Heparin thromboprophylaxis in medical-surgical critically ill patients

A systematic review and meta-analysis of randomized trials

Waleed Alhazzani, Wendy Lim, Roman Z. Jaeschke, Mohammad H Murad, Jack Cade, Deborah J. Cook

Research output: Contribution to journalArticle

65 Citations (Scopus)

Abstract

objective:: Venous thromboembolism prevention during critical illness is a widely used quality metric. The objective of this systematic review was to systematically review the efficacy and safety of heparin thromboprophylaxis in medical-surgical patients in the ICU. DATA sources:: We searched EMBASE, MEDLINE, the Cochrane Controlled Trials Register, Clinicaltrials.gov, and personal files through May 2012. STUDY selection:: Randomized trials in adult medical-surgical ICU patients comparing any heparin (unfractionated heparin or low-molecular-weight heparin) with each other or no anticoagulant prophylaxis, evaluating deep vein thrombosis, pulmonary embolism, major bleeding, or mortality. DATA extraction:: Independently, in duplicate, we abstracted trial characteristics, outcomes, and risk of bias. DATA synthesis:: Seven trials involved 7,226 patients. Any heparin thromboprophylaxis compared with placebo reduced rates of deep vein thrombosis (pooled risk ratio, 0.51 [95% CI, 0.41, 0.63]; p < 0.0001; I = 77%) and pulmonary embolism (risk ratio, 0.52 [95% CI, 0.28, 0.97]; p = 0.04; I = 0%) but not symptomatic deep vein thrombosis (risk ratio, 0.86 [95% CI, 0.59, 1.25]; p = 0.43). Major bleeding (risk ratio, 0.82 [95% CI, 0.56, 1.21]; p = 0.32; I = 50%) and mortality (risk ratio, 0.89 [95% CI, 0.78, 1.02]; p = 0.09; I = 0%) rates were similar. Compared with unfractionated heparin, low-molecular-weight heparin reduced rates of pulmonary embolism (risk ratio, 0.62 [95% CI, 0.39, 1.00]; p = 0.05; I = 53%) and symptomatic pulmonary embolism (risk ratio, 0.58 [95% CI, 0.34, 0.97]; p = 0.04) but not deep vein thrombosis (risk ratio, 0.90 [95% CI, 0.74, 1.08]; p = 0.26; I = 0%), symptomatic deep vein thrombosis (risk ratio, 0.87 [95% CI, 0.60, 1.25]; p = 0.44; I = 0%), major bleeding (risk ratio, 0.97 [95% CI, 0.75, 1.26]; p = 0.83; I = 0%), or mortality (risk ratio, 0.93 [95% CI, 0.82, 1.04]; p = 0.20; I = 31%). conclusions:: Trial evidence to date suggests that any type of heparin thromboprophylaxis decreases deep vein thrombosis and pulmonary embolism in medical-surgical critically ill patients, and low-molecular-weight heparin compared with bid unfractionated heparin decreases pulmonary embolism and symptomatic pulmonary embolism. Major bleeding and mortality rates do not appear to be significantly influenced by heparin thromboprophylaxis in the ICU setting. Trial methodology, indirectness, and the heterogeneity and imprecision of some results temper inferences from this literature.

Original languageEnglish (US)
Pages (from-to)2088-2098
Number of pages11
JournalCritical Care Medicine
Volume41
Issue number9
DOIs
StatePublished - Sep 2013

Fingerprint

Critical Illness
Heparin
Meta-Analysis
Odds Ratio
Pulmonary Embolism
Venous Thrombosis
Low Molecular Weight Heparin
Hemorrhage
Mortality
Venous Thromboembolism
MEDLINE
Anticoagulants
Placebos
Safety

Keywords

  • bleeding
  • critical illness
  • deep vein thrombosis
  • heparin
  • pulmonary embolism
  • venous thromboembolism

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

Heparin thromboprophylaxis in medical-surgical critically ill patients : A systematic review and meta-analysis of randomized trials. / Alhazzani, Waleed; Lim, Wendy; Jaeschke, Roman Z.; Murad, Mohammad H; Cade, Jack; Cook, Deborah J.

In: Critical Care Medicine, Vol. 41, No. 9, 09.2013, p. 2088-2098.

