背景:目的制定关于成人创伤住院患者静脉血栓栓塞(VTE)预防的循证临床实践指南。
方法:沙特重症监护协会(SCCS)赞助了指南的制定,包括22名完成利益冲突表格的多学科小组成员。小组制定并回答了结构化的指导方针问题。对于每个问题,检索相关研究文献。总结治疗效果,进行或更新meta分析。使用分级建议评估证据质量,评估,发展,和评估(等级)方法,然后使用证据决策(EtD)框架来生成建议.建议涵盖以下优先领域:非手术性钝性实体器官损伤的药物VTE预防的时机;孤立性钝性颅脑损伤(TBI);孤立性钝性脊柱创伤或骨折和/或脊髓损伤(SCI);药物VTE预防的类型和剂量;机械VTE预防;常规双工超声检查(US)监测;和下腔静脉滤器(IVCFs)。
结果:小组发布了12项临床实践建议-一项,强烈推荐,10弱和一个没有建议,由于证据不足。小组建议对非手术性钝性实体器官损伤开始早期药物预防VTE,孤立的钝TBIs,和SCIs。小组建议使用低分子量肝素(LMWH)而不是普通肝素(UFH),并建议中高剂量LMWH或常规剂量LMWH。对于不是药理学候选人的患有创伤的成年人,专家组强烈建议使用机械VTE预防和间歇性气动压缩(IPC)。小组建议使用机械和药理学方法联合预防VTE或单独使用药理学预防VTE。此外,该小组建议,对于不适合药物预防VTE的VTE风险升高的创伤成人,常规双侧下肢US,并建议不常规放置预防性IVCFs.由于证据不足,专家组未就需要神经外科介入治疗的孤立性钝性TBI成人应用早期药物预防VTE提出任何建议.
结论:关于成人创伤患者VTE预防的SCCS指南是基于现有的最佳证据和确定的进一步研究领域。该框架可以促进国家/国际准则决策者对建议的调整。
BACKGROUND: To develop evidence-based clinical practice
guidelines on venous thromboembolism (VTE) prevention in adults with trauma in inpatient settings.
METHODS: The Saudi Critical Care Society (SCCS) sponsored
guidelines development and included 22 multidisciplinary panel members who completed conflict-of-interest forms. The panel developed and answered structured
guidelines questions. For each question, the literature was searched for relevant studies. To summarize treatment effects, meta-analyses were conducted or updated. Quality of evidence was assessed using the Grading Recommendations, Assessment, Development, and Evaluation (GRADE) approach, then the evidence-to-decision (EtD) framework was used to generate recommendations. Recommendations covered the following prioritized domains: timing of pharmacologic VTE prophylaxis initiation in non-operative blunt solid organ injuries; isolated blunt traumatic brain injury (TBI); isolated blunt spine trauma or fracture and/or spinal cord injury (SCI); type and dose of pharmacologic VTE prophylaxis; mechanical VTE prophylaxis; routine duplex ultrasonography (US) surveillance; and inferior vena cava filters (IVCFs).
RESULTS: The panel issued 12 clinical practice recommendations-one, a strong recommendation, 10 weak, and one with no recommendation due to insufficient evidence. The panel suggests starting early pharmacologic VTE prophylaxis for non-operative blunt solid organ injuries, isolated blunt TBIs, and SCIs. The panel suggests using low molecular weight heparin (LMWH) over unfractionated heparin (UFH) and suggests either intermediate-high dose LMWH or conventional dosing LMWH. For adults with trauma who are not pharmacologic candidates, the panel strongly recommends using mechanical VTE prophylaxis with intermittent pneumatic compression (IPC). The panel suggests using either combined VTE prophylaxis with mechanical and pharmacologic methods or pharmacologic VTE prophylaxis alone. Additionally, the panel suggests routine bilateral lower extremity US in adults with trauma with elevated risk of VTE who are ineligible for pharmacologic VTE prophylaxis and suggests against the routine placement of prophylactic IVCFs. Because of insufficient evidence, the panel did not issue any recommendation on the use of early pharmacologic VTE prophylaxis in adults with isolated blunt TBI requiring neurosurgical intervention.
CONCLUSIONS: The SCCS
guidelines for VTE prevention in adults with trauma were based on the best available evidence and identified areas for further research. The framework may facilitate adaptation of recommendations by national/international
guideline policymakers.