Applying the Grades of Recommendation for Antithrombotic and Thrombolytic Therapy

Isolated Posterior Acute Myocardial Infarction Presenting to an Emergency Department: Diagnosis and Emergent Fibrinolytic Therapy

Objectives

Isolated posterior acute myocardial infarction (AMI) is rare and possibly underdiagnosed. The incidence of misdiagnosis in the emergency department (ED) is unknown. Delayed diagnosis may prevent timely treatment, particularly emergent fibrinolytic therapy. We describe the experience of an urban ED on this rare condition.

Methodology

A six years and seven months case series of isolated posterior AMI of initial presentation (as identified by inpatient discharge/death ICD-9-CM diagnosis code) was studied. Patients not admitted from the ED, those who developed isolated posterior AMI only after admission and/or those with concomitant ST segment elevation AMI involving other anatomical locations of the heart (e.g. inferior or lateral walls), were excluded.

Results

Eleven cases were included in the study. All the nine cases with electrocardiograms available for review demonstrated features consistent with isolated posterior AMI. Eight out of the eleven (72.7%) cases were correctly diagnosed as isolated posterior AMI in the ED. The other three cases were treated as non-ST elevation myocardial infarction (NSTEMI). Nevertheless, their lack of the typical symptoms of acute coronary syndrome and delayed presentation (more than 12 hours) precluded them from fibrinolytics. Three of the eleven cases received fibrinolytics (all streptokinase). All three cases survived to discharge and there were no haemorrhagic complications. None of the cases underwent emergent percutaneous coronary intervention.

Conclusion

The majority of cases with isolated posterior AMI (72.7%) were diagnosed in the ED. Although three cases were interpreted as NSTEMI, the use of fibrinolytic reperfusion therapy was not affected.

What is the definition of successful lysis: reporting standard?

Deep vein thrombosis, and the resultant development of post-thrombotic syndrome, is a significant health issue. Recent evidence demonstrates that the severity of post-thrombotic syndrome symptoms is directly related to the level of venous thrombosis and following treatment these subsequent symptoms are inversely related to the degree of thrombus removal. If we can improve, and preferably standardise the terminology associated with pre-treatment assessment of thrombus load and post-treatment success of thrombus removal techniques, we should then be able to choose more tailor-made techniques to greater benefit our patients. A number of scoring systems have been devised for the assessment of venous thrombus burden, with a majority impractical for everyday usage. In order to provide a more practical solution, the lower extremity thrombosis classification has been developed, using information on anatomical location for venous thrombus combined with a clinical indicator as to the likely sequelae. Anatomical success following venous thrombolysis can be defined by assessing restoration of anterograde flow in the treated vein or the percentage degree of thrombolysis, using venography. The second option is the method most frequently utilised, with the Venous Registry grading system applied. Data from recent trials have given us conflicting and confusing data mainly because we are not using standardised terminology. We urgently need to agree on a standard method of description of thrombus removal before stent placement which also incorporates the likely clinical impact of the area involved in the thrombosis.

Choosing the Appropriate Antithrombotic Agent for the Prevention and Treatment of VTE: A Case-Based Approach

Objective:

To review the risk of venous thromboembolism (VTE) in various patient populations and evaluate the agents available for the prevention and treatment of VTE using a case-based approach.

Data Sources:

A MEDLINE search (1995–July 2006) was conducted to identify relevant literature. Additional references were reviewed from selected articles.

Study Selection and Data Extraction:

Articles related to the prevention of VTE in orthopedic surgery, general surgery, and medically ill patients, as well as the treatment of VTE, were reviewed.