Research output: Contribution to journalArticle

Alhazzani, Waleed ; Lim, Wendy ; Jaeschke, Roman Z. ; Murad, Mohammad H ; Cade, Jack ; Cook, Deborah J. / Heparin thromboprophylaxis in medical-surgical critically ill patients : A systematic review and meta-analysis of randomized trials. In: Critical Care Medicine. 2013 ; Vol. 41, No. 9. pp. 2088-2098.
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abstract = "objective:: Venous thromboembolism prevention during critical illness is a widely used quality metric. The objective of this systematic review was to systematically review the efficacy and safety of heparin thromboprophylaxis in medical-surgical patients in the ICU. DATA sources:: We searched EMBASE, MEDLINE, the Cochrane Controlled Trials Register, Clinicaltrials.gov, and personal files through May 2012. STUDY selection:: Randomized trials in adult medical-surgical ICU patients comparing any heparin (unfractionated heparin or low-molecular-weight heparin) with each other or no anticoagulant prophylaxis, evaluating deep vein thrombosis, pulmonary embolism, major bleeding, or mortality. DATA extraction:: Independently, in duplicate, we abstracted trial characteristics, outcomes, and risk of bias. DATA synthesis:: Seven trials involved 7,226 patients. Any heparin thromboprophylaxis compared with placebo reduced rates of deep vein thrombosis (pooled risk ratio, 0.51 [95{\%} CI, 0.41, 0.63]; p < 0.0001; I = 77{\%}) and pulmonary embolism (risk ratio, 0.52 [95{\%} CI, 0.28, 0.97]; p = 0.04; I = 0{\%}) but not symptomatic deep vein thrombosis (risk ratio, 0.86 [95{\%} CI, 0.59, 1.25]; p = 0.43). Major bleeding (risk ratio, 0.82 [95{\%} CI, 0.56, 1.21]; p = 0.32; I = 50{\%}) and mortality (risk ratio, 0.89 [95{\%} CI, 0.78, 1.02]; p = 0.09; I = 0{\%}) rates were similar. Compared with unfractionated heparin, low-molecular-weight heparin reduced rates of pulmonary embolism (risk ratio, 0.62 [95{\%} CI, 0.39, 1.00]; p = 0.05; I = 53{\%}) and symptomatic pulmonary embolism (risk ratio, 0.58 [95{\%} CI, 0.34, 0.97]; p = 0.04) but not deep vein thrombosis (risk ratio, 0.90 [95{\%} CI, 0.74, 1.08]; p = 0.26; I = 0{\%}), symptomatic deep vein thrombosis (risk ratio, 0.87 [95{\%} CI, 0.60, 1.25]; p = 0.44; I = 0{\%}), major bleeding (risk ratio, 0.97 [95{\%} CI, 0.75, 1.26]; p = 0.83; I = 0{\%}), or mortality (risk ratio, 0.93 [95{\%} CI, 0.82, 1.04]; p = 0.20; I = 31{\%}). conclusions:: Trial evidence to date suggests that any type of heparin thromboprophylaxis decreases deep vein thrombosis and pulmonary embolism in medical-surgical critically ill patients, and low-molecular-weight heparin compared with bid unfractionated heparin decreases pulmonary embolism and symptomatic pulmonary embolism. Major bleeding and mortality rates do not appear to be significantly influenced by heparin thromboprophylaxis in the ICU setting. Trial methodology, indirectness, and the heterogeneity and imprecision of some results temper inferences from this literature.",
keywords = "bleeding, critical illness, deep vein thrombosis, heparin, pulmonary embolism, venous thromboembolism",
author = "Waleed Alhazzani and Wendy Lim and Jaeschke, {Roman Z.} and Murad, {Mohammad H} and Jack Cade and Cook, {Deborah J.}",
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TY - JOUR

T1 - Heparin thromboprophylaxis in medical-surgical critically ill patients

T2 - A systematic review and meta-analysis of randomized trials

AU - Alhazzani, Waleed

AU - Lim, Wendy

AU - Jaeschke, Roman Z.

AU - Murad, Mohammad H

AU - Cade, Jack

AU - Cook, Deborah J.

