Effectiveness and safety of tourniquet utilization for civilian vascular extremity trauma in the pre-hospital settings: a systematic review and meta-analysis

Table 2 Certainty of evidence (CoE) using the Grading of Recommendations Assessment, Development and Evaluation method to assess the quality of evidence with individual endpoint

No of trials (No of patients)	Risk of bias	Inconsistency	Indirectness	Imprecision	Publication bias	Effect (95% CI)	Overall quality of evidence
Overall mortality
7 (4095)	Downgraded^*	Not downgraded I² = 47%	Not downgraded	Not downgraded	Downgraded^‡	OR = 0.48 (0.27 to -0.86)	⊕⊖⊖⊖ VERY LOW
RBC transfusion
6 (3787)	Downgraded^*	Downgraded I² = 99%	Not downgraded	Downgraded^†	NA	MD = -2.09 (-5.00 to 0.82)	⊕⊖⊖⊖ VERY LOW
FFP transfusion
4 (2732)	Downgraded^*	Downgraded I² = 98%	Not downgraded	Downgraded^†	NA	MD = -1.00 (-4.00 to 2.00)	⊕⊖⊖⊖ VERY LOW
Length of hospital stays (days)
5 (2645)	Downgraded^*	Downgraded I² = 66%	Not downgraded	Downgraded^†	NA	MD = -0.80 (-2.90 to 1.30)	⊕⊖⊖⊖ VERY LOW
Length of hospital stays (days)
3 (2251)	Downgraded^*	Downgraded I² = 92%	Not downgraded	Downgraded^†	NA	MD = -0.51 (-2.08 to 1.06)	⊕⊖⊖⊖ VERY LOW
Amputation
7 (4095)	Downgraded^*	Downgraded I² = 60%	Not downgraded	Downgraded^†	NA	OR = 0.85 (0.43 to 1.68)	⊕⊖⊖⊖ VERY LOW
Compartment syndrome
4 (813)	Downgraded^*	Not downgraded I² = 0%	Not downgraded	Downgraded^†	NA	OR = 0.94 (0.37 to 2.35)	⊕⊖⊖⊖ VERY LOW

CI: Confidence interval; OR, odds ratio; MD, mean difference; NA: non-available
^*Concerns arose because more than half of the included studies had a serious to critical overall risk of bias; therefore, the certainty of the evidence was downgraded by one level
^†Imprecision due to confidence intervals, as 95% CI crosses MD of 0 and OR of 1; therefore, certainty of evidence was downgraded by 1 level
^‡Concerns arose due to possible presence of publication bias led by asymmetry funnel plot; therefore, certainty of evidence was downgraded by 1 level
GRADE Working Group grades of evidence: High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect; however, there is a possibility that it is substantially different Low certainty: Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect

ISSN: 1749-7922