scholarly journals Risk of Clinically Relevant Venous Thromboembolism in Critically Ill Patients With COVID-19: A Systematic Review and Meta-Analysis

2021 ◽  
Vol 8 ◽  
Author(s):  
Johannes Gratz ◽  
Marion Wiegele ◽  
Mathias Maleczek ◽  
Harald Herkner ◽  
Herbert Schöchl ◽  
...  
Keyword(s):  
Systematic Review ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
English Language ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Individual Risk ◽  
Bleeding Events

Background: Early during the course of the ongoing COVID-19 pandemic, reports suggested alarmingly high incidences for thromboembolic events in critically ill patients with COVID-19. However, the clinical relevance of these events was not reported in several studies. Additionally, more recent research showed contradictory results and suggested substantially lower rates of venous thromboembolism. Thus, the aim of the present study was to summarize evidence on the incidence of clinically relevant venous thromboembolism (VTE)—defined as VTE excluding isolated subsegmental pulmonary embolism (PE) and distal deep vein thrombosis (DVT)—in adult critically ill patients with COVID-19.Methods: We performed a systematic review of studies reporting the incidence of clinically relevant PE and/or DVT in critically ill patients with COVID-19. Scientific reports published in the English language between January and October 2020 were included. We conducted a random-effects model meta-analysis to calculate incidence estimates of clinically relevant VTE and bleeding events. We also performed exploratory meta-regression and subgroup analyses of different diagnostic approaches and additional factors that possibly influenced the incidence of these outcomes.Results: Fifty-four articles (5,400 patients) fulfilled the predefined inclusion criteria, of which 41 had a high risk of bias. The majority of included patients were male, > 60 years, and overweight. Twenty-one studies reported the use of prophylactic doses of heparin. Pooled incidences for clinically relevant PE were estimated at 8% (95% CI, 4–11%), for proximal DVT at 14% (95% CI, 9–20%), and—after exclusion of studies with a high risk of bias—for the composite outcome of VTE at 18% (95% CI, 13–24%). Clinically relevant bleeding occurred at a rate of 6% (95% CI, 2–9%).Conclusions: We summarized currently available data on the rate of clinically relevant VTE in critically ill patients with COVID-19. Pooled incidence estimates were lower than those reported by previous review articles. In the absence of evidence-based anticoagulation guidelines for critically ill patients with COVID-19, the results of our study provide clinically important information for an individual risk-benefit assessment in this context.Registration: The study protocol was prospectively registered in PROSPERO on June 22, 2020 (CRD42020193353; https://www.crd.york.ac.uk/prospero).

scholarly journals Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis

BMJ ◽  
2020 ◽  
pp. l6744 ◽  
Author(s):  
Ying Wang ◽  
Zhikang Ye ◽  
Long Ge ◽  
Reed A C Siemieniuk ◽  
Xin Wang ◽  
...  
Keyword(s):  
Systematic Review ◽  
High Risk ◽  
Gastrointestinal Bleeding ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Odds Ratio ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Bleeding Prophylaxis ◽  
Risk Patients

