1
|
Long-term outcomes after using retrievable vena cava filters in major trauma patients with contraindications to prophylactic anticoagulation. Eur J Trauma Emerg Surg 2023; 49:335-341. [PMID: 36030313 PMCID: PMC9419913 DOI: 10.1007/s00068-022-02074-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/05/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To investigate the long-term outcomes of using vena cava filters to prevent symptomatic pulmonary embolism (PE) in major trauma patients who have contraindications to prophylactic anticoagulation. METHODS This was an a priori sub-study of a randomized controlled trial (RCT) involving long-term outcome data of 223 patients who were enrolled in Western Australia. State-wide clinical information system, radiology database and death registry were used to assess long-term outcomes, including incidences of venous thromboembolism, venous injury and mortality beyond day-90 follow-up. RESULTS The median follow-up time of 198 patients (89%) who survived beyond 90 days was 65 months (interquartile range 59-73). Ten patients (5.1%) died after day-90 follow-up; and four patients developed venous thromboembolism, including two with symptomatic PE, all allocated to the control group (0 vs 4%, p = 0.043). Inferior vena cava injuries were not recorded in any patients. The mean total hospitalization cost, including the costs of the filter and its insertion and removal, to prevent one short- or long-term symptomatic PE was A$284,820 (€193,678) when all enrolled patients were considered. The number of patients needed to treat (NNT = 5) and total hospitalization cost to prevent one symptomatic PE (A$1,205 or €820) were, however, substantially lower when the filter was used only for patients who could not be anticoagulated within seven days of injury. CONCLUSION Long-term complications related to retrievable filters were rare, and the cost of using filters to prevent symptomatic PE was acceptable when restricted to those who could not be anticoagulated within seven days of severe injury.
Collapse
|
2
|
Jagiasi BG, Chhallani AA, Dixit SB, Kumar R, Pandit RA, Govil D, Prayag S, Zirpe KG, Mishra RC, Chanchalani G, Kapadia FN. Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit. Indian J Crit Care Med 2022; 26:S51-S65. [PMID: 36896363 PMCID: PMC9989869 DOI: 10.5005/jp-journals-10071-24195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/03/2022] [Indexed: 11/05/2022] Open
Abstract
Deep vein thrombosis (DVT) is a preventable complication of critical illness, and this guideline aims to convey a pragmatic approach to the problem. Guidelines have multiplied over the last decade, and their utility has become increasingly conflicted as the reader interprets all suggestions or recommendations as something that must be followed. The nuances of grade of recommendation vs level of evidence are often ignored, and the difference between a "we suggest" vs a "we recommend" is overlooked. There is a general unease among clinicians that failure to follow the guidelines translates to poor medical practice and legal culpability. We attempt to overcome these limitations by highlighting ambiguity when it occurs and refraining from dogmatic recommendations in the absence of robust evidence. Readers and practitioners may find the lack of specific recommendations unsatisfactory, but we believe that true ambiguity is better than inaccurate certainty. We have attempted to comply with the guidelines on how to create guidelines.1 And to overcome the poor compliance with these guidelines.2 Some observers have expressed concern that DVT prophylaxis guidelines may cause more harm than good.3 We have placed greater emphasis on large randomized controlled trials (RCTs) with clinical end point and de-emphasized RCTs with surrogate end points and also de-emphasized hypothesis generating studies (observational studies, small RCTs, and meta-analysis of these studies). We have de-emphasized RCTs in non-intensive care unit populations like postoperative patients or those with cancer and stroke. We have also considered resource limitation settings and have avoided recommending costly and poorly proven therapeutic options. How to cite this article Jagiasi BG, Chhallani AA, Dixit SB, Kumar R, Pandit RA, Govil D, et al. Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit. Indian J Crit Care Med 2022;26(S2):S51-S65.
Collapse
Affiliation(s)
- Bharat G Jagiasi
- Critical Care Department, Reliance Hospital, Navi Mumbai, Maharashtra, India
| | | | - Subhal B Dixit
- Department of Critical Care, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Rishi Kumar
- Department of Critical Care, PD Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Rahul A Pandit
- Critical Care, Fortis Hospital, Mumbai, Maharashtra, India
| | - Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - Shirish Prayag
- Critical Care, Prayag Hospital, Pune, Maharashtra, India
| | - Kapil G Zirpe
- Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Rajesh C Mishra
- Department of MICU, Shaibya Comprehensive Care Clinic, Ahmedabad, Gujarat, India
| | | | | |
Collapse
|
3
|
A prospective ex vivo biomechanical analysis of retrievable inferior vena cava filters. J Vasc Surg Venous Lymphat Disord 2022; 10:1095-1100.e3. [DOI: 10.1016/j.jvsv.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/12/2022] [Indexed: 11/19/2022]
|
4
|
Honeybul S, Ho KM, Rosenfeld JV. The role of tranexamic acid in traumatic brain injury. J Clin Neurosci 2022; 99:1-4. [PMID: 35220154 DOI: 10.1016/j.jocn.2022.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/12/2022] [Accepted: 02/17/2022] [Indexed: 12/29/2022]
Abstract
Evidence from recent trials evaluating efficacy of antifibrinolytic agents in the context of traumatic brain injury may lead to changes in the management of patients with traumatic brain injury. Tranexamic acid (TXA) reduces the proteolytic action of plasmin on fibrin clots, resulting in an inhibition of fibrinolysis and stabilisation of established blood clots. There has been significant interest in use of the drug as a therapeutic agent in the context of severe haemorrhage; however, considerable controversies regarding its efficacy remain. A number of trials have demonstrated a small but significant decrease in mortality following its administration, but the results have been somewhat inconsistent and may not be generalisable. The results of the CRASH-3 trial were that there was no statistical difference in the number of traumatic brain injury related deaths (18.5% with TXA and 19.8% with placebo; relative risk [RR] 0·94; 95% confidence interval [CI] 0·86-1·02). Nonetheless, there was a subgroup of patients for whom TXA appeared to provide benefit, and this was in patients with mild and moderate injury (with a Glasgow Coma Score > 8). This is potentially a very important finding that may have huge potential implications; however, we believe it does not currently provide indisputable evidence to support the administration of TXA to all patients with TBI. Further work is required to better define the subset of patients who may benefit as well as to evaluate the long-term functional benefit in order to determine which types of severe traumatic brain injury patients would derive more benefits than harms from TXA.
