1
|
Schellenberg M, Owattanapanich N, Emigh B, Van Gent JM, Egodage T, Murphy PB, Ball CG, Spencer AL, Vogt KN, Keeley JA, Doris S, Beiling M, Donnelly M, Ghneim M, Schroeppel T, Bradford J, Breinholt CS, Coimbra R, Berndtson AE, Anding C, Charles MS, Rieger W, Inaba K. When is it safe to start venous thromboembolism prophylaxis after blunt solid organ injury? A prospective American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg 2024; 96:209-215. [PMID: 37872669 DOI: 10.1097/ta.0000000000004163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial, as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests that VTEp ≤48 hours is safe and effective. This study was undertaken to validate this clinical practice. METHODS Blunt trauma patients presenting to 19 participating trauma centers in North America were screened over a 1-year study period beginning between August 1 and October 1, 2021. Inclusions were age older than 15 years; ≥1 liver, spleen, or kidney injury; and initial nonoperative management. Exclusions were transfers, emergency department death, pregnancy, and concomitant bleeding disorder/anticoagulation/antiplatelet medication. A priori power calculation stipulated the need for 1,158 patients. Time of VTEp initiation defined study groups: Early (≤48 hours of admission) versus Late (>48 hours). Bivariate and multivariable analyses compared outcomes. RESULTS In total, 1,173 patients satisfied the study criteria with 571 liver (49%), 557 spleen (47%), and 277 kidney injuries (24%). The median patient age was 34 years (interquartile range, 25-49 years), and 67% (n = 780) were male. The median Injury Severity Score was 22 (interquartile range, 14-29) with Abbreviated Injury Scale Abdomen score of 3 (interquartile range, 2-3), and the median American Association for the Surgery of Trauma grade of solid organ injury was 2 (interquartile range, 2-3). Early VTEp patients (n = 838 [74%]) had significantly lower rates of VTE (n = 28 [3%] vs. n = 21 [7%], p = 0.008), comparable rates of nonoperative management failure (n = 21 [3%] vs. n = 12 [4%], p = 0.228), and lower rates of post-VTEp blood transfusion (n = 145 [17%] vs. n = 71 [23%], p = 0.024) when compared with Late VTEp patients (n = 301 [26%]). Late VTEp was independently associated with VTE (odd ratio, 2.251; p = 0.046). CONCLUSION Early initiation of VTEp was associated with significantly reduced rates of VTE with no increase in bleeding complications. Venous thromboembolism chemoprophylaxis initiation ≤48 hours is therefore safe and effective and should be the standard of care for patients with blunt solid organ injury. LEVEL OF EVIDENCE Therapeutic and Care Management; Level III.
Collapse
Affiliation(s)
- Morgan Schellenberg
- From the Division of Acute Care Surgery (M.S., N.O., B.E., K.I.), LAC+USC Medical Center, University of Southern California, Los Angeles, California; Division of Acute Care Surgery (J.-M.V.G., W.R.), University of Texas Health Sciences Center at Houston, Houston, Texas; Division of Trauma (T.E.), Cooper University Hospital, Camden, New Jersey; Division of Acute Care Surgery (P.B.M.), Froedtert Hospital, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Acute Care Surgery (C.G.B.), Foothills Medical Center, University of Calgary, Calgary, Alberta; Division of Acute Care Surgery (A.L.S.), Atrium Health Wake Forest Baptist Medical Center, Wake Forest University, Winston-Salem, North Carolina; Division of Acute Care Surgery (K.N.V.), London Health Sciences Center, University of Western Ontario, London, Ontario, Canada; Division of Trauma/Acute Care Surgery/Surgical Critical Care (J.A.K.), Harbor UCLA Medical Center, University of California Los Angeles, Los Angeles, California; Division of Acute Care Surgery (S.D.), Grant Medical Center, Columbus, Ohio; Division of Acute Care Surgery (M.B.), Oregon Health and Science University, Portland, Oregon; Division of Acute Care Surgery (M.D.), University of California Irvine, Irvine, California; Program in Trauma (M.G.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Division of Acute Care Surgery, UC Health Memorial Hospital (T.S.), University of Colorado Springs, Colorado Springs, Colorado; Division of Acute Care Surgery (J.B.), Dell Medical School, The University of Texas Austin, Austin, Texas; Division of Trauma, Acute Care Surgery, and Surgical Critical Care (C.S.B.), West Virginia University, Morgantown, West Virginia; Division of Acute Care Surgery (R.C.), Riverside University Health System Medical Center, University of California Riverside, Riverside; Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery (A.E.B.), University of California-San Diego, San Diego, California; Division of Acute Care Surgery (C.A.), Texas Tech University Health Sciences Center, Texas Tech University, Lubbock, Texas; and Division of Acute Care Surgery (M.S.C.), Ascension Medical Group St. John, Tulsa, Oklahoma
