SLR - June 2019 - Hyun W. Shim
Reference: Arabi YM, Al-Hameed F, Burns KEA, Mehta S, Alsolamy SJ, Alshahrani MS, Mandourah Y, Almekhlafi GA, Almaani M, Al Bshabshe A, Finfer S, Arshad Z, Khalid I, Mehta Y, Gaur A, Hawa H, Buscher H, Lababidi H, Al Aithan A, Abdukahil SAI, Jose J, Afesh LY, Al-Dawood A; Saudi Critical Care Trials Group. Adjunctive Intermittent Pneumatic Compression for Venous Thromboprophylaxis. N Engl J Med. 2019 Apr 4; 380(14):1305–1315.Scientific Literature Review
Reviewed By: Hyun W. Shim, DPM
Residency Program: Temple University Hospital, Philadelphia, PA
Podiatric Relevance: Thromboprophylaxis is a crucial component of medical management for foot and ankle surgeons. Venous thromboembolism (VTE) is associated with significant morbidity and mortality, such as pulmonary embolism (PE) and deep vein thrombosis (DVT), which require long-term anticoagulation. Foot and ankle surgeons advocate the use of intermittent pneumatic compression for operative patients and for inpatients to be used as an adjunct to pharmacologic agents. However, no previous studies have shown that adjunctive use of intermittent pneumatic compression along with a pharmacologic agent is more beneficial compared to a pharmacologic agent alone. This article observed the incidences of DVT in patients who received intermittent pneumatic compression with pharmacologic thromboprophylaxis vs. pharmacologic thromboprophylaxis alone in an intensive care unit (ICU).
Methods: The trial protocol was designed and approved by the institutional review boards at all participating facilities. Patients from 20 sites in Saudi Arabia, Canada, Australia and India were randomized into two groups. They were randomly assigned into patients who received intermittent pneumatic compression with pharmacologic thromboprophylaxis (experimental group) vs. pharmacologic thromboprophylaxis (control group) alone. Inclusion criteria were adult patients weighing at least 45 kg, expected to stay for at least 72 hours in the ICU and had no contraindications to pharmacologic thromboprophylaxis. The primary outcome measure was incidence of proximal lower-limb DVT as diagnosed by twice-weekly ultrasonography. The secondary outcome measure was the prevalence of proximal deep vein thrombosis and occurrence of pulmonary embolism.
Results: From a total of 16,503 patients, 2,003 patients underwent randomizations. Nine hundred ninety-one patients were assigned to the experimental group, and 1,012 patients were assigned to the control group. Proximal DVT occurred in 3.9 percent of the experimental group and 4.2 percent of the control group. In regards to secondary outcomes, pulmonary embolism occurred in eight of 991 patients (0.8 percent) in the experimental group and 10 of 1,012 patients (1 percent) in the control group. The prevalence of proximal DVT did not differ significantly between the experimental and control groups.
Conclusions: Previous studies have shown that intermittent pneumatic compression is more beneficial than having no thromboprophylaxis and that pharmacologic thromboprophylaxis is more beneficial than intermittent pneumatic compression alone. However, no previous studies showed the benefits of intermittent pneumatic compression with pharmacologic thromboprophylaxis. This study attempted to examine the benefits of mechanical thromboprophylaxis with pharmacologic thromboprophylaxis. The study revealed that the adjunctive use of intermittent pneumatic compression with pharmacologic thromboprophylaxis did not show significant benefit compared to use of pharmacologic agents alone. However, the study does not show that the use of a mechanical compression as an adjunct harmed the patient. Given this, the use of mechanical compression as an adjunct should still be advocated for our patients.