Data Synthesis:

Pharmacologic options for the prevention and treatment of VTE include warfarin, unfractionated heparin (UFH), low-molecular-weight heparins (LMWH), and fondaparinux. Current guidelines support the use of warfarin, LMWH, or fondaparinux for VTE prophylaxis following lower limb major orthopedic surgery. For VTE prophylaxis in hospitalized medical patients or patients undergoing general surgery, use of UFH and LMWH is supported; however, recent data on fondaparinux suggest that it is also effective in these patient populations. The use of UFH or LMWH (both in conjunction with warfarin) for treatment of acute deep venous thrombosis or nonmassive pulmonary embolism is recommended. Recent data suggest that fondaparinux (in conjunction with warfarin) is also effective for the treatment of VTE. A variety of pharmacokinetic, pharmacodynamic, and pharmacoeconomic factors differentiate each agent for the various indications.

Conclusions:

Currently, a “one-size-fits-all” anticoagulant is not available for treatment of VTE. A variety of patient factors, including type of surgery, medical indication, thrombotic risk factors, bleeding risk, history of heparin-induced thrombocytopenia, and a variety of comorbid conditions can affect the safety, efficacy, and selection of appropriate VTE therapy.

Tonsillectomy in the Anticoagulated Patient

Objectives:

The objectives of this study were to review perioperative bridging strategies for anticoagulated patients and to describe a novel bridging strategy for tonsillectomy in an anticoagulated patient that addresses both primary and secondary hemorrhage risks.

Methods:

A literature review and a case report are presented. PubMed was reviewed for evidence-based recommendations on perioperative management of anticoagulated patients. A case report is detailed of a 28-year-old woman with antiphospholipid syndrome on warfarin for high risk of venous thrombosis who underwent tonsillectomy. A perioperative bridging strategy incorporating outpatient low–molecular weight heparin and inpatient unfractionated heparin was implemented to minimize risks of thrombosis and primary and secondary posttonsillectomy hemorrhage.

Results:

Limited evidence supports a consensus on the best perioperative management of anticoagulated patients. Tonsillectomy in an anticoagulated patient has not been described previously. The patient in this case underwent successful tonsillectomy with no thrombosis or bleeding after 1 month of follow-up.

Conclusions:

Tonsillectomy can be done relatively safely in an anticoagulated patient at high risk for thrombosis. The perioperative bridging strategy should account for its unique risk of primary and secondary postoperative hemorrhage. A proposed algorithm for managing these competing risks is presented.

Leucoreduction of blood components: an effective way to increase blood safety?

Over the past 30 years, it has been demonstrated that removal of white blood cells from blood components is effective in preventing some adverse reactions such as febrile non-haemolytic transfusion reactions, immunisation against human leucocyte antigens and human platelet antigens, and transmission of cytomegalovirus. In this review we discuss indications for leucoreduction and classify them into three categories: evidence-based indications for which the clinical efficacy is proven, indications based on the analysis of observational clinical studies with very consistent results and indications for which the clinical efficacy is partial or unproven.

Systematic review of duration and choice of systemic antibiotic therapy for acute haematogenous bacterial osteomyelitis in children

AIM

Historically, children with acute osteomyelitis received 4-6 weeks of parenteral antibiotics; however, evidence to guide optimal duration of therapy is limited. This study aims to summarise the available evidence on the duration and choice of antimicrobial therapy for acute haematogenous osteomyelitis in children.

METHODS

We systematically reviewed the literature on children with acute osteomyelitis to determine if shorter durations of antibiotic treatment compared with protracted treatment gave different cure rates. We also analysed studies for choice of antibiotics to determine differences in success rates. Randomised controlled trials, cohort studies, case-control studies and case series were eligible for inclusion.

RESULTS

We identified six randomised controlled trials, three of which addressed duration of antibiotic use and three choice of antibiotic for acute osteomyelitis in children. We found 28 observational studies, 20 of which focused on duration and 22 of which allowed analysis of choice of antibiotic. A range of therapy durations and types of antibiotics were assessed. Only one small study looked at treatment of neonates.

CONCLUSIONS

The quality of evidence on antibiotic treatment for acute osteomyelitis is limited, allowing only weak (GRADE 2B) recommendations. Our review suggests that early transition from intravenous to oral therapy, after 3-4 days in patients responding well, followed by oral therapy to a total of 3 weeks may be as effective as longer courses for uncomplicated acute osteomyelitis. This recommendation does not apply to neonates.

