Critical Appraisal Literature Review

This literature review examines the efficacy of using Glascow Coma Scale (GCS) in conjunction with extended pharmacologic thrombo-prophylaxis to prevent Venomous Thrombo Embolism (VTE) after abdominal and orthopedic surgery. The review discusses the purpose, inclusion criteria, study types, search engines used, and limitations of the included studies. It also provides a critique of the studies and levels of evidence. The information from this review can be applied in clinical practice to understand the complexities of using GCS and pharmacologic thromboprophylaxis to prevent VTE.

Running head: CRITICAL APPRAISAL LITERATURE REVIEW
Critical Appraisal Literature Review
Name of the Student
Name of the University
Author Note:

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1. What is the review purpose, objective or question?
The notable determination of the paper is to understand the efficacy of using Glascow
Coma Scale in juxtaposition with the extended pharmacologic thrombo-prophylaxis in order to
thwart Venomous Thrombo Embolism (VTE) after any kinds of abdominal and orthopedic
surgery.
VTE after the surgery is the reason behind numerous deaths in the recent times, the
researcher of the paper highlighted that most of the patients suffering from deep venous
thrombosis have the negative impact as it develops post-thrombotic syndrome (Milinis et al.,
2018). The risk of VTE exists even after weeks after discharging which is major concern in our
society. Thus the primary objective of the paper is to understand the importance of GCS in order
to prevent VTE in surgical patients.
2. Was there a published protocol for this review?
The paper have a published protocol as it was published in PROSPERO in the year 2017.
(Hussein 2017). The data of searching was 4th April 2017 considering the MEDLINE,
clinicaltrials.gov. and Embase and randomised controlled trails wren included in this paper. The
data of publication of the version is 12th April 2017. The entire procedure was managed by
National Institute for Health Research (NHS).
3. What are the inclusion criteria for this review?
The inclusion criteria for this review are discussed in the following table.
Criteria Inclusion Criteria
01 Participant must be a minimum of 21 days of
pharmacologic thromboprophylaxis
02 The Pharmacologic thromboprophylaxis

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prevention technique must include low
molecular weight heparin, unfractionated
heparin, fondaparinux, Vitamin K, as well as
direct oral anti-coagulants.
03 Participants must be receiving prophylactic-
dose pharmacologic thromboprophylaxis
unaccompanied or in unification with
Glascow Coma Scale.
04 The recommendations from the manufacturers
must be considered regarding the closing and
the initialization of the Pharmacologic
thromboprophylaxis.
05 Participants must be a continuously using the
Glascow Coma Scale
06 Participants must be above 18 years of age.
07 Patients has to be going through Orthopedic
or abdominal surgery.
08 Venomous Thrombo Embolism (VTE) must
be confirmed with the help of imaging.
Table 1: Inclusion Criteria of the Criteria
(Source: Created by the author)
4. What types of studies were included?
This article included different types of studies from different time, studies were selected
based on the effectiveness of the research methodologies like total sample size and arm sample
size. Most studies based on hip replacement were considered in this paper along with that it can
be said long and short pharmacologic must be minimum of 20mg and 2.5mg. However,
mechanical duration of the after discharging were not considered in the paper. 1231 studies were
considered in this paper for this systematic review. The paper also considered the pharmacologic
agents such as Parental, Enoxaparin 40mg OD.
5. What databases/search engines were searched?

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The search engines which are considered in this paper is the ClinicalTrial.gov. This
search engine was very much helpful regarding the data collection procedure of the paper. The
effectiveness of this paper is maintained as paper the ClinicalTrial.gov is run by the United
States National Library of Medicine (NLM). The clinical trial database have registrations from
more than 23000 trails and are available in more than 195 countries all over the world.
6. Were the search terms suitable for the purpose of this review?
The search terms suitable to understand the purpose of this review are Glascow Coma
Scale which can defined as the scoring system which are used to describe the level of
consciousness after any kinds of surgery, Pharmacologic thrombo-prophylaxis can be defined
as the preventive tools in order to prevent VTE for critically ill patients; the percentage of
Pharmacologic thrombo-prophylaxis is very much important to be understood and analyzed
before being applied on a patient. Venomous Thrombo Embolism (VTE) can be defined as a
combination of Pulmonary Embolism (PE) and Deep Vein Thrombosis (DVT).
7. What search limits were applied?
The search limits or the exclusion criteria of the paper is that patient younger than 18
years were not considered in the study. Pregnant women are not considered in the review as well,
along with that it can be said that the review excluded patients with clotting disorders. The two
mechanical methods which are considered in the study are low-dose unfractionated heparin
(LDUH) and low-molecular-weight heparin (LMWH). Patients with contraindications to
pharmacologic thromboprophylaxis as well as GCS were excluded from the study.
Along with that the limitation of the paper is that its uses non-randomized comparisons,
there is an always a risk of intervention regarding the data collection. Majority of the studies

