Elliott R Haut1, Luis J Garcia2, Hasan M Shihab3, Daniel J Brotman4, Kent A Stevens2, Ritu Sharma3, Yohalakshmi Chelladurai3, Tokunbo O Akande3, Kenneth M Shermock5, Sosena Kebede4, Jodi B Segal6, Sonal Singh6. 1. Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland2Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland3Depar. 2. Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland. 3. The Johns Hopkins Evidence-Based Practice Center, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland. 4. Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland. 5. Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland7Center for Pharmaceutical Outcomes, The Johns Hopkins Hospital, Baltimore, Maryland. 6. The Johns Hopkins Evidence-Based Practice Center, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland6Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Abstract
IMPORTANCE: Trauma is known to be one of the strongest risk factors for pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin therapy for prevention of PE, but trauma places some patients at risk of excess bleeding. Experts are divided on the role of prophylactic inferior vena cava (IVC) filters to prevent PE. OBJECTIVE: To perform a systematic review and meta-analysis examining the comparative effectiveness of prophylactic IVC filters in trauma patients, particularly in preventing PE, fatal PE, and mortality. DATA SOURCES: We searched the following databases for primary studies: MEDLINE, EMBASE, Scopus, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library (all through July 31, 2012). We developed a search strategy using medical subject headings terms and text words of key articles that we identified a priori. We reviewed the references of all included articles, relevant review articles, and related systematic reviews to identify articles the database searches might have missed. STUDY SELECTION: We reviewed titles followed by abstracts to identify randomized clinical trials or observational studies with comparison groups reporting on the effectiveness and/or safety of IVC filters for prevention of venous thromboembolism in trauma patients. DATA EXTRACTION AND SYNTHESIS: Two investigators independently reviewed abstracts and abstracted data. For studies amenable to pooling with meta-analysis, we pooled using the random-effects model to analyze the relative risks. We graded the quantity, quality, and consistency of the evidence by adapting an evidence-grading scheme recommended by the Agency for Healthcare Research and Quality. RESULTS: Eight controlled studies compared the effectiveness of no IVC filter vs IVC filter on PE, fatal PE, deep vein thrombosis, and/or mortality in trauma patients. Evidence showed a consistent reduction of PE (relative risk, 0.20 [95% CI, 0.06-0.70]; I(2)=0%) and fatal PE (0.09 [0.01-0.81]; I(2)=0%) with IVC filter placement, without any statistical heterogeneity. We found no significant difference in the incidence of deep vein thrombosis (relative risk, 1.76 [95% CI, 0.50-6.19]; P=.38; I(2)=56.8%) or mortality (0.70 [0.40-1.23]; I(2)=6.7%). The number needed to treat to prevent 1 additional PE with IVC filters is estimated to range from 109 (95% CI, 93-190) to 962 (819-2565), depending on the baseline PE risk. CONCLUSIONS AND RELEVANCE: The strength of evidence is low but supports the association of IVC filter placement with a lower incidence of PE and fatal PE in trauma patients. Which patients experience benefit enough to outweigh the harms associated with IVC filter placement remains unclear. Additional well-designed observational or prospective cohort studies may be informative.
IMPORTANCE: Trauma is known to be one of the strongest risk factors for pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin therapy for prevention of PE, but trauma places some patients at risk of excess bleeding. Experts are divided on the role of prophylactic inferior vena cava (IVC) filters to prevent PE. OBJECTIVE: To perform a systematic review and meta-analysis examining the comparative effectiveness of prophylactic IVC filters in traumapatients, particularly in preventing PE, fatal PE, and mortality. DATA SOURCES: We searched the following databases for primary studies: MEDLINE, EMBASE, Scopus, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library (all through July 31, 2012). We developed a search strategy using medical subject headings terms and text words of key articles that we identified a priori. We reviewed the references of all included articles, relevant review articles, and related systematic reviews to identify articles the database searches might have missed. STUDY SELECTION: We reviewed titles followed by abstracts to identify randomized clinical trials or observational studies with comparison groups reporting on the effectiveness and/or safety of IVC filters for prevention of venous thromboembolism in traumapatients. DATA EXTRACTION AND SYNTHESIS: Two investigators independently reviewed abstracts and abstracted data. For studies amenable to pooling with meta-analysis, we pooled using the random-effects model to analyze the relative risks. We graded the quantity, quality, and consistency of the evidence by adapting an evidence-grading scheme recommended by the Agency for Healthcare Research and Quality. RESULTS: Eight controlled studies compared the effectiveness of no IVC filter vs IVC filter on PE, fatal PE, deep vein thrombosis, and/or mortality in traumapatients. Evidence showed a consistent reduction of PE (relative risk, 0.20 [95% CI, 0.06-0.70]; I(2)=0%) and fatal PE (0.09 [0.01-0.81]; I(2)=0%) with IVC filter placement, without any statistical heterogeneity. We found no significant difference in the incidence of deep vein thrombosis (relative risk, 1.76 [95% CI, 0.50-6.19]; P=.38; I(2)=56.8%) or mortality (0.70 [0.40-1.23]; I(2)=6.7%). The number needed to treat to prevent 1 additional PE with IVC filters is estimated to range from 109 (95% CI, 93-190) to 962 (819-2565), depending on the baseline PE risk. CONCLUSIONS AND RELEVANCE: The strength of evidence is low but supports the association of IVC filter placement with a lower incidence of PE and fatal PE in traumapatients. Which patients experience benefit enough to outweigh the harms associated with IVC filter placement remains unclear. Additional well-designed observational or prospective cohort studies may be informative.
Authors: Zachary C Dietch; Robin T Petroze; Matthew Thames; Rhett Willis; Robert G Sawyer; Michael D Williams Journal: J Trauma Acute Care Surg Date: 2015-12 Impact factor: 3.313
Authors: Zachary C Dietch; Brandy L Edwards; Matthew Thames; Puja M Shah; Michael D Williams; Robert G Sawyer Journal: Surgery Date: 2015-05-29 Impact factor: 3.982