AbstractObjectiveTo determine, in critically ill patients, the relative impact of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, or no gastrointestinal bleeding prophylaxis (or stress ulcer prophylaxis) on outcomes important to patients.DesignSystematic review and network meta-analysis.Data sourcesMedline, PubMed, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature up to March 2019.Eligibility criteria for selecting studies and methodsWe included randomised controlled trials that compared gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided critical oversight of the systematic review, including identifying outcomes important to patients. We performed random-effects pairwise and network meta-analyses and used GRADE to assess certainty of evidence for each outcome. When results differed between low risk and high risk of bias studies, we used the former as best estimates.ResultsSeventy two trials including 12 660 patients proved eligible. For patients at highest risk (>8%) or high risk (4-8%) of bleeding, both PPIs and H2RAs probably reduce clinically important gastrointestinal bleeding compared with placebo or no prophylaxis (odds ratio for PPIs 0.61 (95% confidence interval 0.42 to 0.89), 3.3% fewer for highest risk and 2.3% fewer for high risk patients, moderate certainty; odds ratio for H2RAs 0.46 (0.27 to 0.79), 4.6% fewer for highest risk and 3.1% fewer for high risk patients, moderate certainty). Both may increase the risk of pneumonia compared with no prophylaxis (odds ratio for PPIs 1.39 (0.98 to 2.10), 5.0% more, low certainty; odds ratio for H2RAs 1.26 (0.89 to 1.85), 3.4% more, low certainty). It is likely that neither affect mortality (PPIs 1.06 (0.90 to 1.28), 1.3% more, moderate certainty; H2RAs 0.96 (0.79 to 1.19), 0.9% fewer, moderate certainty). Otherwise, results provided no support for any affect on mortality, Clostridium difficile infection, length of intensive care stay, length of hospital stay, or duration of mechanical ventilation (varying certainty of evidence).ConclusionsFor higher risk critically ill patients, PPIs and H2RAs likely result in important reductions in gastrointestinal bleeding compared with no prophylaxis; for patients at low risk, the reduction in bleeding may be unimportant. Both PPIs and H2RAs may result in important increases in pneumonia. Variable quality evidence suggested no important effects of interventions on mortality or other in-hospital morbidity outcomes.Systematic review registrationPROSPERO CRD42019126656.

P0625CONTINUOUS RENAL REPLACEMENT THERAPY WITHOUT ANTICOAGULATION IN CRITICALLY ILL PATIENTS AT HIGH RISK OF BLEEDING-A SYSTEMATIC REVIEW AND META-ANALYSIS

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Shiren Sun ◽  
Wei Zhang ◽  
Ming Bai ◽  
Lijuan Zhao ◽  
Xiaolan Chen ◽  
...  
Keyword(s):  
Systematic Review ◽  
Renal Replacement Therapy ◽  
High Risk ◽  
Replacement Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Meta Analysis ◽  
Bleeding Risk ◽  
Cochrane Library ◽  
Risk Of Bleeding

Abstract Background and Aims Continuous renal replacement therapy (CRRT) has been widely used in the critical care setting and anticoagulation is usually necessitated. However, critically ill patients are commonly at incremental risk of bleeding, which contributed to the hesitation of anticoagulant use for CRRT in clinical practice. The current guideline recommended CRRT proceed without anticoagulation in patients with contraindication to citrate and increased bleeding risk. Nevertheless, the efficacy of anticoagulation-free CRRT remains inconsistent. Therefore, the purpose of our present systematic review is to evaluate the efficacy and safety of anticoagulant-free CRRT based on the current literatures. Method We conducted a comprehensive search of PubMed (US National Library of Medicine, Bethesda, MD, USA), Cochrane Library databases and EMBASE from database inception to January 12, 2019 for potential candidate studies. Studies included adult critically ill (age > 18 years) patients with increased bleeding risk, and underwent CRRT without anticoagulation were considered for the inclusion. Results Finally, 17 observational studies and 3 randomized controlled trials with 1615 patients were included in our present meta-analysis. There was no significant difference in filter lifespan between the anticoagulation-free and systemic heparin group. The filter lifespan was significantly prolonged in the citrate (WMD -23.01, 95%CI [-28.62, -17.39], P < 0.001; I2 = 0%, P = 0.53) and nafamostat (WMD -8.4, 95%CI [-9.9, -6.9], P < 0.001; I2 = 33.7%, P = 0.21) groups, compared with anticoagulation-free group. The averaged filter lifespan of the anticoagulation-free CRRT ranged from 10.2 to 52.5 hours. Conclusion The filter lifespan in anticoagulation-free patients with increased bleeding risk was comparable to that in patients without increased bleeding risk underwent systemic heparin anticoagulation CRRT. Nafamostat was not recommended for CRRT anticoagulation due to its drawbacks. Currently, the optimal choice of anticoagulation strategy for critically ill patients without citrate contraindications at high risk of bleeding should be regional citrate anticoagulation. Further studies should focus on the special cut-off value of activated partial thromboplastin time (APTT), international normalized ratio (INR) and platelet (PLT) count, at which the anticoagulation-free CRRT would be beneficial.

