scholarly journals Appropriateness of using vitamin K for the correction of INR elevation secondary to hepatic disease in critically ill patients: An Observational Study

2021 ◽  
Author(s):  
Khalid Al Sulaiman ◽  
Mashael Al Mutairi ◽  
Omar Al Harbi ◽  
Alanoud Al Duraihim ◽  
Sara Aldosary ◽  
...  
Keyword(s):  
Liver Disease ◽  
Critically Ill ◽  
Vitamin K ◽  
Critically Ill Patients ◽  
Lower Incidence ◽  
Bleeding Events ◽  
Hepatic Diseases ◽  
Increased Risk ◽  
Severity Scores ◽  
Tertiary Teaching

Abstract Background Hepatic diseases have been associated with an increased risk of coagulopathy and increased odds of secondary thrombosis and bleeding. Using vitamin K for correction of coagulopathy in critically ill patients is controversial with limited evidence. Objective To evaluate the efficacy as well as safety of vitamin K in correction of international normalized ratio (INR) elevation secondary to liver disease in critically ill patients. Setting Tertiary teaching hospital in Saudi Arabia. Method A retrospective case-control study of adult ICU patients with coagulopathy secondary to liver disease. A total of 98 patients were included in the study. Patients were divided into two groups based on vitamin K administration to correct INR elevation. differences. The propensity score was generated based on disease severity scores to adjust group. Main outcomes The primary outcome was to evaluate the association between vitamin K administration and the incidence of new bleeding events in critically ill patients with INR elevation secondary to liver disease. Secondary outcomes were to evaluate the incidence of a new thrombotic event and the degree of INR correction with vitamin K. Results Forty-seven patients (48%) received vitamin K during the study period. The incidence of the new bleeding event was not statistically different between groups (OR 2.4, 95% CI 0.28-21.67, P=0.42). Delta of INR reduction was observed with a median of 0.63 when the first dose is given (p-value: <.0001). However, other subsequent doses of vitamin K were not statistically significant. Conclusion Using vitamin K for INR correction in critically ill patients with coagulopathy secondary to liver disease was not associated with a lower incidence of new bleeding events. Vitamin K was efficient in reducing INR level at the first dose, other subsequent doses were not.Impacts on practice: Routine use of vitamin K to correct PT/INR in critically ill patients with liver disease may need be re-evaluated.If the initial dose of vitamin K does not reverse INR elevation, subsequent doses may not have any effect.Using vitamin K to correct INR was not associated with a lower incidence of new bleeding events nor RBCs/Platelets transfusion than patients who did not receive it.

scholarly journals Appropriateness of using vitamin K for the correction of INR elevation secondary to hepatic disease in critically ill patients: An Observational Study

2021 ◽  
Author(s):  
Khalid Al Sulaiman ◽  
Mashael Al Mutairi ◽  
Omar Al Harbi ◽  
Alanoud Al Duraihim ◽  
Sara Aldosary ◽  
...  
Keyword(s):  
Liver Disease ◽  
Critically Ill ◽  
Vitamin K ◽  
Critically Ill Patients ◽  
Lower Incidence ◽  
Bleeding Events ◽  
Hepatic Diseases ◽  
Increased Risk ◽  
Severity Scores ◽  
Tertiary Teaching

Abstract Background: Hepatic diseases have been associated with an increased risk of coagulopathy and increased odds of secondary thrombosis and bleeding. Using vitamin K for correction of coagulopathy in critically ill patients is controversial with limited evidence.Objective: To evaluate the efficacy as well as safety of vitamin K in correction of international normalized ratio (INR) elevation secondary to liver disease in critically ill patients.Setting: Tertiary teaching hospital in Saudi Arabia.Method: A retrospective case-control study of adult ICU patients with coagulopathy secondary to liver disease. A total of 98 patients were included in the study. Patients were divided into two groups based on vitamin K administration to correct INR elevation. differences. The propensity score was generated based on disease severity scores to adjust group.Main outcomes: The primary outcome was to evaluate the association between vitamin K administration and the incidence of new bleeding events in critically ill patients with INR elevation secondary to liver disease. Secondary outcomes were to evaluate the incidence of a new thrombotic event and the degree of INR correction with vitamin K. Results: Forty-seven patients (48%) received vitamin K during the study period. The incidence of the new bleeding event was not statistically different between groups (OR 2.4, 95% CI 0.28-21.67, P=0.42). Delta of INR reduction was observed with a median of 0.63 when the first dose is given (p-value: <.0001). However, other subsequent doses of vitamin K were not statistically significant.Conclusion: Using vitamin K for INR correction in critically ill patients with coagulopathy secondary to liver disease was not associated with a lower incidence of new bleeding events. Vitamin K was efficient in reducing INR level at the first dose, other subsequent doses were not.Impacts on practice: 1. Routine use of vitamin K to correct PT/INR in critically ill patients with liver disease may need be re-evaluated.2. If the initial dose of vitamin K does not reverse INR elevation, subsequent doses may not have any effect.3. Using vitamin K to correct INR was not associated with a lower incidence of new bleeding events nor RBCs/Platelets transfusion than patients who did not receive it.