Collapse
Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia 6009, Australia; Royal Perth Hospital, Wellington Street, Perth, Australia.
| | - Kwok M Ho
- Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Australia
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, The Alfred Hospital, Emeritus Professor of Surgery Monash University, Melbourne, Australia; Surgery, F.Edward Hebert School of Medicine, Uniformed, Services University of the Health Sciences, Bethesda, MD, USA
| |
Collapse
|
5
|
Ho KM, Rogers FB, Rao S, Chamberlain J, Geelhoed E. Cost-effectiveness of early placement of vena cava filters to prevent symptomatic pulmonary embolism in patients with contraindications to prophylactic anticoagulant. Vasc Med 2021; 26:641-647. [PMID: 34169797 DOI: 10.1177/1358863x211023559] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Vena cava filters have been used as a primary means to prevent symptomatic pulmonary embolism (PE) in trauma patients who cannot be anticoagulated after severe injury, but the economic implications for this practice remain unclear. METHODS Using a healthcare system perspective to analyze the a priori primary outcome of the da Vinci trial, we report the cost-effectiveness of using vena cava filters as a primary means to prevent PE in patients who have contraindications to prophylactic anticoagulation after major trauma. RESULTS Of the 240 patients enrolled, complete, prospectively collected, hospital cost data during the entire hospital stay - including costs for the filter, medical/nursing/allied health staff, medical supplies, pathology tests, and radiological imaging - were available in 223 patients (93%). Patients allocated to the filter group (n = 114) were associated with a reduced risk of PE (0.9%) compared to those in the control group (n = 109, 5.5%; p = 0.048); and the filter's benefit was more pronounced among those who could not be anticoagulated within 7 days (filter: 0% vs control: 16%, Bonferroni-corrected p = 0.02). Overall, the cost needed to prevent one PE was high (AUD $379,760), but among those who could not be anticoagulated within 7 days, the costs to prevent one PE (AUD $36,156; ~ USD $26,032) and gain one quality-adjusted life-year (AUD $30,903; ~ USD $22,250) were substantially lower. CONCLUSION The cost of using a vena cava filter to prevent PE for those who have contraindications to prophylactic anticoagulation within 3 days of injury is prohibitive, unless such contraindications remain for longer than 7 days. (Australian New Zealand Clinical Trials Registry no.: ACTRN12614000963628).
Collapse
Affiliation(s)
- Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA, Australia.,The University of Western Australia School of Medicine, Perth, WA, Australia.,Murdoch University School of Veterinary & Life Sciences, Perth, WA, Australia
| | | | - Sudhakar Rao
- State Trauma Unit, Royal Perth Hospital, Perth, WA, Australia
| | - Jenny Chamberlain
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - Elizabeth Geelhoed
- The University of Western Australia School of Allied Health, Perth, WA, Australia
| |
Collapse
|
6
|
Ho KM, Rao S, Nasim S, Rogers FB. Femoral venous catheterisation, lower limb pneumatic compression and venous thromboembolism after severe trauma: A substudy of the da Vinci trial. Anaesth Intensive Care 2020; 49:74-76. [PMID: 33342224 DOI: 10.1177/0310057x20971645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Australia.,Medical School, University of Western Australia, Perth, Australia.,School of Veterinary and Life Sciences, Murdoch University, Perth, Australia
| | - Sudhakar Rao
- State Trauma Unit, Royal Perth Hospital, Perth, Australia
| | - Sana Nasim
- State Trauma Unit, Royal Perth Hospital, Perth, Australia
| | - Frederick B Rogers
- University of Pennsylvania College of Medicine and Lancaster General Health, Lancaster, USA
| |
Collapse
|
7
|
Ho KM, Rogers FB, Lipman J. A Multicenter Trial of Vena Cava Filters in Severely Injured Patients. Reply. N Engl J Med 2019; 381:1496-1497. [PMID: 31597036 DOI: 10.1056/nejmc1911302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Kwok M Ho
- Murdoch University, Perth, WA, Australia
| | | | | |
Collapse
|