Prophylaxis of Venous Thrombosis in Neurocritical Care Patients
Recommendations
VTE Prophylaxis in Critically Ill Patients with Ischemic Stroke
1) We recommend initiating venous thromboembolism (VTE) pharmacoprophylaxis as soon as is feasible in all patients with acute ischemic stroke.
(High, Strong)2) In patients with acute ischemic stroke and restricted mobility, we recommend prophylactic-dose Low-molecular-weight heparin (LMWH) over prophylactic-dose unfractionated heparin (UFH) in combination with intermittent pneumatic compression (IPC).
(High, Strong)3) Due to insufficient evidence, the panel could not issue a recommendation regarding the use of compression stockings (CS) for VTE prophylaxis although their use does not appear to be harmful.
(, )4) In stroke patients undergoing hemicraniotomy or endovascular procedures, we suggest the use of UFH, LMWH, and/or IPC for VTE prophylaxis in the immediate postsurgical or endovascular epoch except when patients have received rTPA, in which case prophylaxis should be delayed 24 h.
(Low, Weak)VTE Prophylaxis in Critically Ill Patients with Intracranial Hemorrhage
1) We recommend the use of IPC and/or GCS for VTE prophylaxis over no prophylaxis beginning at the time of hospital admission.
(High, Strong)2) We suggest using prophylactic doses of subcutaneous UFH or LMWH to prevent VTE in patients with stable hematomas and no ongoing coagulopathy beginning within 48 h of hospital admission.
(Low, Weak)3) We suggest continuing mechanical VTE prophylaxis with IPCs in patients started on pharmacologic prophylaxis.
(Low, Weak)VTE Prophylaxis for Critically Ill Patients with Aneurysmal Subarachnoid Hemorrhage
1) We recommend VTE prophylaxis with UFH in all patients with aneurysmal subarachnoid hemorrhage (aSAH).
(Low, Strong)2) We recommend initiating IPCs as VTE prophylaxis as soon as patients with aSAH are admitted to the hospital.
(Moderate, Strong)3) We recommend VTE prophylaxis with UFH at least 24 h after an aneurysm has been secured by surgical approach or by coiling.
(Moderate, Strong)VTE Prophylaxis for Critically Ill Patients with Traumatic Brain Injury (TBI)
1) We recommend initiating IPC for VTE prophylaxis within 24 h of presentation of TBI or within 24 h after completion of craniotomy as supported by evidence in ischemic stroke and postoperative craniotomy.
(Low, Weak)2) We recommend initiating LMWH or UFH for VTE prophylaxis within 24–48 h of presentation in patients with traumatic brain injury (TBI) and Intracranial hemorrhage (ICH), or 24 h after craniotomy.
(Low, Weak)3) Werecommend usingmechanical devices such as IPC for VTE prophylaxis in patients with TBI, based on data from other neurological injuries such as ischemic stroke.
(Low, Weak)VTE Prophylaxis for Critically Ill Patients with Brain Tumors
In brain tumor patients:
1. We recommend VTE prophylaxis with either LMWH or UFH upon hospitalization for patients with brain tumors who are at low risk for major bleeding and who lack signs of hemorrhagic conversion.
(Moderate, Strong)VTE Prophylaxis for Critically Ill Patients with Spinal Cord Injury
1) We recommend initiating VTE prophylaxis as early as possible, within 72 h of injury.
(High, Strong)2) We recommend against using mechanical measures alone for VTE prophylaxis.
(Low, Weak)3) We recommend LMWH or adjusted dose UFH for VTE prophylaxis as soon as bleeding is controlled.
(Moderate, Strong)4) If VTE prophylaxis with LMWH or UFH is not possible, we suggest mechanical prophylaxis with IPC.
(Low, Weak)VTE Prophylaxis in Critically Ill Patients with Neuromuscular Disease
1) We recommend using prophylactic doses of UFH (bid or tid) LMWH, or fondaparinux as the preferred method of VTE prophylaxis.
(Moderate, Strong)2) We recommend using IPC for VTE prophylaxis for patients in whom the bleeding risk is deemed too high for pharmacologic prophylaxis.
(Moderate, Strong)3) We suggest combining pharmacologic and mechanical VTE prophylaxis (with IPC) in patients with neuromuscular disease.
(Low, Weak)4) We suggest using graduated compression stockings (GCS) only for VTE prophylaxis in patients in whom neither pharmacologic prophylaxis nor IPC use is possible.
(Low, Weak)5) We suggest continuing VTE prophylaxis for an extended period of time, at a minimum for the duration of the acute hospitalization, or until the ability to ambulate returns.
(Very Low, Weak)VTE Prophylaxis in Critically Ill Patients Undergoing Neurosurgical and Neurovascular Interventions
Prevention of VTE in Elective Spine Surgery
1) Ambulatory back surgery with unique positioning strategies such as prone or kneeling has been associated with zero rates of VTE, and we suggest considering the use of IPC only for VTE prophylaxis in this surgical population.
(Low, Weak)2) In standard elective spine surgery, we recommend using ambulation with mechanical VTE prophylaxis (GCS or IPC) alone, or combined with LMWH. In patients with increased risk for VTE, we recommend combined therapy with ambulation, GCS or IPC, and LMWH.
(Moderate, Strong)3) Because of the increased risk of bleeding, we recommend using UFH only as an alternative to other methods of VTE prophylaxis.
(Moderate, Strong)Prevention of VTE in Complicated Spinal Surgery
1) We recommend using IPC with LMWH or UFH.
(Moderate, Strong)2) We recommend against the routine use of inferior venous-caval (IVC) filters in the setting of severe spinal cord injury or complicated spine surgery.
(Low, Weak)3) We suggest considering a removable prophylactic IVC filter as a temporary measure only in patients with pulmonary embolus (PE) and DVT or those with DVT at risk for PE who cannot be anticoagulated.
(Low, Weak)Prevention of VTE in Elective Craniotomy
1) We recommend using IPC with either LMWH or UFH within 24 h after craniotomy.
(Moderate, Strong)2) We recommend the use of IPC with LMWH or UFH within 24 h after standard craniotomy in the setting of glioma resection.
(Moderate, Strong)Prevention of VTE in Elective Intracranial/Intra-arterial Procedures
1) We suggest the use of CS and IPC until the patient is ambulatory.
(Low, Weak)2) We suggest immediate prophylactic anticoagulation with LWMH or UFH.
(Low, Weak)VTE Prevention in Patients Undergoing Intracranial Endovascular Procedures
1) We recommend initiating pharmacoprophylaxis with UFH and/or mechanical VTE prophylaxis with IPC or CS in patients with hemiparesis from stroke or other neurological injury within 24 h if activated prothrombin time is measured.
(Low, Weak)2) Patients undergoing elective procedures may not require LMWH or UFH, but may benefit from early ambulation, and/or mechanical prophylaxis with IPC or CS.
(Very Low, Weak)Recommendation Grading
Overview
Title
Prophylaxis of Venous Thrombosis in Neurocritical Care Patients
Authoring Organization
Neurocritical Care Society
Publication Month/Year
December 1, 2015
Last Updated Month/Year
May 31, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To develop evidence-based guideline to safely reduce VTE and its associated complications.
Target Patient Population
Neurocritical care patients
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Prevention, Management
Diseases/Conditions (MeSH)
D054556 - Venous Thromboembolism, D000925 - Anticoagulants, D010975 - Platelet Aggregation Inhibitors, D003422 - Critical Care
Keywords
venous thromboembolic event (VTE)
Source Citation
Neurocritical Care volume 24, pages47–60(2016)