scholarly journals Appropriateness of using vitamin K for the correction of INR elevation secondary to hepatic disease in critically ill patients: An Observational Study

2021 ◽  
Author(s):  
Khalid Al Sulaiman ◽  
Mashael Al Mutairi ◽  
Omar Al Harbi ◽  
Alanoud Al Duraihim ◽  
Sara Aldosary ◽  
...  
Keyword(s):  
Liver Disease ◽  
Critically Ill ◽  
Vitamin K ◽  
Critically Ill Patients ◽  
Thrombotic Event ◽  
Bleeding Events ◽  
Hepatic Diseases ◽  
Increased Risk ◽  
Severity Scores ◽  
Tertiary Teaching

Abstract Background: Hepatic diseases have been associated with an increased risk of coagulopathy and increased odds of secondary thrombosis and bleeding. Using vitamin K for correction of coagulopathy in critically ill patients is controversial with limited evidence. This study aims to evaluate the efficacy and safety of vitamin K in the correction of international normalized ratio (INR) elevation secondary to liver disease in critically ill patients.Method: A retrospective study of adult ICU patients with coagulopathy secondary to liver disease admitted to a tertiary teaching hospital in Saudi Arabia. The primary outcome was to evaluate the association between vitamin K administration and the incidence of new bleeding events in critically ill patients with INR elevation secondary to liver disease. Secondary outcomes were to evaluate the incidence of a new thrombotic event, and the degree of INR correction with vitamin K. Patients were divided into two groups based on vitamin K administration to correct INR elevation. The propensity score was generated based on disease severity scores and the use of pharmacological DVT prophylaxis. Results: A total of 98 patients were included in the study. Forty-seven patients (48%) received vitamin K during the study period. The incidence of the new bleeding event was not statistically different between groups (OR 2.4, 95% CI 0.28-21.67, P=0.42). Delta of INR reduction was observed with a median of 0.63 when the first dose is given (p-value: <.0001). However, other subsequent doses of vitamin K were not statistically significant.Conclusion: Using vitamin K for INR correction in critically ill patients with coagulopathy secondary to liver disease was not associated with a lower incidence of new bleeding events. Vitamin K was efficient in reducing INR level at the first dose, and other subsequent doses were not.

scholarly journals Appropriateness of Using Vitamin K for the Correction of INR Elevation Secondary to Hepatic Disease in Critically ill Patients: An Observational Study

2021 ◽  
Vol 27 ◽  
pp. 107602962110509
Author(s):  
Khalid Al Sulaiman ◽  
Mashael Al Mutairi ◽  
Omar Al Harbi ◽  
Alanoud Al Duraihim ◽  
Sara Aldosary ◽  
...  
Keyword(s):  
Liver Disease ◽  
Critically Ill ◽  
Vitamin K ◽  
Critically Ill Patients ◽  
Bleeding Event ◽  
International Normalized Ratio ◽  
P Value ◽  
Bleeding Events ◽  
Severity Scores ◽  
Disease Severity Scores

