Venous Thromboembolism Prophylaxis in Critically Ill Adults - A Systematic Review and Network Meta-Analysis.

Abstract

BACKGROUND\nCritically ill adults are at increased risk of venous thromboembolism (VTE), including deep venous thrombosis (DVT), and pulmonary embolism (PE). Various agents exist for venous thromboprophylaxis in this population.\n\n\nRESEARCH QUESTION\nWhat is the comparative efficacy and safety of prophylaxis agents for prevention of VTE in critically ill adults?\n\n\nSTUDY DESIGN AND METHODS\nSystematic review and network meta-analysis of randomized clinical trials (RCTs) evaluating efficacy of thromboprophylaxis agents among critically ill patients. We searched six databases (including PubMed, EMBASE, and Medline) from inception to January 2021 for RCTs of intensive care unit (ICU) patients receiving pharmacologic, mechanical, or combination therapy (pharmacologic agents and mechanical devices) for thromboprophylaxis. Two reviewers performed screening, full-text review, and extraction. We used GRADE to rate certainty of effect estimates.\n\n\nRESULTS\nWe included 13 RCTs (9,619 patients). Compared to control (a composite of no prophylaxis, placebo, or compression stockings only), low molecular weight heparin (LMWH) reduces the incidence of DVT (odds ratio [OR] 0.59 [95% Credible Interval [CrI]: 0.33-0.90]; high certainty) and unfractionated heparin (UFH) may reduce the incidence of DVT (OR 0.82 [95% CrI: 0.47-1.37]; low certainty). LMWH probably reduces DVT compared to UFH (OR 0.72 [95% CrI: 0.46-0.98]; moderate certainty). Compressive devices may reduce risk of DVT compared to controls, however this was based on low certainty evidence (OR 0.85 [95% CrI: 0.50-1.50]). Combination therapy had unclear effect on DVT, compared to either therapy alone (very low certainty).\n\n\nCONCLUSION\nAmong critically ill adults, compared to control, LMWH reduces incidence of DVT while UFH and mechanical compressive devices may reduce risk of DVT. LMWH is probably more effective than UFH in reducing incidence of DVT, and should be considered the primary pharmacologic agent for thromboprophylaxis. The efficacy and safety of combination pharmacologic therapy and mechanical compressive devices was unclear.