Direct oral anticoagulants for venous thromboembolism prophylaxis in critically ill patients: where do we go from here?

Excerpt

Venous thromboembolism (VTE) is an important problem and a particular challenge for critically ill patients. First, admission to an intensive care unit (ICU) is as a strong independent risk factor for provoked VTE [1] with an incidence of approximately 9% [2]. Second, establishing a diagnosis of VTE in critically ill patients is more likely to be delayed or missed than for other patient populations because of comorbid illnesses (e.g., heart failure) and therapies (e.g., sedation) that mask symptoms and signs [1]. Third, critically ill patients diagnosed with VTE experience more anticoagulant therapy-related complications because of increased bleeding risk [1, 3]. Together these three challenges make effective VTE prophylaxis particularly important for critically ill patients. Epidemiological data suggest that earlier initiation of thromboprophylaxis is associated with reduced incidence of VTE and increased survival [4]. Randomized controlled trials (RCTs) have established the efficacy of heparins in the prevention of VTE in ICU patients [5, 6]. The question remains whether new approaches to prophylaxis can further decrease the risk of VTE without increasing complications. …