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Schellenberg M, Costantini T, Joseph B, Price MA, Bernard AC, Haut ER. Timing of venous thromboembolism prophylaxis initiation after injury: Findings from the consensus conference to implement optimal VTE prophylaxis in trauma. J Trauma Acute Care Surg 2023; 94:484-489. [PMID: 36729602 PMCID: PMC9970012 DOI: 10.1097/ta.0000000000003847] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
ABSTRACT Optimizing prophylaxis against venous thromboembolic events (VTEs) is a critical issue in the care of injured patients. Although these patients are at significant risk of developing VTE, they also present competing concerns related to exacerbation of bleeding from existing injuries. Especially after high-risk trauma, including injuries to the abdominal solid organs, brain, and spine, trauma providers must delineate the time period in which VTE prophylaxis successfully reduces VTE rates without encouraging bleeding. Although existing data are primarily retrospective in nature and further study is required, literature supports early VTE chemoprophylaxis initiation even for severely injured patients. Early initiation is most frequently defined as <48 hours from admission but varies from <24 hours to 72 hours and occasionally refers to time from initial trauma. Prior to chemical VTE prophylaxis initiation in patients at risk for bleeding, an observation period is necessary during which injuries must show themselves to be hemostatic, either clinically or radiographically. In the future, prospective examination of optimal timing of VTE prophylaxis is necessary. Further study of specific subsets of trauma patients will allow for development of effective VTE mitigation strategies based upon collective risks of VTE and hemorrhage progression.
Collapse
Affiliation(s)
- Morgan Schellenberg
- Division of Acute Care Surgery, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA
| | - Todd Costantini
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona College of Medicine, Tucson, AZ
| | | | - Andrew C. Bernard
- Division of Acute Care Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Elliott R. Haut
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
3
|
Anteby R, Allar BG, Broekhuis JM, Patel PB, Marcaccio CL, Papageorge MV, Papatheodorou S, Mendoza AE. Thromboprophylaxis Timing After Blunt Solid Organ Injury: A Systematic Review and Meta-analysis. J Surg Res 2023; 282:270-279. [PMID: 36332306 DOI: 10.1016/j.jss.2022.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/29/2022] [Accepted: 10/08/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Trauma patients with blunt abdominal solid organ injuries are at high risk for venous thromboembolism (VTE), but the optimal time to safely administer chemical thromboprophylaxis is controversial, especially for patients who are managed nonoperatively due to increased risk of hemorrhage. We sought to compare failure of nonoperative management (NOM) and VTE events based on timing of chemical thromboprophylaxis initiation. METHODS A systematic review was conducted in PubMed and Embase databases. Studies were included if they evaluated timing of initiation of chemical thromboprophylaxis in trauma patients who underwent NOM of blunt solid organ injuries. Outcomes included failure of NOM and incidence of VTE. A random-effects meta-analysis was performed comparing patients who received late (>48 h) versus early thromboprophylaxis initiation. RESULTS Twelve retrospective cohort studies, comprising 21,909 patients, were included. Three studies, including 6375 patients, provided data on adjusted outcomes. Pooled adjusted analysis demonstrated no difference in failure of NOM in patients receiving late versus early thromboprophylaxis (odds ratio [OR] 0.92, 95% confidence interval [CI]:0.4-2.14). When including all unadjusted studies, even those at high risk of bias, there remained no difference in failure of NOM (OR 1.16, 95% CI:0.72-1.86). In the adjusted analysis for VTE events, which had 6259 patients between two studies, patients receiving late chemical thromboprophylaxis had a higher risk of VTE compared with those who received early thromboprophylaxis (OR 1.89, 95% CI:1.15-3.12). CONCLUSIONS Based on current observational evidence, initiation of prophylaxis before 48 h is associated with lower VTE rates without higher risk of failure of NOM.