scholarly journals Continuous renal replacement therapy without anticoagulation in critically ill patients at high risk of bleeding: a systematic review and meta-analysis

2019 ◽  
Author(s):  
Wei Zhang ◽  
Ming Bai ◽  
Yan Yu ◽  
Xiaolan Chen ◽  
Lijuan Zhao ◽  
...  
Keyword(s):  
Systematic Review ◽  
Renal Replacement Therapy ◽  
High Risk ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Meta Analysis ◽  
Bleeding Risk ◽  
Risk Of Bleeding

Abstract Abstract Background: Continuous renal replacement therapy (CRRT) has been widely used in the critical care setting and anticoagulation is usually necessitated. However, critically ill patients are commonly at incremental risk of bleeding, which contributed to the hesitation of anticoagulant use for CRRT in clinical practice. The current guideline recommended CRRT proceed without anticoagulation in patients with contraindication to citrate and increased bleeding risk. Nevertheless, the efficacy of anticoagulation-free CRRT remains inconsistent. Therefore, the purpose of our present systematic review is to evaluate the efficacy and safety of anticoagulant-free CRRT based on the current literatures. Methods: We conducted a comprehensive search of PubMed (US National Library of Medicine, Bethesda, MD, USA), Cochrane Library databases and EMBASE from database inception to January 12, 2019 for potential candidate studies. Studies included adult critically ill (age > 18 years) patients with increased bleeding risk, and underwent CRRT without anticoagulation were considered for the inclusion. Results: Finally, 17 observational studies and 3 randomized controlled trials with 1615 patients were included in our present meta-analysis. There was no significant difference in filter lifespan between the anticoagulation-free and systemic heparin group. The filter lifespan was significantly prolonged in the citrate (WMD -23.01, 95%CI [-28.62, -17.39], P < 0.001; I 2 = 0%, P = 0.53) and nafamostat (WMD -8.4, 95%CI [-9.9, -6.9], P < 0.001; I 2 = 33.7%, P = 0.21) groups, compared with anticoagulation-free group. The averaged filter lifespan of the anticoagulation-free CRRT ranged from 10.2 to 52.5 hours. Conclusion: The filter lifespan in anticoagulation-free patients with increased bleeding risk was comparable to that in patients without increased bleeding risk underwent systemic heparin anticoagulation CRRT. Nafamostat was not recommended for CRRT anticoagulation due to its drawbacks. Currently, the optimal choice of anticoagulation strategy for critically ill patients without citrate contraindications at high risk of bleeding should be regional citrate anticoagulation. Further studies should focus on the special cut-off value of activated partial thromboplastin time (APTT), international normalized ratio (INR) and platelet (PLT) count, at which the anticoagulation-free CRRT would be beneficial. Key words: Anticoagulation, critically ill patients, continuous renal replacement therapy, filter failure, bleeding

scholarly journals Risk factors for incident delirium among urological patients: a systematic review and meta-analysis with GRADE summary of findings

BMC Urology ◽  
2020 ◽  
Vol 20 (1) ◽  
Author(s):  
L. Sanyaolu ◽  
A. F. M. Scholz ◽  
I. Mayo ◽  
J. Coode-Bate ◽  
C. Oldroyd ◽  
...  
Keyword(s):  
Risk Factors ◽  
Systematic Review ◽  
High Risk ◽  
Patient Group ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Individual Risk ◽  
Future Research ◽  
Clock Drawing Test ◽  
Potential Risk Factors

