Timing of venous thromboprophylaxis in isolated severe pelvic fracture: Effect on mortality and outcomes

Timing of venous thromboembolism prophylaxis initiation and complications in polytrauma patients with high-risk bleeding orthopedic interventions: A nationwide analysis

INTRODUCTION

There are no clear recommendations for the perioperative timing and initiation of venous thromboembolism pharmacologic prophylaxis (VTEp) among polytrauma patients undergoing high-risk bleeding orthopedic operative intervention, leading to variations in VTEp administration. Our study examined the association between the timing of VTEp and VTE complications in polytrauma patients undergoing high-risk operative orthopedic interventions nationwide.

METHODS

We performed a retrospective cohort study of trauma patients 18 years or older who underwent high-risk bleeding operative orthopedic interventions for pelvic, hip, and femur fractures within 24 hours of admission at American College of Surgeons-verified trauma centers using the 2019-2020 American College of Surgeons Trauma Quality Improvement Program databank. We excluded patients with a competing risk of nonorthopedic surgical bleeding. We assessed operative orthopedic polytrauma patients who received VTEp within 12 hours of orthopedic surgical intervention compared with VTEp received beyond 12 hours of intervention. The primary outcome assessed was overall VTE events. Secondary outcomes were orthopedic reinterventions within 72 hours after primary orthopedic surgery, deep venous thromboembolism, and pulmonary embolism rates.

RESULTS

The study included 2,229 patients who underwent high-risk orthopedic operative intervention. The median time to VTEp initiation was 30 hours (interquartile range, 18-44 hours). After adjustment for baseline patient, injury, and hospital characteristics, VTEp initiated more than 12 hours from primary orthopedic surgery was associated with increased odds of VTE (adjusted odds ratio, 2.02; 95% confidence interval, 1.08-3.77). Earlier initiation of prophylaxis was not associated with an increased risk for surgical reintervention (hazard ratio, 0.90; 95% confidence interval, 0.62-1.34).

CONCLUSION

Administering VTEp within 24 hours of admission and within 12 hours of major orthopedic surgery involving the femur, pelvis, or hip demonstrated an associated decreased risk of in-hospital VTE without an accompanying elevated risk of bleeding-related orthopedic reintervention. Clinicians should reconsider delays in initiating or withholding perioperative VTEp for stable polytrauma patients needing major orthopedic intervention.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Research priorities in venous thromboembolism after trauma: Secondary analysis of the National Trauma Research Action Plan

BACKGROUND

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality during recovery from injury and can result in significant health care costs. Despite advances in the past several decades in our approach to VTE prophylaxis after injury, opportunities exist to improve the delivery and implementation of optimal VTE prophylaxis. Here, we aim to identify consensus research questions related to VTE across all National Trauma Research Action Plan (NTRAP) Delphi expert panels to further guide the research agenda aimed at preventing VTE after injury.

METHODS

This is a secondary analysis of consensus-based research priorities that were collected using a Delphi methodology by 11 unique NTRAP panels that were charged with unique topic areas across the spectrum of injury care. The database of questions was queried for the keywords "VTE," "venous thromboembo," and "DVT" and then grouped into relevant topic areas.

RESULTS

There were 86 VTE-related research questions identified across 9 NTRAP panels. Eighty-five questions reached consensus with 24 rated high priority; 60, medium priority; and 1, low priority. Questions related to the timing of VTE prophylaxis (n = 17) were most common, followed by questions related to risk factors for the development of VTE (n = 16), the effects of tranexamic acid on VTE (n = 11), the approach to dosing of pharmacologic prophylaxis (n = 8), and the pharmacologic prophylactic medication choice for optimal VTE prophylaxis (n = 6).

CONCLUSION

National Trauma Research Action Plan panelists identified 85 consensus-based research questions that should drive dedicated extramural research funding opportunities to support quality studies aimed at optimizing VTE prophylaxis after injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Risk factors for deep vein thrombosis in patients with pelvic or lower-extremity fractures in the emergency intensive care unit

Introduction

This study aimed to investigate the incidence of deep vein thrombosis (DVT) in patients with pelvic or lower-extremity fractures in the emergency intensive care unit (EICU), explore the independent risk factors for DVT, and investigate the predictive value of the Autar scale for DVT in these patients.

Methods

The clinical data of patients with single fractures of the pelvis, femur, or tibia in the EICU from August 2016 to August 2019 were retrospectively examined. The incidence of DVT was statistically analyzed. Logistic regression was used to analyze the independent risk factors for DVT in these patients. The receiver-operating characteristic (ROC) curve was used to evaluate the predictive value of the Autar scale for the risk of DVT.

