• Shannon M Fernando, Alexandre Tran, Wei Cheng, Behnam Sadeghirad, Yaseen M Arabi, Deborah J Cook, MøllerMorten HylanderMHDepartment of Intensive Care, Copenhagen University Hospital Righospitalet, Copenhagen, Denmark., Sangeeta Mehta, Robert A Fowler, BurnsKaren E AKEADepartment of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre for Biomedica, Philip S Wells, Marc Carrier, Mark A Crowther, Damon C Scales, Shane W English, Kwadwo Kyeremanteng, Salmaan Kanji, Michelle E Kho, and Bram Rochwerg.
• Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. Electronic address: sfernando@qmed.ca.
• Chest. 2022 Feb 1; 161 (2): 418-428.

BackgroundCritically ill adults are at increased risk of VTE, including DVT, and pulmonary embolism. Various agents exist for venous thromboprophylaxis in this population.Research QuestionWhat is the comparative efficacy and safety of prophylaxis agents for prevention of VTE in critically ill adults?Study Design And MethodsSystematic review and network meta-analysis of randomized clinical trials (RCTs) evaluating efficacy of thromboprophylaxis agents among critically ill patients. We searched six databases (including PubMed, EMBASE, and Medline) from inception through January 2021 for RCTs of patients in the ICU receiving pharmacologic, mechanical, or combination therapy (pharmacologic agents and mechanical devices) for thromboprophylaxis. Two reviewers performed screening, full-text review, and extraction. We used the Grading of Recommendations Assessment, Development, and Evaluation to rate certainty of effect estimates.ResultsWe included 13 RCTs (9,619 patients). Compared with control treatment (a composite of no prophylaxis, placebo, or compression stockings only), low-molecular-weight heparin (LMWH) reduced the incidence of DVT (OR, 0.59 [95% credible interval [CrI], 0.33-0.90]; high certainty) and unfractionated heparin (UFH) may reduce the incidence of DVT (OR, 0.82 [95% CrI, 0.47-1.37]; low certainty). LMWH probably reduces DVT compared with UFH (OR, 0.72 [95% CrI, 0.46-0.98]; moderate certainty). Compressive devices may reduce risk of DVT compared with control treatments; however, this is based on low-certainty evidence (OR, 0.85 [95% CrI, 0.50-1.50]). Combination therapy showed unclear effect on DVT compared with either therapy alone (very low certainty).InterpretationAmong critically ill adults, compared with control treatment, LMWH reduces incidence of DVT, whereas UFH and mechanical compressive devices may reduce the risk of DVT. LMWH is probably more effective than UFH in reducing incidence of DVT and should be considered the primary pharmacologic agent for thromboprophylaxis. The efficacy and safety of combination pharmacologic therapy and mechanical compressive devices were unclear.Trial RegistryOpen Science Framework; URL: https://osf.io/694aj.Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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