Collapse
Affiliation(s)
- Roi Anteby
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of General Surgery, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Benjamin G Allar
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Jordan M Broekhuis
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Priya B Patel
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of General Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Christina L Marcaccio
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Marianna V Papageorge
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Stefania Papatheodorou
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - April E Mendoza
- Department of Surgery, University of California San Francisco - East Bay, Oakland, California
| |
Collapse
|
4
|
Marturano MN, Khan AR, DeBlieux P, Wang H, Ross SW, Cunningham KW, Sing RF, Thomas BW. Timing of venous thromboembolism chemoprophylaxis using objective hemoglobin criteria in blunt solid organ injury. Injury 2022; 54:1356-1361. [PMID: 36581480 DOI: 10.1016/j.injury.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/19/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the safety and efficacy of early venous thromboembolism (VTE) chemoprophylaxis following blunt solid organ injury. METHODS A retrospective review of patients was performed for patients with blunt solid organ injury between 2009-2019. Enoxaparin was initiated when patients had <1g/dl Hemoglobin decline over a 24 h period. These patients were then categorized by initiation: ≤48 h and >48 h. RESULTS There were 653 patients: 328 (50.2%) <48 h and 325 (49.8%) ≥48 h. Twenty-nine (4.4%) developed VTE. Patients in ≥48 h group suffered more frequent VTE events (6.5% vs 2.4%, p = 0.021). Non-operative failure occurred in 6 patients (1.9%) in ≥48 h group, and 5 patients (1.5%) < 48 h group. Blood transfusion following chemophrophylaxis initiation was required in 69 (21.3%) in ≥48 h group, and 46 (14.0%) in < 48 h group, occurring similarly between groups (p=0.021). CONCLUSION Stable hemoglobin in the first 24 h is an efficacious, objective measure that allows early initiation of VTE chemoprophylaxis in solid organ injury. This practice is associated with earlier initiation of and fewer VTE events.
Collapse
Affiliation(s)
- Matthew N Marturano
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | | | - Paige DeBlieux
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Huaping Wang
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | - Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | - Kyle W Cunningham
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | - Ronald F Sing
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | - Bradley W Thomas
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA.
| |
Collapse
|
5
|
Podda M, De Simone B, Ceresoli M, Virdis F, Favi F, Wiik Larsen J, Coccolini F, Sartelli M, Pararas N, Beka SG, Bonavina L, Bova R, Pisanu A, Abu-Zidan F, Balogh Z, Chiara O, Wani I, Stahel P, Di Saverio S, Scalea T, Soreide K, Sakakushev B, Amico F, Martino C, Hecker A, de'Angelis N, Chirica M, Galante J, Kirkpatrick A, Pikoulis E, Kluger Y, Bensard D, Ansaloni L, Fraga G, Civil I, Tebala GD, Di Carlo I, Cui Y, Coimbra R, Agnoletti V, Sall I, Tan E, Picetti E, Litvin A, Damaskos D, Inaba K, Leung J, Maier R, Biffl W, Leppaniemi A, Moore E, Gurusamy K, Catena F. Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document. World J Emerg Surg 2022; 17:52. [PMID: 36224617 PMCID: PMC9560023 DOI: 10.1186/s13017-022-00457-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.
Methods Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.
Results Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications. Conclusion This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.
Collapse
Affiliation(s)
- Mauro Podda
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy.