Inherited thrombophilia and gestational venous thromboembolism

Thromboembolic disease remains a leading cause of maternal mortality during pregnancy and the puerperium. Rational and risk-adapted administration of heparin prophylaxis depends on the identification of those women who have an increased risk of thrombosis and the accurate quantification of this risk. In women without prior thrombosis, the presence of a heterozygous factor V Leiden or heterozygous G20210A mutation in the prothrombin gene is associated with a pregnancy-associated thrombotic risk of approximately 1 in 400. Thus, in pregnant carriers of either one of these mutations, the risk of venous thromboembolism is low. Therefore, no heparin prophylaxis is recommended. A combination of the two genetic risk factors can increase the risk to a modest level of 1 in 25. In all women with prior thrombosis, the authors recommend heparin prophylaxis throughout pregnancy and postpartum for 6 weeks (inconsistent data). However, according to the American College of Chest Physicians recommendations, in the subgroup of women with an episode of prior thrombosis associated with a transient risk factor, such as surgery or trauma, and no additional genetic risk factor, clinical surveillance throughout pregnancy and heparin prophylaxis postpartum is possible. Despite the remarkable progress in risk stratification, the absolute magnitude of risk and the optimum management is, in many cases, an issue of ongoing debate.

Endovascular treatment of a haemodynamically unstable massive pulmonary embolism using fibrinolysis and fragmentation. Experience with 111 patients in a single centre. Why don't we follow ACCP recommendations?

INTRODUCTION

Fibrinolysis is recommended in several consensus documents for the treatment of a haemodynamically unstable massive pulmonary embolism (HUMPE).

MATERIAL AND METHODS

A total of 111 patients were treated in a single centre from January 2001 to December 2009. They were 55 males and 56 females diagnosed with HUMPE (systolic arterial pressure>90 mmHg) with at least two of the following criteria: Miller index>0, ventricular dysfunction, and need of vasoactive drugs. Local fibrinolysis with urokinase was performed in all cases, and fragmentation with a pig-tail catheter in the majority of them. An inferior vena cava (IVC) filter was implanted in 94 patients as a prophylactic measure.

RESULTS

Technical success was 100%. The Miller index improved from 0.7 ± 0.12, pre-treatment, to 0.09 ± 0.16. The mean pulmonary arterial pressure fell from 39.93 ± 7.0 mmHg to 20.47 ± 3.3 mmHg in the 30-90 days review. Of the 94 patients with IVC filters implanted, 79% were withdrawn satisfactorily. Seven patients died: 3 due to their neoplasia, 3 due to right cardiac failure at 1, 7 and 30 days, and another died of a brain haemorrhage in the first 24 hours. There were complications in 12.6% of the cases, of which 4.5% were major.

CONCLUSION

Local fibrinolysis with fragmentation achieves a rapid return to normal of the pulmonary pressure and is a safe and effective method for the treatment of HUMPE.

The Surviving Sepsis Campaign: a history and a perspective

BACKGROUND

The Surviving Sepsis Campaign (SSC) was launched in 2002 as a collaborative initiative of the European Society of Intensive Care Medicine (ESICM), the International Sepsis Forum (ISF), and the Society of Critical Care Medicine (SCCM). Its objective was, through the development and promulgation of evidence-based guidelines that facilitated the application of knowledge derived from clinical trials to bedside practice, to effect a 25% reduction in the relative risk of death from severe sepsis and septic shock.

METHODS

The evolution and content of the SSC is summarized and the scientific basis of the conclusions is reviewed from the literature.

RESULTS

The SSC developed evidence-based management guidelines and undertook a broad educational program to implement them by integrating their recommendations into resuscitation and management bundles. The process engaged practitioners in North America, Europe, and South America and was supported by professional societies around the world. It also engendered controversy based on accusations of undue industry influence and some dissatisfaction among individuals who were antagonistic toward protocolization of care. By its conclusion, more than 22,000 patients with sepsis had been entered in the SSC database, and analysis of the results showed that participation in the SSC was associated with a 5.4% absolute survival benefit.

