Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
School of Medicine, Universidad de los Andes, Bogotá, Colombia.
Blood Adv. 2020 Jun 23;4(12):2798-2809. doi: 10.1182/bloodadvances.2020002195.
The impact of pharmacologic prophylaxis for venous thromboembolism in patients undergoing neurosurgical intervention remains uncertain. We reviewed the efficacy and safety of pharmacologic compared with nonpharmacologic thromboprophylaxis in neurosurgical patients. Three databases were searched through April 2018, including those for randomized controlled trials (RCTs) and for nonrandomized controlled studies (NRSs). Independent reviewers assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Seven RCTs and 3 NRSs proved eligible. No studies reported on symptomatic proximal and distal deep vein thrombosis (DVT). Two RCTs reported on screening-detected proximal and distal DVTs. We used the findings of these 2 RCTs as the closest surrogate outcomes to inform the proximal and distal DVT outcomes. These 2 RCTs suggest that pharmacologic thromboprophylaxis may decrease the risk of developing asymptomatic proximal DVT (relative risk [RR], 0.50; 95% confidence interval [CI], 0.30-0.84; low certainty). Findings were uncertain for mortality (RR, 1.27; 95% CI, 0.57-2.86; low certainty), symptomatic pulmonary embolism (PE) (RR, 0.84; 95% CI, 0.03-27.42; very low certainty), asymptomatic distal DVT (RR, 0.54; 95% CI, 0.27-1.08; very low certainty), and reoperation (RR, 0.43; 95% CI, 0.06-2.84; very low certainty) outcomes. NRSs also reported uncertain findings for whether pharmacologic prophylaxis affects mortality (RR, 0.72; 95% CI, 0.46-1.13; low certainty) and PE (RR, 0.18; 95% CI, 0.01-3.76). For risk of bleeding, findings were uncertain in both RCTs (RR, 1.57; 95% CI, 0.70-3.50; low certainty) and NRSs (RR, 1.45; 95% CI, 0.30-7.12; very low certainty). In patients undergoing neurosurgical procedures, low certainty of evidence suggests that pharmacologic thromboprophylaxis confers benefit for preventing asymptomatic (screening-detected) proximal DVT with very low certainty regarding its impact on patient-important outcomes.
在接受神经外科干预的患者中，药物预防静脉血栓栓塞的效果仍不确定。我们回顾了药物与非药物血栓预防在神经外科患者中的疗效和安全性。通过 2018 年 4 月对三个数据库进行了检索，包括随机对照试验（RCT）和非随机对照研究（NRS）。独立评审员使用推荐评估、制定与评价（GRADE）方法评估证据的确定性。7 项 RCT 和 3 项 NRS 符合纳入标准。没有研究报告症状性近端和远端深静脉血栓形成（DVT）。2 项 RCT 报告了筛查检测到的近端和远端 DVT。我们使用这 2 项 RCT 的结果作为最接近的替代结局来报告近端和远端 DVT 结局。这 2 项 RCT 表明，药物血栓预防可能降低无症状性近端 DVT 的发生风险（相对风险 [RR]，0.50；95%置信区间 [CI]，0.30-0.84；低确定性）。死亡率（RR，1.27；95%CI，0.57-2.86；低确定性）、症状性肺栓塞（PE）（RR，0.84；95%CI，0.03-27.42；非常低确定性）、无症状性远端 DVT（RR，0.54；95%CI，0.27-1.08；非常低确定性）和再次手术（RR，0.43；95%CI，0.06-2.84；非常低确定性）的结局不确定。NRS 也报告了药物预防是否影响死亡率（RR，0.72；95%CI，0.46-1.13；低确定性）和 PE（RR，0.18；95%CI，0.01-3.76）的不确定发现。关于出血风险，两项 RCT（RR，1.57；95%CI，0.70-3.50；低确定性）和 NRS（RR，1.45；95%CI，0.30-7.12；非常低确定性）的结果均不确定。在接受神经外科手术的患者中，低确定性证据表明，药物血栓预防对预防无症状（筛查检测到）近端 DVT 有益，但其对患者重要结局的影响具有非常低的确定性。
