Any heparin thromboprophylaxis compared with placebo significantly reduced deep vein thrombosis (RR 0.51; 95% CI 0.41-0.63; p<0.0001) and pulmonary embolism in critically ill patients.
Systematic Review (n=7,226)
Does heparin thromboprophylaxis reduce deep vein thrombosis and pulmonary embolism in adult medical-surgical critically ill patients?
Heparin thromboprophylaxis significantly reduces deep vein thrombosis and pulmonary embolism in critically ill medical-surgical patients without significantly increasing major bleeding, with low-molecular-weight heparin showing superiority over unfractionated heparin for preventing pulmonary embolism.
Relative Risk: 0.51 (95% CI 0.41–0.63)
p-value: p=<0.0001
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.
Alhazzani et al. (2013) conducted a systematic review in Critical illness (n=7,226). Heparin thromboprophylaxis (unfractionated or low-molecular-weight) vs. Placebo or no anticoagulant prophylaxis was evaluated on Deep vein thrombosis (RR 0.51, 95% CI 0.41, 0.63, p=<0.0001). Any heparin thromboprophylaxis compared with placebo significantly reduced deep vein thrombosis (RR 0.51; 95% CI 0.41-0.63; p<0.0001) and pulmonary embolism in critically ill patients.