Treatment algorithm in cancer-associated thrombosis: Canadian expert consensus.

Management of anticoagulant therapy for the treatment of venous thromboembolism (vte) in cancer patients is complex because of an increased risk of recurrent vte and major bleeding complications in those patients relative to the general population. Subgroups of patients with cancer also show variation in their risk for recurrent vte and adverse bleeding events. Accordingly, a committee of 10 Canadian clinical experts developed the consensus risk- stratification treatment algorithm presented here to provide guidance on tailoring anticoagulant treatment choices for the acute and extended treatment of symptomatic and incidental vte, to prevent recurrent vte, and to minimize the bleeding risk in patients with cancer. During a 1-day live meeting, a systematic review of the literature was performed, and a draft treatment algorithm was developed. The treatment algorithm was refined through the use of a Web-based platform and a series of online teleconferences. Clinicians using this treatment algorithm should consider the bleeding risk, the type of cancer, and the potential for drug-drug interactions in addition to informed patient preference in determining the most appropriate treatment for patients with cancer-associated thrombosis. Anticoagulant therapy should be regularly reassessed as the patient's cancer status and management change over time.

Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 1: prophylaxis.

Patients with cancer are at increased risk of venous thromboembolism (vte). Anticoagulation therapy has been shown to prevent vte; however, unique clinical circumstances in patients with cancer can often complicate the decisions surrounding the administration of prophylactic anticoagulation. No national Canadian guidelines on the prevention of cancer-associated thrombosis have been published. We therefore aimed to develop a consensus-based, evidence-informed guideline on the topic. PubMed was searched for clinical trials and meta-analyses published between 2002 and 2013. Reference lists of key articles were hand-searched for additional publications. Content experts from across Canada were assembled to review the evidence and make recommendations. Low molecular weight heparin can be used prophylactically in cancer patients at high risk of developing vte. Direct oral anticoagulants are not recommended for vte prophylaxis at this time. Specific clinical scenarios, including renal insufficiency, thrombocytopenia, liver disease, and obesity can warrant modifications in the administration of prophylactic anticoagulant therapy. There is no evidence to support the monitoring of anti-factor Xa levels in clinically stable cancer patients receiving prophylactic anticoagulation; however, factor Xa levels could be checked at baseline and periodically in patients with renal insufficiency. The use of anticoagulation therapy to prolong survival in cancer patients without the presence of risk factors for vte is not recommended.

Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 2: treatment.

Patients with cancer are at increased risk of venous thromboembolism (vte). Anticoagulation therapy is used to treat vte; however, patients with cancer have unique clinical circumstances that can often make decisions surrounding the administration of therapeutic anticoagulation complicated. No national Canadian guidelines on the management of established cancer-associated thrombosis have been published. We therefore aimed to develop a consensus-based, evidence-informed guideline on the topic. PubMed was searched for clinical trials and meta-analyses published between 2002 and 2013. Reference lists of key articles were hand-searched for additional publications. Content experts from across Canada were assembled to review the evidence and make recommendations. Low molecular weight heparin is the treatment of choice for cancer patients with established vte. Direct oral anticoagulants are not recommended for the treatment of vte at this time. Specific clinical scenarios, including the presence of an indwelling venous catheter, renal insufficiency, and thrombocytopenia, warrant modifications in the therapeutic administration of anticoagulation therapy. Patients with recurrent vte should receive extended (>3 months) anticoagulant therapy. Incidental vte should generally be treated in the same manner as symptomatic vte. There is no evidence to support the monitoring of anti-factor Xa levels in clinically stable cancer patients receiving prophylactic anticoagulation; however, levels of anti-factor Xa could be checked at baseline and periodically thereafter in patients with renal insufficiency. Follow-up and education about the signs and symptoms of vte are important components of ongoing patient care.

Measuring the ability to meet family needs in an intensive care unit.

OBJECTIVE: To measure the ability to meet family needs in an intensive care unit (ICU). DESIGN: Descriptive survey. SETTING: University hospital ICU. SUBJECTS: Ninety-nine next of kin respondents and 16 secondary family respondents were recruited. INTERVENTIONS: A modified Society of Critical Care Medicine Family Needs Assessment instrument was used. MEASUREMENTS AND MAIN RESULTS: Demographic variables included patient age, gender, diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission, Therapeutic Intervention Scoring System (TISS) score on the date of interview, cumulative TISS of the ICU on the day of interview, number of patients in the ICU at time of interview, nurse/patient ratio for the patient, average nurse/patient ratio of the entire unit, day of the week of the interview, timing of the interview, number of ICU attending physicians who cared for this patient (scheduled for a period of seven consecutive days), number of nurses who cared for the patient, if a nurse was assigned the same patient on two consecutive days worked, length of stay in the ICU, and length of hospital stay. Demographic information concerning the family member included gender, age, commuting time to the hospital, visiting time in the hospital per day, number in family group, relationship to the patient, ethnic background, and education level. The additive score of all questions in the needs assessment instrument was calculated and used as the dependent variable. The independent variables were demographic information concerning patients, ICU, and respondents. The model coefficient of determination (R2adj) was 0.20 with a p = .0079. Greater family dissatisfaction (i.e., higher score) was present if there were more than two ICU attendings per patient (p = .048), or if the same nurse was not assigned on two consecutive days (p = .044). Family satisfaction increased if the respondent was female (p = .006), if the patient had a higher APACHE II score (p = .007), and if the patient's relationship with the most significant family member was brother/sister (p = .012). The family needs instrument was reliable and demonstrated a high degree of concordance with a second respondent in the same family surveyed. CONCLUSIONS: Communication by the same provider was important when measuring the ability of an ICU to meet family needs. Instrument scores and the ability to meet family needs differed depending on the gender and the relationship to the patient of the most significant family member. We speculate that this instrument may be a useful adjunct in assessing quality of critical care services provided.