CONCLUSIONS

The SSC has impacted the care of septic patients and catalyzed changes that are likely to persist and evolve.

A clinician's perspective on rating the strength of evidence in a systematic review

Systematic review is a means of reviewing clearly formulated questions by using an explicit methodology to minimize bias in the location, selection, critical evaluation, and synthesis of research evidence from existing studies. It is not enough, however, to simply know that the best evidence available was captured in a systematic review. Rather, health care decision makers also need to understand what the strength of that evidence is. Strong evidence of a therapy's benefits and harms facilitates sound judgment in clinical practice, compared with weak evidence. In the absence of an organized method, different clinicians may review the same data and differ on their impression of the strength of evidence but not understand why they differ. A wide variety of grading systems are available to rate the strength of evidence, but different organizations may weigh features or domains of these systems differently. Also, the published articles written on how to grade the strength of evidence are not likely to penetrate to the clinician's level and are not written so that practicing clinicians can understand them. In this article, we provide a better understanding of the key criteria or domains that should be considered when rating the strength of a body of evidence, why they are important, and the domains included in some of the validated and commonly used scales. This not only will enable clinicians and health care decision makers to personally grade the strength of evidence and be able to extend it to their clinical practices, but also will allow them to understand which domains are and which are not covered, and how different grading scales can provide different results and still be accurate based on the domains they include.

[Heparin resistance and antithrombin deficiency]

The phenomenon of heparin resistance (HR) is characterized by high doses of unfractionated heparin (UFH) being required to bring activated partial thromboplastin time (aPTT) and activated coagulation time (ACT) within therapeutically desired ranges, or by the impossibility of reaching these ranges. At UFH dosages > 35,000 IU/d, HR should be considered a factor. The most frequent cause of HR is deficiency of antithrombin (AT), the presence of which is essential for UFH to exert its anticoagulatory effect. AT in concentrate form may be applied to overcome AT-dependent HR. The main clinically relevant situations in which AT-dependent HR occurs, with possible indication of AT substitution, are congenital AT deficiency, asparaginase therapy, disseminated intravascular coagulation (DIC) and administration of high doses of heparin during extracorporeal circulation, where it is significant, due to the need to maintain a very high ACT (> 400 s), that use of heart-lung machines is associated with an HR incidence of approximately 20%. The following procedure is recommended when there is no DIC and when extracorporeal circulation is not used: if HR is suspected and AT activity is < or = 60%, UFH should first be reduced to 500 IU/h (to prevent bleeding complications), before AT is substituted. AT activity should then exceed 80%. Under normalized and stable AT activity, the UFH dose should be adjusted such that aPTT is within a range of 60-100 s. If anticoagulation over a longer term is indicated, then overlapping anticoagulation with a vitamin K antagonist should be started as quickly as possible.

Secondary stroke prevention strategies for the oldest patients: possibilities and challenges

Older adults are not only at higher risk of experiencing stroke, but also have multiple co-morbidities that make treatment for secondary stroke prevention challenging. Very few clinical trials specifically related to secondary stroke prevention treatment efficacy have focused on the oldest-old (>or=85 years) and, therefore, evidence-based recommendations for treatment specific to this population are not available. Some of the special considerations for stroke prevention treatments in older patients include careful titration of blood-pressure-lowering drugs to avoid hypotension, the risk of haemorrhagic stroke with HMG-CoA reductase inhibitors (statins) and weighing the risk of recurrent ischaemia versus bleeding in patients taking antiplatelet or anticoagulant therapy. The risk of peri-procedural complications appears to be high with both carotid angioplasty and stenting and carotid endarterectomy in older patients with carotid stenosis. Other common issues in older patients include adverse drug events, recognizing the risk of dementia, depression and osteoporosis and deciding when to discontinue secondary stroke prevention. In this review, we provide the practitioner with the evidence related to specific approaches to secondary stroke prevention in older patients, and identify the knowledge gaps that currently limit our ability to appropriately treat this vulnerable population.

