Dalteparin versus Unfractionated Heparin in Critically Ill Patients

The PROTECT Investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group

March 22, 2011 (10.1056/NEJMoa1014475)

BACKGROUND

The effects of thromboprophylaxis with low-molecular-weight heparin, as compared with unfractionated heparin, on venous thromboembolism, bleeding, and other outcomes are uncertain in critically ill patients.

METHODS

In this multicenter trial, we tested the superiority of dalteparin over unfractionated heparin by randomly assigning 3764 patients to receive either subcutaneous dalteparin (at a dose of 5000 IU once daily) plus placebo once daily (for parallel-group twice-daily injections) or unfractionated heparin (at a dose of 5000 IU twice daily) while they were in the intensive care unit. The primary outcome, proximal leg deep-vein thrombosis, was diagnosed on compression ultrasonography performed within 2 days after admission, twice weekly, and as clinically indicated. Additional testing for venous thromboembolism was performed as clinically indicated. Data were analyzed according to the intention-to-treat principle.

RESULTS

There was no significant between-group difference in the rate of proximal leg deep-vein thrombosis, which occurred in 96 of 1873 patients (5.1%) receiving dalteparin versus 109 of 1873 patients (5.8%) receiving unfractionated heparin (hazard ratio in the dalteparin group, 0.92; 95% confidence interval [CI], 0.68 to 1.23; P=0.57). The proportion of patients with pulmonary emboli was significantly lower with dalteparin (24 patients, 1.3%) than with unfractionated heparin (43 patients, 2.3%) (hazard ratio, 0.51; 95% CI, 0.30 to 0.88; P=0.01). There was no significant between-group difference in the rates of major bleeding (hazard ratio, 1.00; 95% CI, 0.75 to 1.34; P=0.98) or death in the hospital (hazard ratio, 0.92; 95% CI, 0.80 to 1.05; P=0.21). In prespecified per-protocol analyses, the results were similar to those of the main analyses, but fewer patients receiving dalteparin had heparin-induced thrombocytopenia (hazard ratio, 0.27; 95% CI, 0.08 to 0.98; P=0.046).

CONCLUSIONS

Among critically ill patients, dalteparin was not superior to unfractionated heparin in decreasing the incidence of proximal deep-vein thrombosis.

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Glycemic Control in the ICU

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Glycemic Control in the ICU (NEJM)

Quienes proponen la infusión contínua, afirman que es posible lograr mejores excretas urinarias con dosis menores de furosemida, y que existe menos riesgo de efectos adversos. Sin embargo, la literatura ha arrojado resultados variables.

Dejo aca 2 artículos recientes que comparan los dos métodos (hacer click en los enlaces para descargar los archivos):

J Card Fail. 2010 Mar;16(3):188-93.

Am J Cardiol. 2010 Jun 15;105(12):1794-7.

¿La conclusión? Un estudio a favor de la infusión contínua, el otro muestra que no hay diferencia significativa entre los dos métodos. Sin embargo, los dos estudios son pequeños, y por el momento, mientras no haya estudios grandes randomizados, la decisión parece depender de preferencia personal.

Torsade de Pointes (pdf)

Ventilación Mecánica en SIRA – Repaso para principiantes.

Hacer click aquí para ver el documento.

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