From the Guidelines
Yes, you can generally provide VTE prophylaxis to patients with PRES or encephalopathy, but careful risk assessment is essential. When considering VTE prophylaxis for these patients, it's crucial to weigh the benefits of preventing venous thromboembolism against the potential risks, particularly bleeding, as highlighted in the care of patients with acute ischemic stroke 1. For most patients, pharmacological prophylaxis with low molecular weight heparin, such as enoxaparin 40mg subcutaneously once daily, or unfractionated heparin 5000 units subcutaneously two to three times daily, is appropriate.
Key considerations include:
- The patient's mobility status, as reduced mobility increases the risk of VTE
- The presence of hemorrhagic components on neuroimaging, which may necessitate initial use of mechanical prophylaxis
- The severity of PRES/encephalopathy and associated conditions that may influence bleeding risk or thrombosis propensity
- The importance of early mobilization as a preventive strategy for VTE, as soon as the patient's condition allows, as supported by studies on stroke care 1
Given the high risk of VTE in patients with limited mobility and the potential for severe outcomes, initiating VTE prophylaxis as soon as possible is recommended, with a preference for dual pharmacological and mechanical therapy when feasible. However, the decision must be individualized, taking into account the patient's specific clinical picture and risk factors, as the management of VTE prophylaxis in patients with PRES or encephalopathy requires a balanced approach to minimize both thrombotic and bleeding complications.
From the Research
VTE Prophylaxis in Patients with PRES/Encephalopathy
There are no direct studies that address the administration of VTE prophylaxis to patients with PRES (Posterior Reversible Encephalopathy Syndrome) or encephalopathy. However, we can look at studies related to VTE prophylaxis in patients with similar neurological conditions.
Studies on VTE Prophylaxis in Neurocritical Care Patients
- A study published in 2019 2 examined current VTE prophylaxis practices among neurocritical care patients and found that pharmacological VTE prophylaxis was administered on 60.9% of all ICU days, while mechanical VTE prophylaxis was used on 46.9% of all ICU days.
- Another study published in 2016 3 provided guidelines for VTE prophylaxis in immobile patients with acute ischemic stroke, recommending the use of intermittent pneumatic compression (IPC) and prophylactic anticoagulation with unfractionated heparin (UFH) or low molecular weight heparin (LMWH).
Safety of VTE Prophylaxis in Patients with Brain Injury
- A study published in 2012 4 found that the use of LMWH for VTE prophylaxis in patients with traumatic brain injury may not be safe, as it was associated with a higher risk of hemorrhage progression.
- However, a more recent study published in 2021 5 found that administering LMWH for VTE prophylaxis in patients with intracerebral hemorrhage (ICH) is safe, regardless of whether it is started 24 hours or 72 hours after the hemorrhage.
- Another study published in 2017 6 found that LMWH is superior to unfractionated heparin for VTE prophylaxis in patients with severe traumatic brain injuries, as it is associated with better survival and lower thromboembolic complications.
Key Points to Consider
- The decision to administer VTE prophylaxis to a patient with PRES or encephalopathy should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.
- The use of LMWH or other anticoagulants for VTE prophylaxis in patients with brain injury or neurological conditions requires careful consideration of the potential benefits and risks.
- Further research is needed to determine the safest and most effective approach to VTE prophylaxis in patients with PRES or encephalopathy.