Clinical practice guidelines

In the era of evidence-based medicine, clinical practice guidelines (CPGs) have become an integral part of many aspects of medical practice. Because practicing neurosurgeons rarely have the time or, in some cases, the methodological expertise, to assess and assimilate the totality of primary research, CPGs can in theory provide a vehicle through which neurosurgeons could more efficiently integrate the most current evidence into patient management. Clinical practice guidelines have been met with some skepticism, however, particularly within the neurosurgical community. Some have expressed concerns that the promise of CPGs has not been matched by the reality. Others who oppose CPGs fear that they hinder the art of medicine, and limit physician and patient autonomy. The purpose of this paper is to provide the practicing neurosurgeon with an up-to-date review of CPGs. The authors discuss some of the complexities and recent advancements in CPG development, appraisal, and publication. An overview of the various systems for grading medical evidence and issuing CPG recommendations, each of which has its advantages and disadvantages, is included, and the current knowledge on the impact of CPGs in 2 important realms, patient care and medicolegal issues, is discussed. The purpose of this review is to provide a balanced, current synopsis of what CPGs are, how they are developed, and what they can and cannot do. The authors hope that this will allow neurosurgeons to make more informed decisions about the many CPGs that will inevitably become an essential component of medical practice in the years to come.

Thromboembolic risk assessment and the efficacy of enoxaparin prophylaxis in excisional body contouring surgery

BACKGROUND

There is a paucity of evidence within the plastic surgery literature concerning risk stratification and management of patients with respect to thromboembolic disease. A retrospective chart review was conducted to examine whether the Davison-Caprini risk-assessment model could stratify patients undergoing excisional body contouring surgery, allowing prophylaxis to be managed in an evidence-based manner.

METHODS

Three hundred sixty excisional body contouring patients at the University of Texas Southwestern Medical Center in Dallas, Texas, under the senior authors' (J.M.K. and R.J.R.) care were reviewed. Patients were stratified into groups according to the risk-assessment model and into groups based on procedure. Patient characteristics were investigated for their effects on thromboembolic risk. Complications of enoxaparin administration were analyzed. The data were analyzed using appropriate statistical procedures.

RESULTS

The highest risk patients had a significantly increased rate of venous thromboembolism when compared with lower risk patients. Body mass index greater than 30 and hormone therapy use were associated with a significantly increased venous thromboembolism rate. Enoxaparin administration was associated with a statistically significant decrease in deep venous thrombosis in circumferential abdominoplasty patients. Enoxaparin administration was associated with higher bleeding rates.

CONCLUSIONS

Low-molecular-weight heparin may affect the incidence of postoperative thrombotic complications in some surgical populations. In this study, patients who scored greater than four risk factors were at significant risk for venous thromboembolism. Enoxaparin significantly decreased deep venous thrombosis risk in patients undergoing circumferential abdominoplasty. This demonstrates the need for a multicenter, prospective, randomized study to examine various thromboembolic therapies and associated possible complications in these patients.

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008

OBJECTIVE

To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," published in 2004.

DESIGN

Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding.

METHODS

We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation (1) indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations.

RESULTS

Key recommendations, listed by category, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B), targeting a blood glucose < 150 mg/dL after initial stabilization (2C); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); and a recommendation against the use of recombinant activated protein C in children (1B).

CONCLUSIONS

There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008

OBJECTIVE

To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock," published in 2004.

DESIGN

Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding.

METHODS

We used the GRADE system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost), or clearly do not. Weak recommendations indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations.

RESULTS

Key recommendations, listed by category, include: early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures prior to antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for post-operative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B) targeting a blood glucose < 150 mg/dL after initial stabilization ( 2C ); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper GI bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include: greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); a recommendation against the use of recombinant activated protein C in children (1B).