| | - Belinda De Simone
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | - Marco Ceresoli
- General and Emergency Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Francesco Virdis
- Trauma and Acute Care Surgery Department, Niguarda Hospital, Milan, Italy
| | - Francesco Favi
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
| | - Johannes Wiik Larsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital University of Bergen, Stavanger, Norway
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Nikolaos Pararas
- Department of General Surgery, Dr Sulaiman Al Habib/Alfaisal University, Riyadh, Saudi Arabia
| | - Solomon Gurmu Beka
- School of Medicine and Health Science, University of Otago, Wellington Campus, Wellington, New Zealand
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Raffaele Bova
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
| | - Adolfo Pisanu
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy
| | - Fikri Abu-Zidan
- Department of Applied Statistics, The Research Office, College of Medicine and Health Sciences United Arab Emirates University, Abu Dhabi, UAE
| | - Zsolt Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Osvaldo Chiara
- Trauma and Acute Care Surgery Department, Niguarda Hospital, Milan, Italy
| | | | - Philip Stahel
- Department of Surgery, East Carolina University, Brody School of Medicine, Greenville, USA
| | - Salomone Di Saverio
- Department of Surgery, San Benedetto del Tronto Hospital, AV5, San Benedetto del Tronto, Italy
| | - Thomas Scalea
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital University of Bergen, Stavanger, Norway
| | - Boris Sakakushev
- Research Institute of Medical University Plovdiv/University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Francesco Amico
- Trauma Service, John Hunter Hospital, Newcastle, Australia.,The University of Newcastle, Newcastle, Australia
| | - Costanza Martino
- Department of Anesthesiology and Acute Care, Umberto I Hospital of Lugo, Ausl della Romagna, Lugo, Italy
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Nicola de'Angelis
- Unit of General Surgery, Henri Mondor Hospital, UPEC, Créteil, France
| | - Mircea Chirica
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Andrew Kirkpatrick
- General, Acute Care and Trauma Surgery Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Emmanouil Pikoulis
- General Surgery, Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Denis Bensard
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Luca Ansaloni
- Unit of General Surgery, San Matteo Hospital, Pavia, Italy
| | - Gustavo Fraga
- Division of Trauma Surgery, University of Campinas, Campinas, SP, Brazil
| | - Ian Civil
- Director of Trauma Services, Auckland City Hospital, Auckland, New Zealand
| | | | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, University of Catania, Catania, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Raul Coimbra
- Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal
| | - Edward Tan
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Andrey Litvin
- Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | | | - Kenji Inaba
- University of Southern California, Los Angeles, USA
| | - Jeffrey Leung
- Division of Surgery and Interventional Science, University College London (UCL), London, UK.,Milton Keynes University Hospital, Milton Keynes, UK
| | | | - Walt Biffl
- Division of Trauma and Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, La Jolla, CA, USA
| | - Ari Leppaniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Fausto Catena
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
| |
Collapse
|
6
|
Murphy PB, de Moya M, Karam B, Menard L, Holder E, Inaba K, Schellenberg M. Optimal timing of venous thromboembolic chemoprophylaxis initiation following blunt solid organ injury: meta-analysis and systematic review. Eur J Trauma Emerg Surg 2022; 48:2039-2046. [PMID: 34537859 DOI: 10.1007/s00068-021-01783-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The need to prevent venous thromboembolism (VTE) following blunt solid organ injury must be balanced against the concern for exacerbation of hemorrhage. The optimal timing for initiation of VTE chemoprophylaxis is not known. The objective was to determine the safety and efficacy of early (≤ 48 h) VTE chemoprophylaxis initiation following blunt solid organ injury. METHODS An electronic search was performed of medical libraries for English language studies on timing of VTE chemoprophylaxis initiation following blunt solid organ injury published from inception to April 2020. Included studies compared early (≤ 48 h) versus late (> 48 h) initiation of VTE chemoprophylaxis in adults with blunt splenic, liver, and/or kidney injury. Estimates were pooled using random-effects meta-analysis. Odds ratios were utilized to quantify differences in failure of nonoperative management, need for blood transfusion and rates of VTE. RESULTS The search identified 2,111 studies. Of these, ten studies comprising 14,675 patients were included. All studies were non-randomized and only one was prospective. The overall odds of failure of nonoperative management were no different between early and late groups, OR 1.09 (95%CI 0.92-1.29). Similarly, there was no difference in the need for blood transfusion either during overall hospital stay, OR 0.91 (95%CI 0.70-1.18), or post prophylaxis initiation, OR 1.23 (95%CI 0.55-2.73). There were significantly lower odds of VTE when patients received early VTE chemoprophylaxis, OR 0.51 (95%CI 0.33-0.81). CONCLUSIONS Patients undergoing nonoperative management for blunt solid organ injury can be safely and effectively prescribed early VTE chemoprophylaxis. This results in significantly lower VTE rates without demonstrable harm.
Collapse
Affiliation(s)
- Patrick B Murphy
- Department of Surgery, Division of Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Marc de Moya
- Department of Surgery, Division of Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Basil Karam
- Department of Surgery, Division of Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Laura Menard
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erik Holder
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University Of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Morgan Schellenberg
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University Of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA.
