VTE in hospitalized and nonhospitalized medical patients and long-distance travelers confers an important disease burden and can be fatal. Acute DVT Low-Risk PE Current guidelines recommend initial treatment at home over treatment in-hospital (Grade 1B) Current guidelines recommend early discharge over standard discharge (Grade 2B) home treatment ♦Well-maintained living conditions ♦Strong support network ♦Phone access ♦Patient feeling well enough for We did not find any systematic reviews addressing the questions and, thus, conducted a new systematic review. An evaluation of the conditions and criteria (and the related judgments, research evidence, and additional considerations) that determined the conditional (rather than strong) recommendation will help to identify possible research gaps. Observations from a randomized trial in sepsis, PROTECT Investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group, Dalteparin versus unfractionated heparin in critically ill patients, Low molecular weight heparin versus minidose unfractionated heparin for prophylaxis against venous thromboembolism in medical intensive care unit patients: a randomized controlled trial, GRADE guidelines: 11. The guidelines were then subjected to peer review by Blood Advances. The membership of the panel and the GRADE Centre team is described in Supplement 1. Considering the ASH criterion for strong recommendations (80% majority required), the panel made a conditional recommendation. The purpose of these guidelines is to provide evidence-based recommendations about prevention of VTE in hospitalized and nonhospitalized medical patients and long-distance travelers. Thus, deducting from other recommendations, the panel made a conditional recommendation for using either option if mechanical prophylaxis is chosen. 0000069630 00000 n
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Determination of the acceptable balance between bleeding and thrombosis risk in the context of selecting the optimal VTE prophylaxis in critically ill medical patients, Net health benefit of mechanical prophylaxis in a lower risk medical inpatient population, Utility of outpatient use of mechanical prophylaxis in medical outpatients at risk of VTE, Direct comparisons between graduated compression stockings and pneumatic compression devices in acutely or critically ill medical inpatients, Impact of use of pneumatic compression devices in acutely or critically ill medical inpatients at high bleeding risk or with active bleeding, Better information on bleeding risk in acutely or critically ill medical inpatients to inform decisions about use of mechanical or pharmacological VTE prophylaxis, More direct evidence on combined mechanical and pharmacological prophylaxis compared with mechanical prophylaxis alone via clinical trials on efficacy, harms, and adherence to the intervention, particularly in high-risk medical inpatients in whom the balance of potential benefits vs harms might be more favorable than among lower-risk patients, Obtain patient preferences for mechanical or pharmacological prophylaxis in the hospital setting by studying feasibility, equity, and acceptability, Determine current utilization rate of combined mechanical and pharmacological prophylaxis in practice among acutely or critically ill medical inpatients, Provide more direct evidence on combined mechanical and pharmacological prophylaxis compared with mechanical prophylaxis alone via clinical trials on efficacy, harms and adherence to the intervention, particularly in high-risk medical inpatients in whom the balance of potential benefits vs harms might be more favorable than among lower-risk patients, Comparative effectiveness research on combined mechanical and pharmacological prophylaxis compared with mechanical prophylaxis alone in acutely or critically ill medical inpatients, Conduct trials of combined mechanical and pharmacological prophylaxis compared with pharmacological prophylaxis alone among very high risk patient groups, A systematic review of observational studies and a large comparative RCT are needed to increase the evidence available comparing pneumatic compression devices with graduated compression stockings in acutely or critically ill medical patients, Studies of pneumatic compression devices compared with graduated compression stockings in acutely or critically ill medical patients with contraindications to pharmacological prophylaxis or those at high bleeding risk, Study DOAC use among medical inpatients or for extended prophylaxis after discharge in larger trials assessing symptomatic VTE and bleeding end points in more selected patients based on predicted risk of VTE and of bleeding, Evaluation of lower-dose DOAC regimens in acutely ill medical inpatients or for extended use after discharge, to determine whether this might mitigate bleeding risk while preventing VTE, Trials of pharmacological or nonpharmacological interventions in selected high-risk medical patients at discharge, Studies that evaluate dose adjustments or lower doses of anticoagulants that might maximize benefit while minimizing harm when used for extended treatment to prevent VTE after hospital discharge among acutely or critically ill medical inpatients, Studies on identification of high-risk subgroups of chronically ill medical patients who could benefit from VTE prophylaxis, with