CONCLUSION

There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Outpatient management of stable acute pulmonary embolism: proposed accelerated pathway for risk stratification

Pulmonary embolism (PE) is a major health problem and a cause of worldwide morbidity and mortality. The current standard therapy for acute PE encourages admitting patients to the hospital for administration of parenteral anticoagulation therapy as a bridge to oral vitamin K antagonists. Prognostic models that identify patients with stable (nonmassive) acute PE (SPE) who are at low risk for adverse outcome have recently been reported. Based on these risk stratification models, hospital-based therapy is warranted for patients with PE who meet the criteria associated with a high risk for adverse outcome. However, a growing body of evidence suggests the feasibility of partial outpatient management and accelerated hospital discharge (AHD) in a subset of patients with SPE. Prospective validation of these risk stratification models for predicting patient suitability for AHD is needed.

Multi-institutional study of symptomatic deep venous thrombosis and pulmonary embolism in prostate cancer patients undergoing laparoscopic or robot-assisted laparoscopic radical prostatectomy

OBJECTIVES

The true incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing laparoscopic radical prostatectomy is unknown. Our aim was to determine the incidence of symptomatic DVT and PE and the risk factors for these complications.

METHODS

Fourteen surgeons from 13 referral institutions from both Europe and the United States provided retrospective data for all 5951 patients treated with laparoscopic radical prostatectomy (LRP), with or without robotic assistance, since the start of their institution's experience. Symptomatic DVT and PE within 90 d of surgery were regarded as venous thromboembolism (VTE). DVT was diagnosed mostly by Doppler ultrasound or contrast venography and PE by lung ventilation/perfusion scan or chest computed tomography or both. Statistical analysis included evaluation of incidence of symptomatic DVT and PE and risk factors as determined by exact methods and logistic regression.

RESULTS

Of 5951 patients in the study, 31 developed symptomatic VTE (0.5%; 95% confidence interval [CI], 0.4%, 0.7%). Among patients with an event, 22 (71%) had DVT only, 4 had PE without identified DVT, and 5 had both. Two patients died of PE. Prior DVT (odds ratio [OR]=13.5; 95%CI, 1.4, 61.3), current tobacco smoking (OR=2.8; 95%CI, 1.0, 7.3), larger prostate volume (OR=1.18; 95%CI, 1.09, 1.28), patient re-exploration (OR=20.6; 95%CI, 6.6, 54.0), longer operative time (OR=1.05; 95%CI, 1.02, 1.09), and longer hospital stay (OR=1.05; 95%CI, 1.01, 1.09) were associated with VTE in univariate analysis. Neoadjuvant therapy, body mass index, surgical experience, surgical approach, pathologic stage, perioperative transfusion, and heparin administration were not significant predictors.

CONCLUSIONS

The incidence of symptomatic VTE after LRP is low. These data do not support the administration of prophylactic heparin to all patients undergoing LRP, especially those without risk factors for VTE.

Thromboembolic Therapies in Dogs and Cats: An Evidence-Based Approach

In veterinary medicine, we are forced to make use of less than ideal "evidence," such as extrapolation from experimental studies in dogs and cats without naturally occurring diseases and from clinical trials in other species (particularly human clinical trials), as well as limited information gained from veterinary clinical experience, small clinical trials, case studies, and anecdotal reports. In this article, specific treatment recommendations are made for each of the common thromboembolic conditions seen in dogs and cats. These recommendations are made with the important caveat that, to date, such suggested therapeutic approaches are based on limited evidence.

Evaluating and minimizing cardiac risk in surgical patients

Cardiovascular complications are a major cause of postoperative morbidity and mortality. Proper assessment of risk and subsequent interventions can help diminish these complications. Assessing the patient's risk is based on the type of surgery performed and on individual patient characteristics. The latter can be established with a thorough history and physical, laboratory testing, risk indices, and cardiology studies.