Results

A total of 817 patients were enrolled in this study; of these, 142 (17.38%) had DVT. Significant differences were found in the incidence of DVT among the pelvic fractures, femoral fractures, and tibial fractures (P < 0.001). The multivariate logistic regression analysis showed multiple injuries (OR = 2.210, 95% CI: 1.166-4.187, P = 0.015), fracture site (compared with tibia fracture group, femur fracture group OR = 4.839, 95% CI: 2.688-8.711, P < 0.001; pelvic fracture group OR = 2.210, 95% CI: 1.225-3.988, P = 0.008), and Autar score (OR = 1.198, 95% CI: 1.016-1.353, P = 0.004) were independent risk factors for DVT in patients with pelvic or lower-extremity fractures in the EICU. The area under the ROC curve (AUROC) of the Autar score for predicting DVT was 0.606. When the Autar score was set as the cutoff value of 15.5, the sensitivity and specificity for predicting DVT in patients with pelvic or lower-extremity fractures were 45.1% and 70.7%, respectively.

Discussion

Fracture is a high-risk factor for DVT. Patients with a femoral fracture or multiple injuries have a higher risk of DVT. In the case of no contraindications, DVT prevention measures should be taken for patients with pelvic or lower-extremity fractures. Autar scale has a certain predictive value for the occurrence of DVT in patients with pelvic or lower-extremity fractures, but it is not ideal.

Angioembolization in Severe Pelvic Trauma is Associated with Venous Thromboembolism

INTRODUCTION

Management of hemorrhage from pelvic fractures is complex and requires multidisciplinary attention. Pelvic angioembolization (AE) has become a key intervention to aid in obtaining definitive hemorrhage control. We hypothesized that pelvic AE would be associated with an increased risk of venous thromboembolism (VTE).

METHODS

All adults (age >16) with a severe pelvic fracture (Abbreviated Injury Scale ≥ 4) secondary to a blunt traumatic mechanism in the 2017-2019 American College of Surgeons Trauma Quality Improvement Program database were included. Patients who did not receive VTE prophylaxis during their admission were excluded. Patients who underwent pelvic AE during the first 24 h of admission were compared to those who did not using propensity score matching. Matching was performed based on patient demographics, admission physiology, comorbidities, injury severity, associated injuries, other hemorrhage control procedures, and VTE prophylaxis type, and time to initiation of VTE prophylaxis. The rates of VTE (deep vein thrombosis and pulmonary embolism) were compared between the matched groups.

RESULTS

Of 72,985 patients with a severe blunt pelvic fracture, 1887 (2.6%) underwent pelvic AE during the first 24 h of admission versus 71,098 (97.4%) who did not. Pelvic AE patients had a higher median Injury Severity Score and more often required other hemorrhage control procedures, with laparotomy being most common (24.7%). The median time to initiation of VTE prophylaxis in pelvic AE versus no pelvic AE patients was 60.1 h (interquartile range = 36.6-98.6) versus 27.7 h (interquartile range = 13.9-52.4), respectively. After propensity score matching, pelvic AE patients were more likely to develop VTE compared to no pelvic AE patients (11.8% versus 9.5%, P = 0.03).

CONCLUSIONS

Pelvic AE for control of hemorrhage from severe pelvic fractures is associated with an increased risk of in-hospital VTE. Patients who undergo pelvic AE are especially high risk for VTE and should be started as early as safely possible on VTE prophylaxis.

Race does matter: venous thromboembolism in trauma patients with isolated severe pelvic fractures

PURPOSE

Studies in non-trauma populations have shown that Black patients have a higher risk of venous thromboembolism (VTE) compared to other races. We sought to determine whether this association exists in trauma patients. The incidence of VTE is particularly high following severe pelvic fractures. To limit confounding factors associated with additional injuries, we examined patients with isolated blunt severe pelvic fractures.

METHODS

The TQIP database (2013-2017) was queried for all patients who sustained isolated blunt severe pelvic fractures (AIS ≥ 3) and received VTE prophylaxis (VTEp) with either unfractionated heparin or low molecular weight heparin. The study groups were Asian, Black, and White race as defined by TQIP. The primary outcome was differences in the rate of thromboembolic events.