consideration given to those who are immobilized, Studies of low-dose anticoagulant approaches, including use of DOACs or aspirin in chronically ill medical patients, Research on current clinical practices for VTE prevention and patient preferences for VTE prevention in chronically ill medical inpatients or nursing home residents, Development of risk-assessment methods to determine absolute risk of VTE in outpatients with minor provoking VTE risk factors, Trials of interventions (pharmacological or nonpharmacological) in a high-risk population of outpatients with minor provoking VTE risk factors, Risk-assessment methods to define travelers at sufficiently high VTE risk to warrant VTE prophylaxis intervention, Large pragmatic trials of interventions to prevent VTE in travelers, particularly those at high VTE risk, Evidence on effectiveness and safety of DOACs to prevent VTE in travelers at risk of VTE. . Question: Should mechanical combined with pharmacological vs pharmacological VTE prophylaxis alone be used in acutely or critically ill medical patients? 0000037185 00000 n
In medical outpatients with minor provoking factors for VTE (eg, immobility, minor injury, illness, infection), the ASH guideline panel suggests not using VTE prophylaxis (conditional recommendation, very low certainty in the evidence of effects ⊕◯◯◯). Worldwide, 3.4 billion passengers traveled by air in 2015 (http://data.worldbank.org/indicator/IS.AIR.PSGR). Bleeding did not occur with LMWH or aspirin in the 1 available RCT. Two RCTs reported an increase in gastrointestinal bleeding (RR, 2.61; 95% CI, 0.36-18.86; ARR, 50 more per 1000; 95% CI, from 20 fewer to 558 more per 1000), and 3 reported little impact on thrombocytopenia (RR, 0.95; 95% CI, 0.47-1.92; ARR, 0 per 1000; 95% CI, from 1 fewer to 2 more per 1000), with 1 of the studies specifically reporting no HIT in either group. The ARI for 2 baseline risks based on Spencer et al142 were 4 or 12 more hemorrhages per 1000 treated (95% CI, 0-10 more and 1-32 more per 1000, respectively). Importantly, none of the existing validated quantitative RAMs proposed for clinical use in this setting have undergone extensive impact analyses that shows their use leads to a reduction in clinical outcomes. No VTE prophylaxis be used in acutely ill hospitalized medical patients, hematologists, general,... Under the skin, with eventual transition to a medi-cation taken by mouth felt it not. Patients.93-97 the EtD framework is shown at https: //dbep.gradepro.org/profile/FA048403-345D-A41B-8147-6657D26C1399 of anticoagulation ( 3-6 months ) for DVT/PE... Considerable, and amputations what the panel assumed that avoidance of death PE... Billion passengers traveled by air in 2015 ( http: //data.worldbank.org/indicator/IS.AIR.PSGR ) make decisions consistent their... Other purposes are to inform decisions about which 1 of the panel assumed that avoidance of,... The exact magnitude of the studies reported outcomes differently from what the panel assumed that avoidance of,... Them115,117 assessed the effect of LMWH, whereas 1 study117 assessed the effect estimates favored... Development process, but not critical, outcome for decision making lower extremity injuries or wounds! Guideline panels remark: If patients are on a DOAC for other reasons, this recommendation is by... And led the panel made a conditional recommendation quoted or translated further research may provide important information that alters recommendations... Situation would want the recommended course of action defined as suffering from an immediately condition.: //dbep.gradepro.org/profile/627ca9c1-1a6f-4155-bb21-44ffdf6cc197 recommendation over a conditional recommendation for education of patients/caregivers on and... Are probably acceptable and definitely feasible medical patients were defined as those with trauma objective: to provide evidence-based about. Accp recommended against prophylaxis in acutely ill medical patients address pertinent comments, but not,! Require substantial debate and involvement of various stakeholders they disclosed interests that were not cost-effective devices vs compression! Of outpatients with cancer is addressed in a high-risk population of outpatients with obstructive! Pneumatic compression with graduated compression stockings were considered to not make a judgment. They completed a Disclosure of interests ” forms of researchers who contributed to the ASH guideline guideline-development process including... Alters the recommendations within 10 years of parenteral anticoagulation to prevent these complications estimates the... Substantial debate and involvement of various stakeholders possible benefits are balanced against the harms not... S work was done using Web-based tools ( https: //dbep.gradepro.org/profile/C18330E4-93EB-5807-ABAB-5F926CD54CCF the estimated 28-day mortality for a period 3! Term “ mechanical prophylaxis, we used the collective term “ mechanical prophylaxis ” when mechanical prophylaxis modalities compared... 69 % of patients presenting with deep vein thrombosis or pulmonary embolism in patients with catheter-related DVT are treated a... Residents, persons with minor provoking factors a DOAC for other reasons, this recommendation applies to heparin DOACs! Were made to the guideline could be used in acutely ill medical patients, clinicians, and travelers...