Background Using vitamin K for correction of coagulopathy in critically ill patients is controversial with limited evidence. This study aims to evaluate the efficacy and safety of vitamin K in the correction of international normalized ratio (INR) elevation secondary to liver disease in critically ill patients. Method A retrospective study of critically ill patients with coagulopathy secondary to liver disease. The primary outcome was to evaluate the association between vitamin K administration and the incidence of new bleeding events in critically ill patients with INR elevation; other outcomes were considered secondary. Patients were categorized into two groups based on vitamin K administration to correct INR elevation. The propensity score was generated based on disease severity scores and the use of pharmacological DVT prophylaxis. Results A total of 98 patients were included in the study. Forty-seven patients (48%) received vitamin K during the study period. The odds of the new bleeding event was not statistically different between groups (OR 2.4, 95% CI 0.28-21.67, P = .42). Delta of INR reduction was observed with a median of 0.63 when the first dose is given ( P-value: <.0001). However the INR reduction with other subsequent doses of vitamin K was not statistically significant. Conclusion The administration of vitamin K for INR correction in critically ill patients with coagulopathy secondary to liver disease was not associated with a lower odds of new bleeding events. Further studies are needed to assess the value of vitamin K administration in critically ill patients with liver diseases related coagulopathy.

scholarly journals Adjunctive Therapy with Ascorbic in Critically Ill Patients with COVID-19: A Multicenter Propensity Score Matched Study

2021 ◽  
Author(s):  
Khalid Al Sulaiman ◽  
Ohoud Al Juhani ◽  
Hisham A. Badreldin ◽  
Khalid Bin Salah ◽  
Abdullah Al Harthi ◽  
...  
Keyword(s):  
Ascorbic Acid ◽  
Propensity Score ◽  
Propensity Score Matching ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Lower Incidence ◽  
Adjunctive Therapy ◽  
P Value ◽  
Relative Safety ◽  
Severity Scores

Abstract Background: Due to its supposed clinical efficacy, relative safety, and low cost, ascorbic acid represents an appealing option for clinicians to utilize in the context of a global health pandemic of COVID-19 patients.Objectives: The aim of this study was to evaluate the efficacy and safety of using ascorbic acid as adjunctive therapy in critically ill patients with COVID-19. Methods: This was a multi-center, non-interventional, retrospective cohort study. All critically ill adult patients admitted to ICU with a confirmed COVID-19 between March 1st to December 31st, 2020 were included in the final analysis. The study was conducted at two large governmental tertiary hospitals in Saudi Arabia. The purpose was to investigate the association between clinical outcomes with ascorbic acid use as an adjunctive therapy in COVID-19 after propensity score matching using baseline severity scores, systemic use of corticosteroids and study centers. Results: A 739 patients were included in this study; 296 patients were included after propensity score matching. There was no association between the administration of ascorbic acid and in-hospital mortality nor 30-day ICU mortality (OR (95%CI): 0.77 (0.476, 1.234), p-value=0.2738 and OR (95%CI): 0.73 (0.438 ,1.204), p-value=0.215 respectively). Using ascorbic acid was associated with lower incidence of thrombosis compared with the non-ascorbic acid group (6.1% vs. 13% respectively); OR (95%CI): 0.42 (0.184, 0.937), p-value=0.0342).Conclusion: Ascorbic acid use as an adjunctive therapy in COVID19 critically ill patients was not associated with mortality benefits; but associated with lower incidence of thrombosis. Further studies are required to confirm these findings.

scholarly journals Coagulation disorders in patients with severe hemophagocytic lymphohistiocytosis

2021 ◽  
Author(s):  
Sandrine Valade ◽  
Bérangère S. Joly ◽  
Agnès Veyradier ◽  
Jehane Fadlallah ◽  
Lara Zafrani ◽  
...  
Keyword(s):  
Plasminogen Activator ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Hemophagocytic Lymphohistiocytosis ◽  
Multivariable Analysis ◽  
Biological Marker ◽  
Severe Bleeding ◽  
Coagulation Disorders ◽  
Bleeding Events ◽  
Increased Risk