RESULTS

A total of 9491 patients were included in the study. Of these, 232 (2.4%) were Asian, 1238 (13.0%) Black, and 8021 (84.5%) White. There was no significant difference in the distribution of pelvis AIS 3,4,5 between the groups. Black patients had a significantly higher incidence of VTE, DVT and PE compared to Asians and Whites. After adjusting for differences between the groups, Black patients had higher odds of developing pulmonary embolism (OR 1.887, 95% CI 1.101-3.232, p = 0.021) compared to White patients.

CONCLUSIONS

In this nationwide study of trauma patients with severe pelvic fractures, Black patients were more likely to develop pulmonary embolism compared to White patients. Further research to identify the determinants of racial disparities in trauma-related VTE is warranted, to target interventions that can improve VTE outcomes for all patients.

Venous thromboembolism risk after spinal cord injury: A secondary analysis of the CLOTT study

INTRODUCTION

Patients with spinal cord injury (SCI) are at high risk of venous thromboembolism (VTE). Pharmacologic VTE prophylaxis (VTEppx) is frequently delayed in patients with SCI because of concerns for bleeding risk. Here, we hypothesized that delaying VTEppx until >48 hours would be associated with increased risk of thrombotic events.

METHODS

This is a secondary analysis of the 2018 to 2020 prospective, observational, cohort Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study of patients aged 18 to 40 years, at 17 US level 1 trauma centers. Patients admitted for >48 hours with documented SCI were evaluated. Timing of initiation of VTEppx, rates of thrombotic events (deep vein thrombosis [DVT] and pulmonary embolism [PE]), and missed VTEppx doses were analyzed. The primary outcome was VTE (DVT + PE).

RESULTS

There were 343 patients with SCI. The mean ± SD age was 29.0 ± 6.6 years, 77.3% were male, and 78.7% sustained blunt mechanism. Thrombotic events occurred in 33 patients (9.6%): 30 DVTs (8.7%) and 3 PEs (0.9%). Venous thromboembolism prophylaxis started at ≤24 hours in 21.3% of patients and 49.3% at ≤48 hours. The rate of VTE for patients started on VTEppx ≤48 hours was 7.1% versus 12.1% if started after 48 hours ( p = 0.119). After adjusting for differences in risk factors between cohorts, starting ≤48 hours was independently associated with fewer VTEs (odds ratio, 0.45; 95% confidence interval, 0.101-0.978; p = 0.044). Unfractionated heparin was associated with a VTE rate of 21.0% versus 7.5% in those receiving enoxaparin as prophylaxis ( p = 0.003). Missed doses of VTEppx were common (29.7%) and associated with increased thrombotic events, although this was not significant on multivariate analysis.

CONCLUSION

Rates of thrombotic events in patients with SCI are high. Prompt initiation of VTEppx with enoxaparin and efforts aimed at avoiding missed doses are critical to limit thrombotic events in these high-risk patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Preperitoneal Pelvic Packing for Hypotension Has a Greater Risk of Venous Thromboembolism Than Angioembolization: Management of Refractory Hypotension in Closed Pelvic Ring Injury

BACKGROUND

Patients with traumatic pelvic ring injury may present with hypotension secondary to hemorrhage. Preperitoneal pelvic packing (PPP) and angioembolization (AE) are alternative interventions for management of hypotension associated with pelvic ring injury refractory to resuscitation and circumferential compression. We hypothesized that PPP may be independently associated with increased risk of venous thromboembolism (VTE) compared with AE in patients with hypotension and pelvic ring injury.

METHODS

Adult patients with pelvic ring injury and hypotension managed with PPP or AE were retrospectively identified in the Trauma Quality Improvement Program (TQIP) database from 2015 to 2019. Patients were matched on a propensity score for receiving PPP based on patient, injury, and treatment factors. The primary outcome was the risk of VTE after matching on the propensity score for treatment. The secondary outcomes included inpatient clinically important deep vein thrombosis, pulmonary embolism, respiratory failure, mortality, unplanned reoperation, sepsis, surgical site infection, hospital length of stay, and intensive care unit (ICU) length of stay.

RESULTS

In this study, 502 patients treated with PPP and 2,439 patients treated with AE met inclusion criteria. After propensity score matching on age, smoking status, Injury Severity Score, Tile B or C pelvic ring injury, bilateral femoral fracture, serious head injury, units of plasma and platelets given within 4 hours of admission, laparotomy, and level-I trauma center facility designation, 183 patients treated with PPP and 183 patients treated with AE remained. PPP, compared with AE, was associated with a 9.8% greater absolute risk of VTE, 6.5% greater risk of clinically important deep vein thrombosis, and 4.9% greater risk of respiratory failure after propensity score matching.

