Guidelines for VTE prophylaxis in Neurocritical Care

Nyquist, Paul, Jichici, Draga et el recently published evidence based guidelines for prevention of venous thromboembolism in neurocritical care.

Risk of venous thromboembolism is present in all hospitalized patients and specially higher in neurocritical patients due to immobility. Combination therapy with chemoprophylaxis (Unfractioned heparin, Low molecular heparin) and mechanical prophylaxis (Intermittent pneumatic compression devices) is superior to either approach alone in preventing DVT.  Either therapy alone should be used when any of them is contraindicated.

Here is the summary of these recommendations-

Condition Recommendations
Ischemic stroke Pharmacoprophylaxis as soon as is feasible, dual(pharmacological and mechanical) in patients with poor mobility, delay for 24 hours in case of tPA,
Intracranial hemorrhage Mechanical prophylaxis on admission,  ADD Chemoprophylaxis after 48 hours in patients with stable hematomas
Aneurysmal Subarachnoid Hemorrhage Initiate mechanical prophylaxis, add UFH at least 24 hours after an aneurysm has been secured by surgical approach or by coiling
Traumatic Brain Injury Initiate mechanical prophylaxis , Chemo prophylaxis within 24–48 hours of presentation in patients with TBI and ICH, or 24 hours after craniotomy
Brain Tumors Chemoprophylaxis in patients who have low risk for major bleeding and who lack signs of hemorrhagic conversion
Spinal Cord Injury Chemoprophylaxis as soon as bleeding is controlled
Neuromuscular Disease Chemoprophylaxis, mechanical if chemoprophylaxis is contraindicated. Ideally both.
Patients Undergoing Neurosurgical and Neurovascular Interventions Ambulation with mechanical VTE prophylaxis
Elective

Craniotomy

Start with mechanical, add Chemoprophylaxis after 24 hours.
Patients Undergoing Intracranial

Endovascular Procedures

Chemo +/- mechanical prophylaxis as soon as ACT is normalized

 

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