AbstractBackgroundCoagulation disorders are common in patients with hemophagocytic lymphohistiocytosis (HLH), associated with an increased risk of bleeding and death. We aim to investigate coagulation disorders and their outcome implications in critically ill patients with HLH.MethodsWe prospectively evaluated 47 critically ill patients with HLH (median age of 54 years [42-67]) between April 2015 and December 2018. Coagulation assessments were performed at day 1. Abnormal standard coagulation was defined as prothrombin time (PT) <50% and/or fibrinogen <2g/L. HLH aetiology was mostly ascribed to haematological malignancies (74% of patients).ResultsCoagulation disorders and severe bleeding events were frequent, occurring in 30 (64%) and 11 (23%) patients respectively. At day 1, median fibrinogen level was 2·65g/L [1.61-5.66]. Fibrinolytic activity was high as suggested by increased median levels of D-dimers, fibrin monomers, PAI-1 (plasminogen activator inhibitor) and tPA (tissue plasminogen activator). Forty-one (91%) patients had a decreased ADAMTS13 activity (A Disintegrin-like And Metalloproteinase with ThromboSpondin type 1 repeats, member 13). By multivariable analysis, the occurrence of a severe bleeding (OR 3.215 [1.194-8.653], p=0·021) and SOFA score (Sepsis-Related Organ Failure Assessment) at day 1 (OR 1.305 per point [1.146-1.485], p<0·001) were independently associated with hospital mortality. No early biological marker was associated with severe bleeding.ConclusionsHyperfibrinolysis may be the primary mechanism responsible for hypofibrinogenemia and may also participate in ADAMTS13 degradation. Targeting the plasmin system appears as a promising approach in severe HLH-related coagulation disorders.

scholarly journals Chemical Versus Mechanical and Chemical Venous Thromboembolism Prophylaxis in Neurocritically Ill Patients: A Cohort Study

2021 ◽  
Author(s):  
Abdulrahman Alshaya ◽  
Hayaa Alyahya ◽  
Reema Alzoman ◽  
Rawa Faden ◽  
Omar Alshaya ◽  
...  
Keyword(s):  
Cohort Study ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Bleeding Events ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Prophylaxis Group ◽  
Tertiary Teaching ◽  
Significant Difference ◽  
Chemical Prophylaxis

Abstract Background: Patients admitted with neurocritical illness are presumed to be at high risk for venothromboembolism (VTE). The administration of chemical and/or mechanical VTE prophylaxis is a common practice in critically ill patients. Recent data did not show a significant difference in the incidence of VTE between chemical compared to chemical and mechanical VTE prophylaxis in critically ill patients with limited data in neurocritically ill population. The objective of this study is to investigate the incidence of VTE between chemical alone compared to chemical and mechanical VTE prophylaxis in neurocritically ill patients. This was a retrospective cohort study at a tertiary teaching hospital. Data were obtained from electronic medical records for all patients admitted with neurocritical illness from 1/1/2016 to 1/12/2020. Patients were excluded if they did not receive VTE prophylaxis during admission or were younger than 18 YO. Major outcomes were symptomatic VTE based on clinical and radiological findings, intensive care unit (ICU) length of stay (LOS), and hospital LOS. Minor outcomes included severe or life-threatening bleeding based on GUSTO criteria, and mortality at 28-days. Results: Two hundred and twelve patients were included in this study. Patients did not have any significant differences in their baseline characteristics. The incidence of VTE was not different between chemical only compared to chemical and mechanical VTE prophylaxis groups (19/166 (11.3%) vs 7/46 (15.2%); P=0.49. No difference between groups in their ICU LOS 6 [3 – 16.2] vs 6.5 [3 – 19]; P=0.52, nor their mortality (18/166 (10.7%) vs 3/46 (6.5%); P=0.38, respectively. Less bleeding events were seen in the chemical prophylaxis group compared to the combined VTE prophylaxis group (19/166 (11.3%) vs 12/46 (26.1%); P= 0.013. Conclusion: Our findings observed no difference between the administration of chemical prophylaxis alone compared to combined VTE prophylaxis in neurocritically ill patients. More data are needed to confirm this finding with more robust methodology.

scholarly journals Ascorbic acid as an adjunctive therapy in critically ill patients with COVID-19: a propensity score matched study

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Khalid Al Sulaiman ◽  
Ohoud Aljuhani ◽  
Khalid Bin Saleh ◽  
Hisham A. Badreldin ◽  
Abdullah Al Harthi ◽  
...  
Keyword(s):  
Ascorbic Acid ◽  
Propensity Score ◽  
Propensity Score Matching ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Lower Incidence ◽  
Adjunctive Therapy ◽  
Low Dose ◽  
P Value ◽  
Severity Scores