| |
Collapse
|
7
|
Lamb T, Lenet T, Zahrai A, Shaw JR, McLarty R, Shorr R, Le Gal G, Glen P. Timing of pharmacologic venous thromboembolism prophylaxis initiation for trauma patients with nonoperatively managed blunt abdominal solid organ injury: a systematic review and meta-analysis. World J Emerg Surg 2022; 17:19. [PMID: 35468835 PMCID: PMC9036793 DOI: 10.1186/s13017-022-00423-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/15/2022] [Indexed: 11/29/2022] Open
Abstract
Background Blunt abdominal solid organ injury is common and is often managed nonoperatively. Clinicians must balance risk of both hemorrhage and thrombosis. The optimal timing of pharmacologic venous thromboembolism prophylaxis (VTEp) initiation in this population is unclear. The objective was to evaluate early (< 48 h) compared to late initiation of VTEp in adult trauma patients with blunt abdominal solid organ injury managed nonoperatively. Methods Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched from inception to March 2021. Studies comparing timeframes of VTEp initiation were considered. The primary outcome was failure of nonoperative management (NOM) after VTEp initiation. Secondary outcomes included risk of transfusion, other bleeding complications, risk of deep vein thrombosis (DVT) and pulmonary embolism, and mortality. Results Ten cohort studies met inclusion criteria, with a total of 4642 patients. Meta-analysis revealed a statistically significant increase in the risk of failure of NOM among patients receiving early VTEp (OR 1.76, 95% CI 1.01–3.05, p = 0.05). There was no significant difference in risk of transfusion. Odds of DVT were significantly lower in the early group (OR 0.36, 95% CI 0.22–0.59, p < 0.0001). There was no difference in mortality (OR 1.50, 95% CI 0.82–2.75, p = 0.19). All studies were at serious risk of bias due to confounding. Conclusions Initiation of VTEp earlier than 48 h following hospitalization is associated with an increased risk of failure of NOM but a decreased risk of DVT. Absolute failure rates of NOM are low. Initiation of VTEp at 48 h may balance the risks of bleeding and VTE. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00423-1.
Collapse
|
8
|
Moore K, Barton CA, Wang Y, Ran R, Chi A, Rowell S, Schreiber M. Early initiation of thromboembolic prophylaxis in critically ill trauma patients with high-grade blunt liver and splenic lacerations is not associated with increased rates of failure of non-operative management. TRAUMA-ENGLAND 2022. [DOI: 10.1177/14604086211046099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Non-operative management (NOM) is the current standard of care of hemodynamically stable patients with traumatic blunt solid abdominal organ injuries. Guidelines do not define the optimal timing of initiation of venous thromboembolism (VTE) prophylaxis in this population, and fear of failure of NOM may lead to delayed initiation of prophylaxis specifically in patients with high-grade injuries. Methods This was a single-center, retrospective study of patients with high-grade (AAST grades ≥3) blunt liver and splenic lacerations presenting to our level 1 trauma center between January 2010 and October 2017. Patients were divided into groups based on timing of low-molecular weight heparin (LMWH) initiation for VTE prophylaxis. The primary outcome was rate of failure of NOM, defined as the need for interventional radiology or surgical intervention for management of abdominal organ bleeding. Secondary outcomes included rates of VTE, lengths of ICU and hospital stay, and in-hospital mortality. Results A total of 207 patients with high-grade blunt liver and splenic injuries undergoing an initial attempt at NOM were identified. The distribution of grades 3, 4, and 5 liver and splenic injuries were similar across all groups. Overall, 55.5% of patients received LMWH during their index admission. Early administration of LMWH was not associated with a statistically significant increased risk of failure of NOM ( p = 0.054). Rates of VTE and in-hospital mortality were similar. Conclusions Early initiation of VTE prophylaxis was not associated with an increased rate of failure of NOM in patients with high-grade blunt abdominal organ injuries in patients who survived 24 h post-admission and did not require massive transfusion; however, the study was likely underpowered to detect a difference among groups due to small sample size.
