1.
Randomized trials of therapeutic heparin for COVID-19: A meta-analysis
Sholzberg M, da Costa BR, Tang GH, Rahhal H, AlHamzah M, Baumann Kreuziger L, Ní Áinle F, Almarshoodi MO, James PD, Lillicrap D, et al
Research and practice in thrombosis and haemostasis. 2021;5(8):e12638
Abstract
BACKGROUND Pulmonary endothelial injury and microcirculatory thromboses likely contribute to hypoxemic respiratory failure, the most common cause of death, in patients with COVID-19. Randomized controlled trials (RCTs) suggest differences in the effect of therapeutic heparin between moderately and severely ill patients with COVID-19. We did a systematic review and meta-analysis of RCTs to determine the effects of therapeutic heparin in hospitalized patients with COVID-19. METHODS We searched PubMed, Embase, Web of Science, medRxiv, and medical conference proceedings for RCTs comparing therapeutic heparin with usual care, excluding trials that used oral anticoagulation or intermediate doses of heparin in the experimental arm. Mantel-Haenszel fixed-effect meta-analysis was used to combine odds ratios (ORs). RESULTS AND CONCLUSIONS There were 3 RCTs that compared therapeutic heparin to lower doses of heparin in 2854 moderately ill ward patients, and 3 RCTs in 1191 severely ill patients receiving critical care. In moderately ill patients, there was a nonsignificant reduction in all-cause death (OR, 0.76; 95% CI, 0.57-1.02), but significant reductions in the composite of death or invasive mechanical ventilation (OR, 0.77; 95% CI, 0.60 0.98), and death or any thrombotic event (OR, 0.58; 95% CI, 0.45-0.77). Organ support-free days alive (OR, 1.29; 95% CI, 1.07-1.57) were significantly increased with therapeutic heparin. There was a nonsignificant increase in major bleeding. In severely ill patients, there was no evidence for benefit of therapeutic heparin, with significant treatment-by-subgroup interactions with illness severity for all-cause death (P = .034). In conclusion, therapeutic heparin is beneficial in moderately ill patients but not in severely ill patients hospitalized with COVID-19.
2.
The effectiveness of junctional tourniquets: a systematic review and meta-analysis
Smith S, White J, Wanis KN, Beckett A, McAlister VC, Hilsden R
The journal of trauma and acute care surgery. 2018
Abstract
BACKGROUND Junctional tourniquets have been incorporated into tactical combat casualty care for junctional vascular trauma. They apply external compression to stop blood flow in the groin and axilla. OBJECTIVES The primary outcome was effectiveness in achieving arterial occlusion. Secondary outcomes included time to application and pain scores. DATA SOURCES Medline and EMBASE databases were searched. STUDY APPRAISAL AND SYNTHESIS METHODS A random effects meta-analysis was conducted to estimate the average effectiveness and time to effective application for each device. RESULTS Eight studies reported the effectiveness of junctional tourniquets in healthy volunteers. The average effectiveness was 52% (95% CI: 15-87%) for the abdominal application of the Abdominal Aortic and Junctional Tourniquet (AAJT), 83% (95% CI: 73 to 89%, I: 26%) for the Junctional Emergency Treatment Tool (JETT), 87% (95% CI: 79 to 92%, I: 15%) for the SAM Junctional Tourniquet (SJT), and 95% (95% CI: 90-98%) for the Combat Ready Clamp (CRoC). The groin application of the AAJT was studied in two papers with 100% in both studies. The average time to application was 101 seconds for the SJT (95% CI: 50-152 seconds) and the CRoC (95% CI: 63-139 seconds), while it was 130 seconds (95% CI: 85 to 176 seconds) for the JETT. The abdominal application of AAJT had a time to application of 92 and 171 seconds in two studies. LIMITATIONS All studies were conducted in healthy volunteers. CONCLUSIONS AND IMPLICATIONS Junctional tourniquets may meet a medical need in combat, and in the civilian environment, to control hemorrhage from these difficult injuries. All four FDA-approved devices demonstrate the ability to achieve vascular occlusion in healthy volunteers; however, effectiveness in patient transport has not been evaluated, and outcomes of their use in the field needs to be captured and reported. LEVEL OF EVIDENCE Systematic review, level III.