AbstractAscorbic acid represents an appealing option for clinicians to utilize in the context of the global COVID-19 pandemic due to its proposed clinical efficacy, relative safety, and low cost. The aim of this study was to evaluate the efficacy and safety of using ascorbic acid in supplemental doses as adjunctive therapy for patients critically ill with COVID-19. This was a two-center, non-interventional, retrospective cohort study. All critically ill adult patients admitted to ICU with a confirmed COVID-19 diagnosis between March 1st and December 31st, 2020, were included in the final analysis. The study was conducted at two large governmental tertiary hospitals in Saudi Arabia. The purpose was to investigate the clinical outcomes of low-dose ascorbic acid as adjunctive therapy in COVID-19 after propensity score matching using baseline severity scores, systematic use of corticosteroids, and study centers. A number of 739 patients were included in this study, among whom 296 patients were included after propensity score matching. There was no association between the administration of ascorbic acid and in-hospital mortality or the 30-day mortality [OR (95% CI) 0.77 (0.47, 1.23), p value = 0.27 and OR (95% CI) 0.73 (0.43, 1.20), p value = 0.21, respectively]. Using ascorbic acid was associated with a lower incidence of thrombosis compared with the non-ascorbic-acid group [6.1% vs. 13% respectively; OR (95% CI) 0.42 (0.184, 0.937), p value = 0.03]. Low dose of ascorbic acid as an adjunctive therapy in COVID-19 critically ill patients was not associated with mortality benefits, but it was associated with a lower incidence of thrombosis. Further studies are required to confirm these findings.

scholarly journals Ascorbic Acid as an Adjunctive Therapy in Critically Ill Patients with COVID-19: A Multicenter Propensity Score Matched Study

2021 ◽  
Author(s):  
Khalid Al Sulaiman ◽  
Ohoud Al Juhani ◽  
Khalid Bin Salah ◽  
Hisham A. Badreldin ◽  
Abdullah Al Harthi ◽  
...  
Keyword(s):  
Ascorbic Acid ◽  
Propensity Score ◽  
Propensity Score Matching ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Lower Incidence ◽  
Adjunctive Therapy ◽  
P Value ◽  
Severity Scores ◽  
Supplemental Dose

Abstract Background: Ascorbic acid represents an appealing option for clinicians to utilize in the context of a global health pandemic of COVID-19 patients due to its proposed clinical efficacy, relative safety, and low cost.Objectives:The aim of this study was to evaluate the efficacy and safety of using ascorbic acid in supplemental dose as adjunctive therapy in critically ill patients with COVID-19. Methods: This was a multi-center, non-interventional, retrospective cohort study. All critically ill adult patients admitted to ICU with a confirmed COVID-19 between March 1st to December 31st, 2020 were included in the final analysis. The study was conducted at two large governmental tertiary hospitals in Saudi Arabia. The purpose was to investigate the association between clinical outcomes with ascorbic acid use as an adjunctive therapy in COVID-19 after propensity score matching using baseline severity scores, systemic use of corticosteroids and study centers. Results:A 739 patients were included in this study; 296 patients were included after propensity score matching. There was no association between the administration of ascorbic acid and in-hospital mortality nor 30-day ICU mortality (OR (95%CI): 0.77 (0.476, 1.234), p-value=0.2738 and OR (95%CI): 0.73 (0.438 ,1.204), p-value=0.215 respectively). Using ascorbic acid was associated with lower incidence of thrombosis compared with the non-ascorbic acid group (6.1% vs. 13% respectively); OR (95%CI): 0.42 (0.184, 0.937), p-value=0.0342).Conclusion:Supplemental dose of ascorbic acid as an adjunctive therapy in COVID19 critically ill patients was not associated with mortality benefits; but associated with lower incidence of thrombosis. Further studies are required to confirm these findings.

scholarly journals The effect of vitamin K on prothrombin time in critically ill patients: an observational registry study

2021 ◽  
Vol 9 (1) ◽  
Author(s):  
Sofia Dahlberg ◽  
Ulf Schött ◽  
Thomas Kander
Keyword(s):  
Propensity Score ◽  
Prothrombin Time ◽  
Critically Ill ◽  
Vitamin K ◽  
Critically Ill Patients ◽  
International Normalized Ratio ◽  
University Hospital ◽  
Red Blood Cell Transfusion ◽  
Registry Study ◽  
Exclusion Criteria