Collapse
Affiliation(s)
- Kerry Moore
- Department of Pharmacy, Oregon Health & Science University, Portland, OR, USA
| | - Cassie A Barton
- Department of Pharmacy, Oregon Health & Science University, Portland, OR, USA
| | - Yuxuan Wang
- Department of Trauma and Acute Care Surgery, PeaceHealth, Vancouver, WA, USA
| | - Ran Ran
- Department of Pulmonary & Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Albert Chi
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Susan Rowell
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Martin Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
9
|
Arvieux C, Frandon J, Tidadini F, Monnin-Bares V, Foote A, Dubuisson V, Lermite E, David JS, Douane F, Tresallet C, Lemoine MC, Rodiere M, Bouzat P, Bosson JL, Vilotitch A, Barbois S, Thony F. Effect of Prophylactic Embolization on Patients With Blunt Trauma at High Risk of Splenectomy: A Randomized Clinical Trial. JAMA Surg 2021; 155:1102-1111. [PMID: 32936242 DOI: 10.1001/jamasurg.2020.3672] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Splenic arterial embolization (SAE) improves the rate of spleen rescue, yet the advantage of prophylactic SAE (pSAE) compared with surveillance and then embolization only if necessary (SURV) for patients at high risk of spleen rupture remains controversial. Objective To determine whether the 1-month spleen salvage rate is better after pSAE or SURV. Design, Setting, and Participants In this randomized clinical trial conducted between February 6, 2014, and September 1, 2017, at 16 institutions in France, 133 patients with splenic trauma at high risk of rupture were randomized to undergo pSAE or SURV. All analyses were performed on a per-protocol basis, as well as an intention-to-treat analysis for specific events. Interventions Prophylactic SAE, preferably using an arterial approach via the femoral artery, or SURV. Main Outcomes and Measures The primary end point was an intact spleen or a spleen with at least 50% vascularized parenchyma detected on an arterial computed tomography scan at 1 month after trauma, assessed by senior radiologists masked to the treatment group. Secondary end points included splenectomy and pseudoaneurysm, secondary SAE after inclusion, complications, length of hospital stay, quality-of-life score, and length of time off work or studies during the 6-month follow-up. Results A total of 140 patients were randomized, and 133 (105 men [78.9%]; median age, 30 years [interquartile range, 23-47 years]) were retained in the study. For the primary end point, data from 117 patients (57 who underwent pSAE and 60 who underwent SURV) could be analyzed. The number of patients with at least a 50% viable spleen detected on a computed tomography scan at month 1 was not significantly different between the pSAE and SURV groups (56 of 57 [98.2%] vs 56 of 60 [93.3%]; difference, 4.9%; 95% CI, -2.4% to 12.1%; P = .37). By the day 5 visit, there were significantly fewer splenic pseudoaneurysms among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 8 of 65 [12.3%]; difference, -10.8%; 95% CI, -19.3% to -2.1%; P = .03), significantly fewer secondary embolizations among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 19 of 65 [29.2%]; difference, -27.7%; 95% CI, -41.0% to -15.9%; P < .001), and no difference in the overall complication rate between the pSAE and SURV groups (19 of 65 [29.2%] vs 27 of 65 [41.5%]; difference, -12.3%; 95% CI, -28.3% to 4.4%; P = .14). Between the day 5 and month 1 visits, the overall complication rate was not significantly different between the pSAE and SURV groups (11 of 59 [18.6%] vs 12 of 63 [19.0%]; difference, -0.4%; 95% CI, -14.4% to 13.6%; P = .96). The median length of hospitalization was significantly shorter for patients in the pSAE group than for those in the SURV group (9 days [interquartile range, 6-14 days] vs 13 days [interquartile range, 9-17 days]; P = .002). Conclusions and Relevance Among patients with splenic trauma at high risk of rupture, the 1-month spleen salvage rate was not statistically different between patients undergoing pSAE compared with those receiving SURV. In view of the high proportion of patients in the SURV group needing SAE, both strategies appear defendable. Trial Registration ClinicalTrials.gov Identifier: NCT02021396.
