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Mawla, Tamer Sayed Abdel MD1,∗; Amin, Arsany Thabet MBBCh1; El Kayal, Engy Shawky MD2; Momtaz, Osama Mahmoud MD1
2Radiology Department, Fayoum University, Egypt
∗Corresponding author: Tamer Sayed Abdel Mawla, MD, Critical Care Department, Fayoum University, Fayoum, El Naboy El Mohands Street, El Abody Region in front of El Nada Hospital, 11563, Egypt. E-mail: [email protected]
Ethics approval and consent to participate: Not applicable.
Consent for publication: Not applicable as the study did not include any practice on the patients.
Availability of data and material: The dataset(s) supporting the conclusions of this article is (are) included within the article [and its additional file(s)].
Authors’ contributions: TS collected the data and had a major role in writing the manuscript. AT collected the data and had a major role in writing the manuscript. ES analyzed and interpreted the data. Um analyzed and interpreted the data. All authors read and approve the final manuscript.
Conflict of interests: The authors reported no conflicts of interest.
This is an-open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0
In our study we aimed to determine the prevalence and risk factors that make the incidence of central line associated deep venous thrombosis increase.
This descriptive study was conducted on 80 critically ill patients with inserted central venous catheter. Venous duplex was done before 5th and 10th day of central venous catheters insertion.
The incidence of thrombosis was 22.5% (18 cases); 61.1% (11 cases) of them developed at 5th day and 38.9% (7 cases) developed at 10th day of using central line. There was higher incidence of thrombosis in patients with presence of malignancy (38.9%) with risk ratio 7.25 (bladder cancer was associated with the most significant high risk of catheter related thrombosis), autoimmune disease (27.8%) with risk ratio 7.5, patients with chronic kidney disease (27.8%), and shocked patients on vasopressors (55.6%). There was higher incidence of thrombosis among patients with Mahurkar insertion (35.7%) versus (15.3%) among patients with central line insertion with P: .05.
Central venous catheter related thrombosis is a frequent complication that occurs frequently, affecting about 1 quarter of ICU patients. Most cases occur as early as 5 days with increasing frequency over days. Mahurkar catheters carry more risk of thrombosis than central venous line catheters. Malignancy and autoimmune diseases have the higher risk of thrombosis, as well as shock and chronic kidney disease.
Central venous catheters (CVCs) have an essential part in the management of critically ill patients. They are useful for hemodynamic monitoring as well as for administration of specific medications like vasopressors, parenteral nutrition, and hemodialysis. These are associated with substantial risk of complications which can be mechanical, septic, and thrombotic.1
Deep vein thrombosis and pulmonary embolism are evolving and becoming well known to the public. They are both conditions that are recognized to have life-threatening consequences. The focus for deep vein thrombosis and pulmonary embolism has been mostly on the lower extremities. Upper extremity thrombosis is normally viewed as a more benign entity, but recent data suggested that the significance of morbidity and mortality is equal to that of the lower extremities. The prevalence of upper extremity thrombosis has increased due to the increase in usage of central venous catheters. Although, a majority of patients present with pain, swelling or prominent veins throughout the upper extremity, many patients will present as asymptomatic.2
Using ultrasound (duplex) is very important in early detection of subclinical venous thrombosis. Also it is useful in detection of site and size of the thrombus.3
Accurate diagnosis of CVC associated thrombosis is essential for planning prophylaxis and tailoring management for CVCs associated thrombosis patients to achieve better ICU outcome.4
This study aimed to study the prevalence of central venous catheter-associated venous thrombosis in critically ill patients using venous duplex despite of adequate prophylactic anticoagulation.
This descriptive study was conducted over 80 patients admitted to Critical Care Department, Fayoum University Hospital from December 2017 to December 2018. The study is approved by the Ethics Committee of the Faculty of Medicine, Fayoum University.
All patients with inserted CVC for various indications during the course of ICU admission were included in the study.
Excluded from our study patients with discharge or demise before 10 days of CVC insertion and concurrent use of anticoagulant therapy.
Assessment of the prevalence of CVC associated venous thrombosis in critically ill patients despite of adequate prophylactic anticoagulation.
The importance of routine venous duplex assessment of CVC as a daily practice in ICU and helped the practitioners to shift the anticoagulation from prophylactic to therapeutic doses.
After full history, complete clinical examination and routine laboratory investigations; all patients were subjected to the following:
Data were statistically described in terms of range, mean ± standard deviation (SD), median for quantitative variables, frequencies (number of cases), and relative frequencies (percentages) for categorical variables. Comparison of quantitative variables between the study groups was done using Student T test for independent samples when normally distributed and Mann-Whitney U test for independent samples when not normally distributed. For comparing categorical data, Chi square (χ2) test was performed. Exact test was used instead when the expected frequency is less than 5. A probability value (P-value) less than .05 was considered statistically significant. All statistical calculations were done using computer programs Microsoft Excel version XP (Microsoft corporation, NY) and Statistical Package for the Social Science (SPSS) (SPSS Inc., Chicago, IL) version 19 Microsoft Windows.
Our study population consisted of 80 patients that were admitted to the general I.C.U. of the Critical Care Department from December 2017 to December 2018 for diagnosis of central venous catheter-associated thrombosis (Table 1).
Among the included 80 patients, 33 (41.3%) of them were hypertensive, 24 (30%) were diabetic, 8 (10%) of them were associated with autoimmune diseases, and 12 (15%) of them were diagnosed with malignancy (Table 2).