PY - 2013/9

Y1 - 2013/9

N2 - objective:: Venous thromboembolism prevention during critical illness is a widely used quality metric. The objective of this systematic review was to systematically review the efficacy and safety of heparin thromboprophylaxis in medical-surgical patients in the ICU. DATA sources:: We searched EMBASE, MEDLINE, the Cochrane Controlled Trials Register, Clinicaltrials.gov, and personal files through May 2012. STUDY selection:: Randomized trials in adult medical-surgical ICU patients comparing any heparin (unfractionated heparin or low-molecular-weight heparin) with each other or no anticoagulant prophylaxis, evaluating deep vein thrombosis, pulmonary embolism, major bleeding, or mortality. DATA extraction:: Independently, in duplicate, we abstracted trial characteristics, outcomes, and risk of bias. DATA synthesis:: Seven trials involved 7,226 patients. Any heparin thromboprophylaxis compared with placebo reduced rates of deep vein thrombosis (pooled risk ratio, 0.51 [95% CI, 0.41, 0.63]; p < 0.0001; I = 77%) and pulmonary embolism (risk ratio, 0.52 [95% CI, 0.28, 0.97]; p = 0.04; I = 0%) but not symptomatic deep vein thrombosis (risk ratio, 0.86 [95% CI, 0.59, 1.25]; p = 0.43). Major bleeding (risk ratio, 0.82 [95% CI, 0.56, 1.21]; p = 0.32; I = 50%) and mortality (risk ratio, 0.89 [95% CI, 0.78, 1.02]; p = 0.09; I = 0%) rates were similar. Compared with unfractionated heparin, low-molecular-weight heparin reduced rates of pulmonary embolism (risk ratio, 0.62 [95% CI, 0.39, 1.00]; p = 0.05; I = 53%) and symptomatic pulmonary embolism (risk ratio, 0.58 [95% CI, 0.34, 0.97]; p = 0.04) but not deep vein thrombosis (risk ratio, 0.90 [95% CI, 0.74, 1.08]; p = 0.26; I = 0%), symptomatic deep vein thrombosis (risk ratio, 0.87 [95% CI, 0.60, 1.25]; p = 0.44; I = 0%), major bleeding (risk ratio, 0.97 [95% CI, 0.75, 1.26]; p = 0.83; I = 0%), or mortality (risk ratio, 0.93 [95% CI, 0.82, 1.04]; p = 0.20; I = 31%). conclusions:: Trial evidence to date suggests that any type of heparin thromboprophylaxis decreases deep vein thrombosis and pulmonary embolism in medical-surgical critically ill patients, and low-molecular-weight heparin compared with bid unfractionated heparin decreases pulmonary embolism and symptomatic pulmonary embolism. Major bleeding and mortality rates do not appear to be significantly influenced by heparin thromboprophylaxis in the ICU setting. Trial methodology, indirectness, and the heterogeneity and imprecision of some results temper inferences from this literature.

AB - objective:: Venous thromboembolism prevention during critical illness is a widely used quality metric. The objective of this systematic review was to systematically review the efficacy and safety of heparin thromboprophylaxis in medical-surgical patients in the ICU. DATA sources:: We searched EMBASE, MEDLINE, the Cochrane Controlled Trials Register, Clinicaltrials.gov, and personal files through May 2012. STUDY selection:: Randomized trials in adult medical-surgical ICU patients comparing any heparin (unfractionated heparin or low-molecular-weight heparin) with each other or no anticoagulant prophylaxis, evaluating deep vein thrombosis, pulmonary embolism, major bleeding, or mortality. DATA extraction:: Independently, in duplicate, we abstracted trial characteristics, outcomes, and risk of bias. DATA synthesis:: Seven trials involved 7,226 patients. Any heparin thromboprophylaxis compared with placebo reduced rates of deep vein thrombosis (pooled risk ratio, 0.51 [95% CI, 0.41, 0.63]; p < 0.0001; I = 77%) and pulmonary embolism (risk ratio, 0.52 [95% CI, 0.28, 0.97]; p = 0.04; I = 0%) but not symptomatic deep vein thrombosis (risk ratio, 0.86 [95% CI, 0.59, 1.25]; p = 0.43). Major bleeding (risk ratio, 0.82 [95% CI, 0.56, 1.21]; p = 0.32; I = 50%) and mortality (risk ratio, 0.89 [95% CI, 0.78, 1.02]; p = 0.09; I = 0%) rates were similar. Compared with unfractionated heparin, low-molecular-weight heparin reduced rates of pulmonary embolism (risk ratio, 0.62 [95% CI, 0.39, 1.00]; p = 0.05; I = 53%) and symptomatic pulmonary embolism (risk ratio, 0.58 [95% CI, 0.34, 0.97]; p = 0.04) but not deep vein thrombosis (risk ratio, 0.90 [95% CI, 0.74, 1.08]; p = 0.26; I = 0%), symptomatic deep vein thrombosis (risk ratio, 0.87 [95% CI, 0.60, 1.25]; p = 0.44; I = 0%), major bleeding (risk ratio, 0.97 [95% CI, 0.75, 1.26]; p = 0.83; I = 0%), or mortality (risk ratio, 0.93 [95% CI, 0.82, 1.04]; p = 0.20; I = 31%). conclusions:: Trial evidence to date suggests that any type of heparin thromboprophylaxis decreases deep vein thrombosis and pulmonary embolism in medical-surgical critically ill patients, and low-molecular-weight heparin compared with bid unfractionated heparin decreases pulmonary embolism and symptomatic pulmonary embolism. Major bleeding and mortality rates do not appear to be significantly influenced by heparin thromboprophylaxis in the ICU setting. Trial methodology, indirectness, and the heterogeneity and imprecision of some results temper inferences from this literature.

KW - bleeding

KW - critical illness

KW - deep vein thrombosis

KW - heparin

KW - pulmonary embolism

KW - venous thromboembolism

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