RESUMEN
Essentials Critically ill cancer patients require pharmacologic prophylaxis for venous thromboembolism (VTE). Patients from 566 hospitals in the United States between 2010 and 2014 were included. Low-molecular-weight heparin (LMWH) prophylaxis was not associated in a reduction of VTE rates. LMWH prophylaxis was associated with a reduction in bleeding and heparin induced thrombocytopenia. SUMMARY: Background Critically ill patients with cancer are at increased risk of venous thromboembolism (VTE) from physical and cellular factors, requiring pharmacologic prophylaxis to reduce the risk of VTE. Objectives To assess whether low-molecular-weight heparin (LMWH) prophylaxis reduces in-hospital rates of VTE or improves clinical outcomes compared with unfractionated heparin (UFH) prophylaxis in critically ill patients with cancer. Methods We used a propensity-matched comparative-effectiveness cohort from the Premier Database. Patients aged 18 years or older with a primary diagnosis of cancer, intensive care unit admission and VTE prophylaxis within 2 days of admission between 1 January 2010 and 31 December 2014 were included. Patients were divided into LMWH or UFH prophylaxis groups. Results A total of 103 798 patients were included; 75 321 (72.6%) patients received LMWH and 28 477 (27.4%) patients received UFH. Propensity analysis matched (2 : 1) 42 343 LMWH patients and 21 218 UFH patients. Overall, LMWH was not associated with a decreased incidence of VTE (5.32% vs. 5.50%). LMWH prophylaxis was associated with a reduction in pulmonary embolism (0.70% vs. 0.99%), significant bleeding (13.3% vs. 14.8%) and heparin-induced thrombocytopenia (HIT) (0.06% vs. 0.19%). In non-metastatic solid disease, LMWH was associated with decreased VTE (4.27% vs. 4.84%) and PE (0.47% vs. 0.95%). Conclusions The use of an LMWH for VTE prophylaxis was not associated with a reduction in the incidence of in-hospital VTE as compared with UFH, but was associated with significant reductions in PE, clinically important bleeding events, and incidence of HIT in critically ill patients with cancer.
Asunto(s)
Anticoagulantes/uso terapéutico , Inhibidores del Factor Xa/uso terapéutico , Fondaparinux/uso terapéutico , Heparina de Bajo-Peso-Molecular/uso terapéutico , Neoplasias/tratamiento farmacológico , Tromboembolia Venosa/prevención & control , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anticoagulantes/efectos adversos , Investigación sobre la Eficacia Comparativa , Enfermedad Crítica , Bases de Datos Factuales , Inhibidores del Factor Xa/efectos adversos , Femenino , Fondaparinux/efectos adversos , Hemorragia/inducido químicamente , Heparina de Bajo-Peso-Molecular/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/sangre , Neoplasias/complicaciones , Factores de Riesgo , Trombocitopenia/inducido químicamente , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Tromboembolia Venosa/sangre , Tromboembolia Venosa/etiología , Adulto JovenRESUMEN
WHAT IS KNOWN AND OBJECTIVE: Practices vary between institutions and amongst prescribers regarding when to initiate stress ulcer prophylaxis (SUP), which agent to choose (including doses and frequencies) and rationale, and decisions about escalation or discontinuation of therapy. The purpose of this survey is to evaluate the perceptions of prescribers about risk assessment of stress-related mucosal bleeding (SRMB) and practice patterns of SUP. METHODS: A cross-sectional survey of 800 US critical care prescribers using the membership of the Society of Critical Care Medicine. The levels of agreement with specific statements were rated on a nine-point Likert scale. RESULTS: Of 712 eligible recipients, 245 (34·4%) completed the questionnaire. Respondents were primarily attending physicians (81·2%) working in adult medical or surgical (59·2%) intensive care units. Mucosal ischaemia was identified as the pathophysiological cause of SRMB by 110 (44·9%) respondents. Respondents agreed that risk factors for SRMB were acute hepatic failure, anticoagulant use, burns >35%, coagulopathy, absence of enteral feeding, recent gastroduodenal ulcer, corticosteroid use, Helicobacter pylori infection, neurologic injury, trauma, NSAID use, mechanical ventilation, shock and sepsis. Histamine subtype 2 receptor antagonists (58·4%) and proton pump inhibitors (39·6%) were the most frequently chosen agents. No consensus was reached about whether either class is associated with clostridium difficile infection or nosocomial pneumonia. Reasons to discontinue therapy included clinically improved patient status (73·1%), extubation (68·2%), reversal of 'nil-by-mouth' (68·6%) and transfer to a non-ICU setting (67·8%). WHAT IS NEW AND CONCLUSIONS: Considerable variability exists in the perceptions surrounding risk factors for SRMB and prescribing patterns for SUP therapy likely because limited or conflicting data are available addressing these issues. Opportunities exist to educate prescribers and conduct research about the pathologic cause and risk factors for SRMB, the preferred class of agents, and the appropriate discontinuation of therapy.