Whether an optimal strategy exists for VTE prevention in critically ill patients: Insights from guidelines and randomized controlled trials.

Abstract

Critically ill patients face challenges in venous thromboembolism (VTE) prevention, with limited consensus on the efficacy of different anticoagulants and prevention methods. This study aims to systematically evaluate the quality of existing clinical practice guidelines (CPGs) and the efficacy and safety of various anticoagulation regimens for VTE prevention in such patients. CPGs quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II and Reporting Items for Practice Guidelines in Healthcare (RIGHT) tools. A network comparison was conducted to evaluate the efficacy and safety of distinct low-molecular-weight heparins (LMWHs) and unfractionated heparin (UFH) for thromboprophylaxis. Seventeen CPGs and 12 randomized controlled trials (7636 patients) were systematically reviewed. The scores for "stakeholder involvement" (58.8%) and "applicability" (60.7%) were relatively low in AGREE II. The RIGHT checklist identified insufficient reporting in "review and quality assurance" (44.1%) and "evidence" (57.1%). Four CPGs (NICE2019, ACCP2012, ASH2018, and ASH2019) demonstrated high clinical applicability. Network analysis revealed no significant differences among separate LMWHs (bemiparin, enoxaparin, nadroparin, dalteparin) or between different LMWHs and UFH in reducing deep vein thrombosis (DVT), pulmonary embolism, or VTE. However, pooled LMWHs analysis demonstrated a significant reduction only in DVT compared to UFH (odds ratio 0.71, 95% credible interval: 0.42-0.99). Although the 17 CPGs propose various strategies for VTE prevention, substantial differences exist in their quality and clinical applicability. Existing clinical evidence fails to demonstrate superior prophylactic efficacy among VTE prevention strategies in critically ill patients.