Venous thromboembolism in critically ill COVID-19 patients receiving prophylactic or therapeutic anticoagulation: a systematic review and meta-analysis

Many aspects of care such as management of hypercoagulable state in COVID-19 patients, especially those admitted to intensive care units is challenging in the rapidly evolving pandemic of novel coronavirus disease 2019 (COVID-19). We seek to systematically review the available evidence regarding the anticoagulation approach to prevent venous thromboembolism (VTE) among COVID-19 patients admitted to intensive care units. Electronic databases were searched for studies reporting venous thromboembolic events in patients admitted to the intensive care unit receiving any type of anticoagulation (prophylactic or therapeutic). The pooled prevalence (and 95% confidence interval [CI]) of VTE among patients receiving anticoagulant were calculated using the random-effects model. Subgroup pooled analyses were performed with studies reported prophylactic anticoagulation alone and with studies reported mixed prophylactic and therapeutic anticoagulation. We included twelve studies (8 Europe; 2 UK; 1 each from the US and China) in our systematic review and meta-analysis. All studies utilized LMWH or unfractionated heparin as their pharmacologic thromboprophylaxis, either prophylactic doses or therapeutic doses. Seven studies reported on the proportion of patients with the previous history of VTE (range 0–10%). The pooled prevalence of VTE among ICU patients receiving prophylactic or therapeutic anticoagulation across all studies was 31% (95% CI 20–43%). Subgroup pooled analysis limited to studies reported prophylactic anticoagulation alone and mixed (therapeutic and prophylactic anticoagulation) reported pooled prevalences of VTE of 38% (95% CI 10–70%) and 27% (95% CI 17–40%) respectively. With a high prevalence of thromboprophylaxis failure among COVID-19 patients admitted to intensive care units, individualised rather than protocolised VTE thromboprophylaxis would appear prudent at interim

Factor XIa-triggered thrombin generation in severe haemophilia A

Severe haemophilia A is associated with a severe bleeding phenotype (Richards et al, 2010). The factor VIII (FVIII) level is the mainstay of investigation and monitoring for these patients. However, there are often inconsistencies between the FVIII level and bleeding phenotype in haemophilia A (Franchini et al, 2009). Consequently, other tests have been under investigation to determine if they might have superior predictive value for assessing the bleeding risk for patients with haemophilia A

Factor XIa-triggered thrombin generation in severe haemophilia A

Severe haemophilia A is associated with a severe bleeding phenotype (Richards et al, 2010). The factor VIII (FVIII) level is the mainstay of investigation and monitoring for these patients. However, there are often inconsistencies between the FVIII level and bleeding phenotype in haemophilia A (Franchini et al, 2009). Consequently, other tests have been under investigation to determine if they might have superior predictive value for assessing the bleeding risk for patients with haemophilia A

Desmopressin for treatment of platelet dysfunction and reversal of antiplatelet agents: a systematic review and meta-analysis of randomised controlled trials

Background Platelet dysfunction, including that caused by antiplatelet agents, increases the risk of peri-operative bleeding. The optimal management of patients with platelet dysfunction undergoing surgery is unclear. Objectives To assess whether desmopressin reduces peri-operative allogeneic red cell transfusion and bleeding for patients with platelet dysfunction. Patients/Methods We searched for randomised controlled trials in The Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Embase, the Transfusion Evidence Library and ISI Web of Science to 7th July 2016. Data were pooled using mean difference (MD), relative risks or Peto odds ratios (pOR) using a random-effects model. Results Ten trials with 596 participants were identified, all in the setting of cardiac surgery. Platelet dysfunction was due to antiplatelet agents in six trials and cardiopulmonary bypass in four trials. Patients treated with desmopressin were transfused with fewer red cells (MD -0.65 units, 95% CI -1.16 to -0.13); lost less blood (MD -253.93 ml, 95% CI -408.01 to -99.85 ml); and had a lower risk of re-operation due to bleeding (pOR 0.39, 95% CI 0.18 to 0.84). Similar results were found for the subgroups with platelet dysfunction due to antiplatelet agents or other causes, with little evidence of statistical heterogeneity between subgroups. The GRADE quality of evidence was very low to moderate suggesting considerable uncertainty over the results Conclusions Desmopressin may be a useful agent to reduce bleeding and transfusion requirements for people with platelet dysfunction or with a history of recent anti-platelet drug administration undergoing surgery

Desmopressin for treatment of platelet dysfunction and reversal of antiplatelet agents: a systematic review and meta-analysis of randomised controlled trials

Background Platelet dysfunction, including that caused by antiplatelet agents, increases the risk of peri-operative bleeding. The optimal management of patients with platelet dysfunction undergoing surgery is unclear. Objectives To assess whether desmopressin reduces peri-operative allogeneic red cell transfusion and bleeding for patients with platelet dysfunction. Patients/Methods We searched for randomised controlled trials in The Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Embase, the Transfusion Evidence Library and ISI Web of Science to 7th July 2016. Data were pooled using mean difference (MD), relative risks or Peto odds ratios (pOR) using a random-effects model. Results Ten trials with 596 participants were identified, all in the setting of cardiac surgery. Platelet dysfunction was due to antiplatelet agents in six trials and cardiopulmonary bypass in four trials. Patients treated with desmopressin were transfused with fewer red cells (MD -0.65 units, 95% CI -1.16 to -0.13); lost less blood (MD -253.93 ml, 95% CI -408.01 to -99.85 ml); and had a lower risk of re-operation due to bleeding (pOR 0.39, 95% CI 0.18 to 0.84). Similar results were found for the subgroups with platelet dysfunction due to antiplatelet agents or other causes, with little evidence of statistical heterogeneity between subgroups. The GRADE quality of evidence was very low to moderate suggesting considerable uncertainty over the results Conclusions Desmopressin may be a useful agent to reduce bleeding and transfusion requirements for people with platelet dysfunction or with a history of recent anti-platelet drug administration undergoing surgery

Alternative agents to prophylactic platelet transfusion for preventing bleeding in people with thrombocytopenia due to chronic bone marrow failure: a meta-analysis and systematic review (Russian translation of Cochrane plain language summary)

This publication is the Russian translation of the Plain Language Summary (PLS) of the Cochrane Systematic Review: Desborough MJR, Hadjinicolaou AV, Chaimani A, Trivella M, Vyas P, Doree C, Hopewell S, Stanworth SJ, Estcourt LJ. Alternative agents to prophylactic platelet transfusion for preventing bleeding in people with thrombocytopenia due to chronic bone marrow failure: a meta-analysis and systematic review. Cochrane Database of Systematic Reviews 2016, Issue 10. Art. No.: CD012055. DOI: 10.1002/14651858.CD012055.pub

Alternative agents to prophylactic platelet transfusion for preventing bleeding in people with thrombocytopenia due to chronic bone marrow failure: a meta-analysis and systematic review (Russian translation of Cochrane plain language summary)

This publication is the Russian translation of the Plain Language Summary (PLS) of the Cochrane Systematic Review: Desborough MJR, Hadjinicolaou AV, Chaimani A, Trivella M, Vyas P, Doree C, Hopewell S, Stanworth SJ, Estcourt LJ. Alternative agents to prophylactic platelet transfusion for preventing bleeding in people with thrombocytopenia due to chronic bone marrow failure: a meta-analysis and systematic review. Cochrane Database of Systematic Reviews 2016, Issue 10. Art. No.: CD012055. DOI: 10.1002/14651858.CD012055.pub