Collapse
Affiliation(s)
- Catherine Arvieux
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Julien Frandon
- Department of Imaging and Interventional Radiology, Nîmes University Hospital (CHU), Nîmes, France
| | - Fatah Tidadini
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Valérie Monnin-Bares
- Department of Imaging and Interventional Radiology, Montpellier University Hospital (CHU), Montpellier, France
| | - Alison Foote
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Vincent Dubuisson
- Department of Vascular and General Surgery, Bordeaux University Hospital (CHU), Bordeaux, France
| | - Emilie Lermite
- Department of Visceral Surgery, Angers University Hospital (CHU), Angers, France
| | - Jean-Stéphane David
- Department of Anesthesia and Intensive Care, Lyon-Sud University Hospital (CHU), Pierre Bénite, France
| | - Frederic Douane
- Department of Imaging and Interventional Radiology, Nantes University Hospital (CHU), Nantes, France
| | - Christophe Tresallet
- Department of General, Digestive, Oncologic, Bariatric, and Metabolic Surgery, Avicenne University Hospital (CHU), Bobigny, France
| | | | - Mathieu Rodiere
- Department of Imaging and Interventional Radiology, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Pierre Bouzat
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Jean-Luc Bosson
- Department of Medical Information, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Antoine Vilotitch
- Department of Medical Information, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Sandrine Barbois
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Frédéric Thony
- Department of Imaging and Interventional Radiology, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | | |
Collapse
|
10
|
Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
11
|
Rappold JF, Sheppard FR, Carmichael Ii SP, Cuschieri J, Ley E, Rangel E, Seshadri AJ, Michetti CP. Venous thromboembolism prophylaxis in the trauma intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2021; 6:e000643. [PMID: 33718615 PMCID: PMC7908288 DOI: 10.1136/tsaco-2020-000643] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/27/2021] [Accepted: 02/06/2021] [Indexed: 02/06/2023] Open
Abstract
Venous thromboembolism (VTE) is a potential sequela of injury, surgery, and critical illness. Patients in the Trauma Intensive Care Unit are at risk for this condition, prompting daily discussions during patient care rounds and routine use of mechanical and/or pharmacologic prophylaxis measures. While VTE rightfully garners much attention in clinical patient care and in the medical literature, optimal strategies for VTE prevention are still evolving. Furthermore, trauma and surgical patients often have real or perceived contraindications to prophylaxis that affect the timing of preventive measures and the consistency with which they can be applied. In this Clinical Consensus Document, the American Association for the Surgery of Trauma Critical Care Committee addresses several practical clinical questions pertaining to specific or unique aspects of VTE prophylaxis in critically ill and injured patients.
Collapse
Affiliation(s)
| | | | | | - Joseph Cuschieri
- Surgery, University of Washington Seattle Campus, Seattle, Washington, USA
| | - Eric Ley
- Surgery, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Erika Rangel
- Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anupamaa J Seshadri
- Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | |
Collapse
|
12
|
Gaitanidis A, Breen KA, Nederpelt C, Parks J, Saillant N, Kaafarani HMA, Velmahos GC, Mendoza AE. Timing of thromboprophylaxis in patients with blunt abdominal solid organ injuries undergoing nonoperative management. J Trauma Acute Care Surg 2021; 90:148-156. [PMID: 33048907 DOI: 10.1097/ta.0000000000002972] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Decision making regarding the optimal timing for initiating thromboprophylaxis in patients with blunt abdominal solid organ injuries (BSOIs) remains ill-defined, with no guidelines defining optimal timing. In this study, we aimed to evaluate the relationship of the timing of thromboprophylaxis with thromboembolic and bleeding complications in the setting of BSOIs. METHODS A retrospective analysis of the Trauma Quality Improvement Program database was performed between 2013 and 2016. All patients with isolated BSOIs (liver, spleen, pancreas, or kidney, Abbreviated Injury Scale score, <3 in other regions) who underwent initial nonoperative management (NOM) were included. Patients were divided into three groups (early, <48 hours; intermediate, 48-72 hours; and late, >72 hours) based on timing of thromboprophylaxis initiation. Primary outcomes were rates of thromboembolism and bleeding after thromboprophylaxis initiation. RESULTS Of the 25,118 patients with isolated BSOIs, 3,223 met the inclusion criteria (age, 38.7 ± 17.3 years; males, 2.082 [64.6%]), among which 1,832 (56.8%) received early thromboprophylaxis, 703 (21.8%) received intermediate thromboprophylaxis, and 688 (21.4%) received late thromboprophylaxis. Late thromboprophylaxis initiation was independently associated with a higher likelihood of both deep vein thrombosis (odds ratio [OR], 3.15; 95% confidence interval [CI], 1.68-5.91, p < 0.001) and pulmonary embolism (OR, 4.29; 95% CI, 1.95-9.42; p < 0.001). Intermediate thromboprophylaxis initiation was independently associated with a higher likelihood of deep venous thrombosis (OR, 2.38; 95% CI, 1.20-4.74; p = 0.013), but not pulmonary embolism (p = 0.960) compared with early initiation. Early (but not intermediate) thromboprophylaxis initiation was independently associated with a higher likelihood of bleeding (OR, 2.05; 95% CI, 1.11-2.18; p = 0.023), along with a history of diabetes mellitus, splenic, and high-grade liver injuries. CONCLUSION Early thromboprophylaxis should be considered in patients with BSOIs undergoing nonoperative management who are at low likelihood of bleeding. An intermediate delay (48-72 hours) of thromboprophylaxis should be considered for patients with diabetes mellitus, splenic injuries, and Grades 3 to 5 liver injuries. LEVEL OF EVIDENCE Therapeutic, Level IV.
