
 
Cook D. .Attia J. .Weaver B. .et al Venous thromboembolic disease: an observational study in medical-surgical intensive care unit patients. J Crit Care. 2000;15:127-132 [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]
 
Muscedere J.G. .Heyland D.K. .Cook D. . Venous thromboembolism in critical illness in a community intensive care unit. J Crit Care. 2007;22:285-289 [PubMed]journal. [CrossRef] [PubMed]
 

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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]
 
Cook D. .Attia J. .Weaver B. .et al Venous thromboembolic disease: an observational study in medical-surgical intensive care unit patients. J Crit Care. 2000;15:127-132 [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]
 
Muscedere J.G. .Heyland D.K. .Cook D. . Venous thromboembolism in critical illness in a community intensive care unit. J Crit Care. 2007;22:285-289 [PubMed]journal. [CrossRef] [PubMed]
 
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