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were considered in the field of orthopaedic surgery thus, it can be said that findings may not be
suitable to the other surgical specialities. Complexities of the subgroup analysis is the other
constraint of this paper. The sample size of the GCS are not always aligned with the PE rates.
The studies which were considered in the paper is from a period of 20 years as a result new and
effective VTE preventive technique have already arrived which is the other limitation of the
paper.
8. Does the Prisma flowchart adequately describe how articles were identified, screened,
assessed for eligibility, appraised and selected for inclusion in the review?
The Prisma Chart of the paper help in understanding how records were identified through
database searching among the 1226 articles. Screening or Eligibility of the records on the basis
of title and abstract considering the inclusion criteria of the paper was easily understood from the
Meta analysis diagram. Qualitative synthesis was explained well in the flowchart diagram using
all the criteria’s such as determination of GCS and republication.
9. What critical appraisal instrument(s) was/were used to determine methodological quality
of the articles? Were these instruments appropriate?
The methodological quality of the articles were maintained with the MS Excel 2016
which were used to synthesis and analyse all the collected data. Random effects model were
considered to study and measure the uncertainties of the collected data. The MedCare for
Windows are also used in the statistical analysis of the paper

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10. Are the included studies summarised adequately? (Study type, study population,
location, interventions, outcomes, results)
The included studies are summarised adequately considering the clinical type of the
study. The population of the sample was also very much important to understand the reliability
of paper. The study which were selected in the paper is from all over the Europe such as Austria,
Denmark, United States, Norway, France, Germany and Sweden. The VTE diagnosis which are
considered in the paper are BL Vernography, Compression USS Vernography and Ipsilateral
Vernography. The outcomes of each of the studies are professionally explained in the paper
considering the total DVT and PE. The VE related death is also quantified in the paper which
helps in understanding the importance of pharmacologic thrombo-prophylaxis for preventing
VTE.
11. Are excluded studies listed with reasons for their exclusion?
The reasons behind the exclusion criteria is very much understandable as it will remove
any kinds of contradictions. Patients having clotting disorder have other complexities which
might be the reason behind their death, at the same time it can be said that pregnant women have
numerous complexities such as the Ectopic pregnancy and placenta previa and gestational
diabetes which can be the reason behind their death. At the same time, it can be also said that
puberty related issue can also be a reason behind the death of VTE patients.
12. How was the data abstracted and synthesised?
Data abstraction was performed by KM and APC. The different criteria of data
abstraction are as follows:
 VTE related death.

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 Pulmonary Embolism
 Total DVT
 Proximal DVT
 Symptomatic DVT
 Pre-randomization VTE diagnosis
 GCE use
 Method of VTE diagnosis
 Operation Type
 Sample Size
 Country of origin
 Publication data
 First author
Data Synthesis of the paper was done with the help of the Freeman-Tukey transformation and by
assuming random effects as pronounced by DerSimonian and Laird. Confidence Intervals of
VTE rates were premeditated using the random effects model.
13. Is there adequate critique of the studies reviewed, including discussion of study
limitations?
All the studies which have been considered in this paper are critically reviewed by other
researchers and clinical laboratories. Cases were considered with a wide range of population
such as Hip Anrthroplasty, Hip fracture, Hip replacement, colorectal cancer, Femur fracture, and
Malignancy and Abdominal surgery. The limitations of those paper wee also considered and
reviewed with the help of the sub group analysis.

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14. Were the levels of evidence reported in this systematic review? What is your assessment
of the level of evidence included in this review?
The different level of evidence which are reported in this systematic review are discussed
in the following table.
Level Type of evidence
I Most of the patients receive extended
pharmacologic thromboprophylaxis in
addition with the GCS
II.1 VTE rates in patients were not considered in
both GCD pharmacologic as well as extended
pharmacologic thromboprophylaxis.
II.2  The length of the GCS are different in
each study.
 Only the LMWH was used as the
pharmacologic agent in the paper.
III The chemoprophylaxis was ranged from 21 to
42 days, however the GCS were prescribed
for a maximum of 7days.
Table 2: level of evidence
(Source: Created by the author)

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Based on the three different levels of evidence which are included in the review, it can be
said that the quality of evidence which can strongly support the use of GCS in associated with
extended pharmacologic prophylaxis is missing from the paper. Clinical trials are very much
recommended to address this issue of using GCS.
15. How should the information from this systematic review be applied in clinical practice
(knowledge transfer)?
The information from the review can be very much beneficial for the readers to
understand the complexities regarding the use of GCS associated with pharmacologic
thromboprophylaxis which are used to prevent Venomous Thrombo Embolism in the surgical
patients.

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Reference
Hussein Khalafalla, A. (2017). https://juniperpublishers.com/jojun/JOJUN.MS.ID.555575.php.
JOJ Urology & Nephrology, 2(5). doi: 10.19080/jojun.2017.01.555600
Milinis, K., Shalhoub, J., Coupland, A. P., Salciccioli, J. D., Thapar, A., & Davies, A. H. (2018).
The effectiveness of graduated compression stockings for prevention of venous
thromboembolism in orthopedic and abdominal surgery patients requiring extended
pharmacologic thromboprophylaxis. Journal of Vascular Surgery: Venous and
Lymphatic Disorders.