Collapse
Affiliation(s)
- Apostolos Gaitanidis
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Is early chemical thromboprophylaxis in patients with solid organ injury a solid decision? J Trauma Acute Care Surg 2020; 87:1104-1112. [PMID: 31299694 DOI: 10.1097/ta.0000000000002438] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The optimal time to initiate chemical thromboprophylaxis (CTP) in patients who have undergone nonoperative management (NOM) of blunt solid organ injuries (SOI) remains controversial. The aim of our study was to assess the impact of early initiation of CTP in patients with blunt abdominal SOIs. METHODS We performed a 2-year (2013-2014) retrospective analysis of American College of Surgeons Trauma Quality Improvement Program. We included all adult trauma patients (age, ≥ 18 years) with blunt SOI who underwent NOM. Patients were stratified into three groups based on timing of CTP (early, ≤48 hours of injury; late, >48 hours of injury,; and no prophylaxis group). Our primary outcomes were rates of failure of NOM, pRBC transfusion, and mortality. Our secondary outcomes were the rate of venous thromboembolic (VTE) events (i.e., deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) and length of stay. RESULTS A total of 36,187 patients met the inclusion criteria. Mean age was 49.5 ± 19 years and 36% of patients received CTP (early, 37% (n = 4,819) versus late, 63% (n = 8,208)). After controlling for confounders, patients receiving early CTP had lower rates of DVT (p = 0.01) and PE (p = 0.01) compared with the no prophylaxis and late CTP groups. There was no difference between the three groups regarding the postprophylaxis pRBC transfusions, failure of NOM, and mortality. CONCLUSION Our results suggest that in patients undergoing NOM of blunt abdominal SOI, early initiation of CTP should be considered. It is associated with decreased rates of DVT and PE, with no significant difference in post prophylaxis pRBC transfusion, failure of nonoperative management, and mortality. LEVEL OF EVIDENCE Therapeutic, level V.
Collapse
|
14
|
Lin B, Matsushima K, De Leon L, Piccinini A, Recinos G, Love B, Inaba K, Demetriades D. Early Venous Thromboembolism Prophylaxis for Isolated High-Grade Blunt Splenic Injury. J Surg Res 2019; 243:340-345. [DOI: 10.1016/j.jss.2019.05.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/23/2019] [Accepted: 05/30/2019] [Indexed: 11/30/2022]
|
15
|
It's sooner than you think: Blunt solid organ injury patients are already hypercoagulable upon hospital admission - Results of a bi-institutional, prospective study. Am J Surg 2019; 218:1065-1073. [PMID: 31540685 DOI: 10.1016/j.amjsurg.2019.08.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 05/15/2019] [Accepted: 08/25/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis in blunt solid organ injury (BSOI) patients is debated. We hypothesize that 1) BSOI patients are hypercoagulable within 12 h of injury and 2) hypercoagulability dominates in patients who develop clot complications (CC). MATERIAL AND METHODS This is a prospective study of BSOI patients admitted to two Level-1 Trauma Centers' trauma intensive care units (ICU). Serial kaolin thrombelastography (TEG) and tissue plasminogen activator (tPA)-challenge TEGs were performed. CC included VTE and cerebrovascular accidents. RESULTS On ICU admission, all patients (n = 95) were hypercoagulable, 58% were in fibrinolysis shutdown, and 50% of patients were tPA-resistant. Twelve patients (13%) developed CC. Compared to those without CC, they demonstrated decreased fibrinolysis at 12 h and higher clot strength at 48 h CONCLUSIONS: BSOI patients are universally hypercoagulable upon ICU admission. VTE chemoprophylaxis should be started immediately in BSOI patients with hypercoagulability on TEG.
Collapse
|
16
|
Ferguson C, Lewin J. BET 2: Is early chemical thromboprophylaxis safe in patients with blunt trauma solid organ injury (SOI) undergoing non-operative management (NOM)? Emerg Med J 2018; 35:127-129. [PMID: 29351927 DOI: 10.1136/emermed-2017-207424.3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A short cut review was carried out to establish whether chemical thromboprophylaxis was a safe early intervention in patients with solid organ injury that is being managed non-operatively. Eight papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that there is inadequate evidence assessing safety of low molecular weight heparin (LMWH) within 24 hours of trauma. The current available evidence does suggest that administration of LMWH within 48 hours is safe in non-operative management of patients who have sustained solid organ injury from blunt trauma.
Collapse
|