Among the 12 patients with malignancy, the most frequent malignancy was bronchogenic carcinoma (4 patients) followed by bladder cancer (3 patients), and breast cancer.
Two patients were associated with brain metastasis, 1 patient had hepatocellular carcinoma, and 1 had lymphoma (Table 3).
This study included 25 shocked patients on vasopressors, 17 patients with respiratory failure I, 14 with acute kidney injury (AKI), 12 had respiratory failure II, 11 had stroke, 6 were associated with systemic lupus erythematous (SLE), 6 had chronic kidney disease, 4 were admitted with diabetic ketoacidosis, 2 had hepatic encephalopathy, 1 was associated with primary anti-phospholipid syndrome, and 1 was associated with rheumatoid arthritis (Table 4).
Sixty-five percent of cases used central line, versus 35% used Mahurkar (Table 5).
It was found that the incidence of thrombosis was 22.5% (18 cases); 61.1% (11 cases) of them developed at 5th day and 38.9% (7 cases) developed at 10th day of using central line (Table 6).
There was no statistically significant difference regarding thrombosis in correlation to age (P: .9) and sex (P: .8) (Table 7).
There was statistically significant difference between groups regarding presence of autoimmune disease and malignancy with higher percentage of thrombosis among patients with autoimmune disease (5 cases) (27.8% with risk ratio 7.5) and malignancy (7 cases) (38.9% with risk ratio 7.25). On the other hand there was no statistically significant difference regarding presence of hypertension and diabetes mellitus (Table 8).
Regarding specific types of malignancy, bladder cancer was associated with the most significant high risk of catheter related thrombosis (risk ratio is very high and cannot be calculated). It also may be due to the usage of large caliber dialysis catheters, that is, Mahurkar. There was statistically significant difference between study groups with higher percentage of thrombosis (16.7%).
Other malignancies, that is, bronchogenic carcinoma, lymphoma, and patients associated with brain metastasis also carried high risk (risk ratio 3.7, 3.6, 3.6, respectively); although this risk was not statistically significant (Table 9).
There was statistically significant difference between study groups regarding presence of chronic kidney disease with higher percentage of thrombosis (27.8%) among patients with CKD and shocked patients on vasopressors.
On the other hand there was no statistically significant difference regarding presence of other comorbidities (Table 10).
There was statistically higher incidence of thrombosis among patients on vasopressors (55.6% with calculated risk ratio reveals 3.9) compared to haemodynamically stable patients (24.2%) (Table 11).
There was statistically higher incidence of thrombosis among patients with inserted Mahurkar type (35.7%) compared to patients who had central venous line catheter (15.3%) with P: .05. The calculated risk ratio for occurrence of catheter related thrombosis revealed that Mahurkar catheters carried 3.1 more risk of thrombosis than using central venous catheter (Table 12).
Venous thromboembolism remains a major cause of morbidity and mortality in ICU.5
Upper extremity deep vein thrombosis (UEDVT) is an increasingly recognized complication in medical ICU, especially after the wide usage of CVC for different purposes. Secondary UEDVT is more common than primary UEDVT. Secondary UEDVT occurs due to thrombosis as a result of indwelling devices such as CVC, pacemaker or defibrillator leads, and tunneled central access lines. Catheter-associated UEDVT is the most common etiology comprising 93% of all UEDVT.6
In our study we aimed to evaluate the incidence of CVC associated deep venous thrombosis in 80 patients who had been admitted at medical ICU with central venous catheter insertion for different purposes and to study various risk factors associated with thrombosis.
It was found that CVC associated thrombosis was detected in 18 patients (22.5%); of which 11 patients (61.1%) were readily detected at day 5 whereas 7 patients (38.9%) at day 10.
The most frequent associated risk factors in the current study were the presence of autoimmune disease and malignancies which carried 7.5 and 7.25 risk ratio, respectively. The most frequent malignancy was bronchogenic carcinoma (4 patients) followed by bladder cancer (3 patients) and breast cancer.
In agreement to our study in which malignancy was found in 38.9% of patients with thrombosis compared to 8.1% incidence of thrombosis without malignancy. Mansour et al. found that the incidence of thrombosis is significantly higher in patients with malignancy than those without malignancy (45% versus 17%) in a study conducted on 87 patients.7
In agreement to the current results regarding the higher incidence of thrombosis in patients with autoimmune disease (27.8%), Nikolova-Vlahova et al. found that 34.7% were diagnosed with different autoimmune diseases in their study which had been conducted on 46 patients.8
Analysis of other comorbidities revealed that presence of shock, IV vasopressor therapy, and chronic kidney disease were associated with higher risk of thrombosis. On the other hand, there was no significant risk of age, sex, diabetes, hypertension, or respiratory failure.
Similarly, in Lu and Liao et al. study which included 3564 ESRD patients after exclusion of patients with previous DVT, they found that incidence of thrombosis is substantially higher in the ESRD group than in the without-ESRD group (20.9% versus 1.46%).9
It was also found a statistically significant difference in occurrence of thrombosis between study groups regarding types of central line with higher percentage of thrombosis among patients who used Mahurkar type (35.7%) compared to patients who used central venous line catheter (15.3%). Mahurkar catheters carried 3.1 more risk of thrombosis than using central venous catheter.
central venous catheter; pulmonary embolism; upper extremity deep vein thrombosis; venous duplex
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