Abstract Background Post-operative delirium is an important, yet under-researched complication of surgery. Patients undergoing urological surgery may be at especially high risk of POD, as they are often older, and interventions can be associated with conditions that trigger delirium. The main aim of this systematic review was to evaluate the available evidence for risk factors in this patient group. Methods Five databases were searched (MEDLINE, Web of Science, EMBASE, CINAHL and PsychInfo) between January 1987 and June 2019. The Newcastle–Ottawa Scale was used to assess for risk of bias. Pooled odds ratio or mean difference (MD) for individual risk factors were estimated using the Mantel–Haenzel and inverse variance methods. Results Seven articles met the inclusion criteria, giving a total population of 1937. The incidence of POD ranged from 5 to 29%. Three studies were deemed low risk of bias and four at a high risk of bias. Nine risk factors were suitable for meta-analysis, with age (MD 4.314 95% CI 1.597, 7.032 p = 0.002) and the clock drawing test (MD − 2.443 95% CI − 3.029, − 1.857 p < 0.001) having a statistically significant association with POD in pooled analyses. Conclusion Delirium is common in urological patients. This review has identified a lack of studies in this surgical population, with wide heterogeneity and high risk of bias. It also highlights a number of potential risk factors for post-operative delirium, of which some are modifiable. However, the strength of evidence is weak at present and so future research should focus on assessing comparable risk factors in this patient group in order to inform future clinical practice. Review registration The review protocol was prospectively registered with the PROSPERO database (reference CRD42017054613)

Prognostic Factors Associated With Development of Venous Thromboembolism in Critically Ill Patients—A Systematic Review and Meta-Analysis

2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Alexandre Tran ◽  
Shannon M. Fernando ◽  
Bram Rochwerg ◽  
Deborah J. Cook ◽  
Mark A. Crowther ◽  
...  
Keyword(s):  
Systematic Review ◽  
Prognostic Factors ◽  
Venous Thromboembolism ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Meta Analysis ◽  
Factors Associated

scholarly journals Anticoagulation strategies in critical care for the treatment of atrial fibrillation: a protocol for a systematic review and meta-analysis

BMJ Open ◽  
2020 ◽  
Vol 10 (10) ◽  
pp. e037591
Author(s):  
Brian Johnston ◽  
Alexandra Nelson ◽  
Alicia C Waite ◽  
Gedeon Lemma ◽  
Ingeborg Welters
Keyword(s):  
Atrial Fibrillation ◽  
Systematic Review ◽  
Critical Care ◽  
Length Of Stay ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Care Setting ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Critical Care Setting

IntroductionAtrial fibrillation (AF) is the most common cardiac arrhythmia in critically ill patients and is associated with an increased risk of thromboembolic events and mortality. Oral anticoagulation for thromboembolism prophylaxis is a key component of managing AF in the general population and is recommended by National Institute for Health and Care Excellence guidelines. However, assessment tools used to aid decision making about anticoagulation have not yet been validated in the critical care setting. There is a paucity of data assessing the impact of anticoagulation strategies on clinical outcomes in critically ill patients with AF. We present a protocol for a systematic review and meta-analysis to evaluate the effectiveness of anticoagulation strategies for AF used specifically in critical care.Methods and analysisWe will conduct a systematic review of the literature by searching MEDLINE, EMBASE, CENTRAL and PubMed databases for articles published from January 1990 to October 2019. Studies reporting anticoagulation strategies for AF in adults (>18 years) admitted to a general critical care setting will be assessed for inclusion. Outcomes of interest will include (1) percentage of patients started on anticoagulation in critical care for AF, (2) incidence of thromboembolism, (3) incidence of bleeding events, (4) intensive care unit (ICU) mortality, (5) hospital mortality, (6) ICU length of stay and (7) hospital length of stay. We will conduct a meta-analysis of trials. Risk of bias will be assessed using the Cochrane Risk of Bias tool for randomised trials or the Newcastle-Ottawa Risk of Bias assessment tool for non-randomised studies. This protocol and subsequent systematic review will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.Ethics and disseminationThis proposed systematic review will include data extracted from published studies; therefore, ethical approval is not required. The results of this review will be published in clinical specialty journals and presented at international meetings and conferences.Trial registration numberCRD42020158237.

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