Méta-analyses ou méga-essais: un même niveau de preuves?

Results of meta-analyses may differ from those of megatrials only because of the bias that could be introduced by a unadequate methodology of some meta-analyses. A meta-analysis must be based on an exhaustive review of the literature - of all studies, those with negative as well as positive results. The quality of a meta-analysis depends on the methodological quality of the studies it analyzes; accordingly they must be selected according to strict methodological inclusion and exclusion criteria, defined a priori. The value of a meta-analysis is that allows a treatment strategy to be assessed in populations more heterogeneous than those in clinical trials. Nonetheless the heterogeneity of protocols, of dosing, and of outcome measures can lead to bias of the treatment effect estimation. Different analytic techniques must be used to assess possible publication or selection bias (the so-called "funnel plot" method) and potential sources of heterogeneity (heterogeneity test, meta-regression, etc.). Meta-analyses of individual data make it possible to assess the treatment effect according to patient characteristics. Prospective meta-analyses or those planned before clinical trials can help to limit data heterogeneity by making study protocols less varied (treatment, follow-up, evaluation, etc.).

Risk of venous thromboembolism in patients undergoing cancer surgery and options for thromboprophylaxis

Patients with cancer have an increased risk of developing venous thromboembolism (VTE) due to a hypercoagulable state associated with malignancy. This risk is further complicated in patients undergoing cancer-related surgery due to immobility, other cancer treatments, and biologic changes associated with surgery. Despite this relatively high risk of VTE, many patients are not prescribed adequate prophylaxis in the pre- or post-operative periods. This article reviews available measures for thromboprophylaxis in light of current guidelines.

Deep vein thrombosis in hospitalized patients: a review of evidence-based guidelines for prevention

Deep vein thrombosis affects many hospitalized patients because of decreased activity and therapeutic equipment. This article reviews known risk factors for developing deep vein thrombosis, current prevention methods, and current evidence-based guidelines in order to raise nurses' awareness of early prevention methods in all hospitalized patients. Early prophylaxis can reduce patient risk of deep vein thrombosis and its complications.

Grading the evidence: levels of evidence and grades of recommendation

Evidence-based medicine is using the best available evidence in order to make accurate and knowledgeable treatment decisions. It is not the automatic gainsay of "low quality" evidence and acceptance of randomized controlled trials (RCT's). To be able to make a sound recommendation for a therapy based on the best available evidence, it is necessary to follow steps in acquiring literature, appraising it for study design and quality, and to assess its results, as well as look at the net benefits and net harms.

Managing Oral Anticoagulation Requires Expert Experience and Clinical Evidence

The management of patients on chronic oral anticoagulant therapy, namely Vitamin K antagonists such as warfarin, is often associated with difficult and challenging issues for the healthcare practitioner. Many of these issues, such as warfarin failure or resistance, the optimal warfarin initiation dose, the optimal target International Normalized Ratio in antiphospholipid syndrome, the optimal monitoring frequency and use of point-of-care monitoring, the management of oral anticoagulation during invasive procedures, and the management of over-anticoagulation, have not been evaluated in rigorously-designed clinical trials. The latest American College of Chest Physician recommendations concerning these issues are Grade 2C, the weakest recommendations available. It remains up to the experience and expertise of the individual practitioner along with whatever clinical evidence is available in a particular healthcare environment-especially one associated with an anticoagulant management service-to implement management strategies with respect to these issues in patients on oral anticoagulation.

Recognition, treatment, and prevention of heparin-induced thrombocytopenia: Review and update

Heparin-induced thrombocytopenia (HIT) is one of the most important life- and limb-threatening adverse drug events encountered by physicians. Serious sequelae associated with HIT can be avoided with early recognition and appropriate treatment. This review examines the recommendations published in 2004 by the American College of Chest Physicians on the recognition, treatment, and prevention of HIT together with more recent data, especially regarding treatment with direct thrombin inhibitors.