CLINICAL FOCUS

Preventing Venous Thromboembolism in

Critical Care (ICU)

Jonathan Busby

Version 1.0
February 11, 2019

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info@arjo.com
A focus on Intermittent Pneumatic Compression: non-
invasive effective prophylaxis
Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism
(PE), is a potentially serious complication that delays recovery and discharge, leads to long-term and
often life changing complications, while increasing healthcare cost.1, 2

With sub-optimal prophylaxis, the risk of VTE in ICU patients may be as high as 80%. 3 Even with
preventative measures, up to 15% of patients4 will be diagnosed with VTE, many during their first
week of admission.3 However, because the condition may remain clinically ‘silent’,5, 6 the actual
incidence may be underestimated and the first evidence of a PE may still be at post mortem.7, 8
Fortunately, unexpected hospital death from PE is declining,9 perhaps due to diligent prophylaxis,
but VTE remains the most common, preventable, cause of inpatient mortality.4

Why are ICU patients particularly vulnerable?

Patients transferred to ICU typically present with multiple and rapidly changing risk factors. This is in
part due to their underlying diagnosis, such as age, previous VTE, malignancy, trauma, surgery10
and also because medical interventions may affect mobility, circulation and tendency to clot (e.g.
sedation, vasopressors, paralytic agents and central venous catheterisation).
In addition, prolonged ICU stay, high APACHE score and mechanical
ventilation are indicative of heightened risk. 4, 6, 8

As resuscitation and stabilisation is prioritised on admission, early signs and

symptoms of VTE may be masked and further obscured by supportive
interventions. As VTE can be difficult to diagnose, 11 even extensive thrombi
may be present, but remain undetected.12 Individually, these risk factors align
directly to VTE pathology (Fig. 1).
Figure 1: Vichow’s Triad,
Venous stasis principle cause of VTE

ICU patients are typically immobile, often sedated and sometimes paralysed, leading to a marked
decrease in venous blood flow and resultant venous stasis.

Hypercoagulation and vessel injury

• Vessel damage from surgery, trauma or invasive procedures, such as central arterial and
venous lines stimulate a release of naturally occurring mediators (procoagulants), which raise
the tendency of blood to form clots. While, major surgery and trauma can provoke potentially
life-threatening fibrinolytic dysregulation, including ‘fibrinolytic shutdown’:13 a process that occurs
during or soon after the trauma/procedure reducing natural micro thrombus breakdown. This
disruption of the natural physiological balance between essential blood clotting (coagulation)
and targeted clot breakdown (thrombolysis) can lead to VTE formation – an inappropriate blood
clot in an inappropriate location. This balance is challenged frequently in ICU patients.

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Prevention of VTE in ICU

Clinicians have choice of pharmacological and mechanical treatments available. Anticoagulants are
routinely administered, unless contraindicated, and generally used in combination with mechanical
methods for this highest risk group. Although vena cava filters may reduce thrombus migration and
lower PE risk, there are questions about the cost-effectiveness of this approach and, ironically, an
increased risk of adverse events including DVT have been reported.14, 15 As always, it is better to
prevent than treat.

Why Flowtron IPC?

Flowtron Systems are classified as mechanical prophylaxis along

with anti-embolic stockings (AES). However, IPC’s active mode of
action differs from passive compression (AES) and, unlike all other
forms of prophylaxis, addresses both venous stasis and
hypercoagulation.

Figure 2: Flowtron Active Compression System

• Prevention of venous stasis

Active compression, whether applied in a uniform or sequential manner, systematically squeezes the
leg and/or foot to augment of blood flow (Fig. 2).16 The benefits, established more than two decades
ago, include reduced stasis, pulsatile flush to valve pockets where many thrombi originate,
decreased venous hypertension and reduced interstitial oedema.17 -24

• Anticoagulant and profibrinolytic effect

The mechanical action of intermittent compression also triggers the release of chemical mediators
from the endothelial cells that line the deep veins.25 These mediators stimulate vessel dilatation,
reduce platelet aggregation and have a measurable antithrombotic effect by increasing the fibrinolytic
activity of the blood, 26, 27 while suppressing procoagulant factors28 and aiding the reversal or
prevention of fibrinolytic shutdown.

• Safety

Because Flowtron IPC mimics natural physiological activity, it is one of the safest methods of
prophylaxis when correctly applied.29 As a safe modality, IPC is recommended for use in combination
with chemical prophylaxis in high-risk patients3, 5, 30 and is the modality of choice when
anticoagulation is contraindicated.31-33 For example, ICU patients may present with severe trauma,
thrombocytopenia, renal insufficiency or active bleeding where the risk of catastrophic haemorrhage
precludes the use of anticoagulants.

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Recommendations for ICU patients

The publication of expert-lead national and international guidelines has provided a clear evidence-
base for prescribers caring for patients receiving intensive care.4, 31, 33 Additional reviews highlight
how multimodality prophylaxis may be beneficial.3, 12, 34-36

These recommendations define an important role for Flowtron IPC as either a stand alone or
combined therapy and are summarised below:

• Assess all ICU patients for VTE and risk of bleeding daily and more often if the patient’s
condition changes rapidly.
• Individualised patient regimens should be drawn up based upon patients’ risk of bleeding
and thrombosis.
• Low molecular weight heparin is indicated for all ICU patients unless contraindicated.
• For patients at high risk of bleeding, mechanical prophylaxis is recommended until the
bleeding risk diminishes.
• Use IPC on admission for people with serious or major trauma.
• If using IPC, start on admission and continue until the person reaches their normal or
anticipated mobility level.
• Combined pharmacological and mechanical methods of prophylaxis may provide greater
protection than either alone.

Summary

ICU patients have a unique and complicated clinical profile, they are typically at an elevated risk of
developing VTE and challenge clinical decision-making. Fortunately, expert consensus groups have
reviewed the available evidence and published clear guidelines asserting the essential need for
prophylaxis, including a specific role for IPC as both an independent and combination therapy in high
risk groups.

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© Arjo 2019
Arjo.A00045.1.0.INT.EN