Risk factors and impact of major bleeding in critically ill patients receiving heparin thromboprophylaxis.


Journal Article

PURPOSE: Bleeding frequently complicates critical illness and may have serious consequences. Our objectives are to describe the predictors of major bleeding and the association between bleeding and mortality in medical-surgical critically ill patients receiving heparin thromboprophylaxis. METHODS: We prospectively studied patients from 67 intensive care units and six countries enrolled in a thromboprophylaxis trial (NCT00182143) comparing dalteparin with unfractionated heparin. Patients with trauma, orthopedic surgery or neurosurgery were excluded. Trained research coordinators used a validated tool to document bleeding, which underwent duplicate independent blinded adjudication. Major bleeding was defined as hypovolemic shock, bleeding into critical sites, requiring an invasive intervention or transfusion of at least two units of red blood cells, or associated with hypotension or tachycardia in the absence of other causes. Adjusted Cox proportional hazard regression analysis was used to identify major bleeding predictors and the association between bleeding and mortality. RESULTS: Among 3,746 patients, bleeding occurred in 208 [5.6 %, 95 % confidence interval (CI) 4.9-6.3 %]. Time-dependent predictors were prolonged activated partial thromboplastin time [hazard ratio (HR) 1.10, 1.05-1.14 per 10 s increase], lower platelet count (HR 1.16, 1.09-1.24 per 50 × 10(9)/L decrease), therapeutic heparin (HR 3.26, 1.72-6.17), antiplatelet agents (HR 1.38, 1.02-1.88), renal replacement therapy (HR 1.75, 1.20-2.56), and recent surgery (HR 1.64, 1.01-2.65). Type of pharmacologic thromboprophylaxis was not associated with bleeding. Patients with bleeding had a higher risk of in-hospital death (HR 2.09, 1.69-2.57). CONCLUSIONS: As major bleeding has modifiable risk factors and is associated with in-hospital mortality, strategies to mitigate these factors should be evaluated in critically ill patients.

Full Text

Duke Authors

Cited Authors

  • Lauzier, F; Arnold, DM; Rabbat, C; Heels-Ansdell, D; Zarychanski, R; Dodek, P; Ashley, BJ; Albert, M; Khwaja, K; Ostermann, M; Skrobik, Y; Fowler, R; McIntyre, L; Nates, JL; Karachi, T; Lopes, RD; Zytaruk, N; Finfer, S; Crowther, M; Cook, D

Published Date

  • December 2013

Published In

Volume / Issue

  • 39 / 12

Start / End Page

  • 2135 - 2143

PubMed ID

  • 23942857

Pubmed Central ID

  • 23942857

Electronic International Standard Serial Number (EISSN)

  • 1432-1238

Digital Object Identifier (DOI)

  • 10.1007/s00134-013-3044-3


  • eng

Conference Location

  • United States