Abstract Background Previous studies have indicated that vitamin K deficiency is common in non-bleeding critically ill patients with slightly prolonged prothrombin time-international normalized ratio (PT-INR). It has never been investigated thoroughly whether the administration of vitamin K to these patients could affect their PT-INR. Therefore, the aim of this registry study was to evaluate changes in PT-INR in response to vitamin K in critically ill patients with PT-INR in the range of 1.3–1.9. Methods Patients admitted to a mixed 9-bed general intensive care unit at a University Hospital, between 2013 and 2019 (n = 4541) with a PT-INR between 1.3 and 1.9 at any time during the stay were identified. Patients who received vitamin K with appropriate sampling times for PT-INR and without exclusion criteria were matched with propensity score to patients from the same cohort who did not receive vitamin K (controls). PT-INR was measured at admission, within 12 h before vitamin K administration and 12–36 h following vitamin K administration. Exclusion criteria included pre-existing liver cirrhosis, any plasma or platelet transfusion, or > 1 unit red blood cell transfusion between PT-INR samplings. Results Propensity score matching resulted in two groups of patients with 129 patients in each group. PT-INR decreased in both groups (1.4 [1.3–1.4] in the vitamin K group and 1.4 [1.3–1.6] in the controls, p < 0.001 and p = 0.004, respectively). The decrease in PT-INR was slightly more pronounced in patients who received vitamin K (delta PT-INR − 0.10 [− 0.30 to − 0.10] in the vitamin K group and − 0.10 [− 0.20 to 0.10] in the controls, p = 0.01). Conclusion In critically ill patients with a PT-INR of 1.3–1.9, the administration of vitamin K resulted in a slightly larger decrease of PT-INR 12–36 h after administration compared to controls. Future studies should focus on identifying which patient populations may benefit most from vitamin K administration as well as whether vitamin K could be a better alternative than plasma or prothrombin complex concentrate to improve PT-INR before non-emergent invasive procedures.

A Systematic Review of Anticoagulation Strategies for Patients With Atrial Fibrillation in Critical Care.

2021 ◽  
Author(s):  
Alexandra Jayne Nelson ◽  
Brian W Johnston ◽  
Alicia Achiaa Charlotte Waite ◽  
Gedeon Lemma ◽  
Ingeborg Dorothea Welters
Keyword(s):  
Atrial Fibrillation ◽  
Critical Care ◽  
Critically Ill ◽  
Major Bleeding ◽  
Critically Ill Patients ◽  
Thromboembolic Events ◽  
Bleeding Events ◽  
Major Bleeding Events ◽  
The Impact ◽  
Anticoagulated Patients

Background. Atrial fibrillation (AF) is the most common cardiac arrhythmia in critically ill patients. There is a paucity of data assessing the impact of anticoagulation strategies on clinical outcomes for general critical care patients with AF. Our aim was to assess the existing literature to evaluate the effectiveness of anticoagulation strategies used in critical care for AF. Methodology. A systematic literature search was conducted using MEDLINE, EMBASE, CENTRAL and PubMed databases. Studies reporting anticoagulation strategies for AF in adults admitted to a general critical care setting were assessed for inclusion. Results. Four studies were selected for data extraction. A total of 44087 patients were identified with AF, of which 17.8-49.4% received anticoagulation. The reported incidence of thromboembolic events was 0-1.4% for anticoagulated patients, and 0-1.3% in non-anticoagulated patients. Major bleeding events were reported in three studies and occurred in 7.2-8.6% of the anticoagulated patients and up to 7.1% of the non-anticoagulated patients. Conclusions. There was an increased incidence of major bleeding events in anticoagulated patients with AF in critical care compared to non-anticoagulated patients. There was no significant difference in the incidence of reported thromboembolic events within studies, between patients who did and did not receive anticoagulation. However, the outcomes reported within studies were not standardised, therefore, the generalisability of our results to the general critical care population remains unclear. Further data is required to facilitate an evidence-based assessment of the risks and benefits of anticoagulation for critically ill patients with AF.

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