Thromboprophylaxis for Intensive Care Patients

The advent of low-molecular-weight heparin (LMWH) marked a new chapter in the prevention of venous thromboembolism. The enviable pharmacokinetic properties associated with this class of medication, ensured the place of LMWH as an attractive, if albeit more expensive alternative to unfractionated heparin. Predictable and reproducible dose response continues to negate the need for monitoring in most patient groups, while the availability of antidotes further boosts the safety profile of LMWH. These agents have long proven their worth in the medico-surgical patient population. However we have recently shown in randomised studies, that LMWH at the current recommended dose may not be as effective for critically ill patients. Critically ill patients encompass that population of patients with profound disturbance of physiology, who are at imminent risk of death and in need of continuous care. Such patients have proven to be somewhat resistant, and current evidence indicates that they may benefit from a higher dose of LMWH. A difficult undertaking, considering the heterogeneity of this population, as well as their predisposition to both haemorrhage and thromboembolism. A variety of new oral antithrombotics has recently become available for use among certain patient populations, but has not yet been studied in the intensive care unit (ICU) setting. These agents have been associated with increased risk of bleeding, and as yet, a definitive strategy in the event of major bleeding does not exist. In addition, they are more costly when compared with LMWH. All the aforementioned factors combine to make the new oral agents, unattractive alternatives for thromboprophylaxis in the ICU population.