CONCLUSIONS

PPP for the management of hypotension associated with pelvic ring injury is associated with higher rates of inpatient VTE events and sequelae compared with AE.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Chemoprophylaxis for venous thromboembolism in pelvic and/or acetabular fractures: A systematic review

BACKGROUND

It is unclear which pharmacological agents, and at what dosage and timing, are most effective for venous thromboembolism (VTE) prophylaxis in patients with pelvic/acetabular fractures.

METHODS

We searched the Cochrane Database of Systematic Reviews, Embase, Web of Science, EBSCO, and PubMed on October 3, 2020, for English-language studies of VTE prophylaxis in patients with pelvic/acetabular fractures. We applied no date limits. We included studies that compared efficacy of pharmacological agents for VTE prophylaxis, timing of administration of such agents, and/or dosage of such agents. We recorded interventions, sample sizes, and VTE incidence, including deep vein thrombosis (DVT) and pulmonary embolism.

RESULTS

Two studies (3604 patients) compared pharmacological agents, reporting that patients who received direct oral anticoagulants (DOACs) were less likely to develop DVT than those who received low molecular weight heparin (LMWH) (p < 0.01). Compared with unfractionated heparin (UH), LMWH was associated with lower odds of VTE (odds ratio [OR] = 0.37, 95% confidence interval [CI]: 0.22-0.63) and death (OR = 0.27, 95% CI: 0.10-0.72). Three studies (3107 patients) compared timing of VTE prophylaxis, reporting that late prophylaxis was associated with higher odds of VTE (OR = 1.9, 95% CI: 1.2-3.2) and death (OR = 4.0, 95% CI: 1.5-11) and higher rates of symptomatic DVT (9.2% vs. 2.5%, p = 0.03; and 22% vs. 3.1%, p = 0.01). One study (31 patients) investigated dosage of VTE prophylaxis, reporting that a higher proportion of patients with acetabular fractures were underdosed (23% of patients below range of anti-Factor Xa [aFXa] had acetabular fractures vs. 4.8% of patients within adequate range of aFXa, p<0.01).

CONCLUSIONS

Early VTE chemoprophylaxis (within 24 or 48 h after injury) was better than late administration in terms of VTE and death. Many patients with acetabular fractures are underdosed with LMWH, with inadequate aFXa levels. Compared with UH, LMWH was associated with lower odds of VTE and death. DOACs were associated with lower risk of DVT compared with LMWH.

LEVEL OF EVIDENCE

III, systematic review of retrospective cohort studies.

Relationship Between Anti-Xa Level Achieved with Prophylactic Low-Molecular Weight Heparin and Venous Thromboembolism in Trauma Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Trauma patients have simultaneously high venous thromboembolism (VTE) and bleeding risk. Optimal chemoprophylaxis regimens remain unclear. This study aims to answer three questions for trauma patients. Is there any association between anti-Xa and VTE? Does dose adjustment improve prophylactic anti-Xa rates? Does dose adjustment improve anti-Xa adequacy and VTE compared to standard dosing?

METHODS

Systematic search of MEDLINE, Embase, Scopus, and Web of Science occurred in May 2021.Two author review included trauma studies that: evaluated low molecular weight heparin chemoprophylaxis, reported anti-Xa level, and evaluated ≥1 outcome. Data was dually extracted and estimated effects were calculated using RevMan 5.4 applying the Mantel-Haenszel method. Analysis #1 compared patients with peak anti-Xa ≥ 0.2 IU/ml or trough ≥0.1 IU/ml to those with lower anti-Xa using VTE as the primary outcome. Analysis #2 reported the effect of dose adjustment on anti-Xa. Analysis #3 compared standard dosing to dose adjustment with the primary outcome being anti-Xa adequacy; secondary outcomes were VTE, pulmonary embolism, and bleeding complications.

RESULTS

3401 studies were evaluated with 24 being included (19 retrospective studies, 5 prospective studies). In analysis #1, achieving adequate anti-Xa was associated with reduced odds of VTE (4.0% to 3.1%, OR 0.52, p = 0.03). Analysis #2 demonstrated that 768 (75.3%) patients achieved prophylactic anti-Xa with adjustment protocols.Analysis three suggested that dose adjusted chemoprophylaxis achieves prophylactic anti-Xa more frequently (OR 4.05, p = 0.007) but without VTE (OR 0.72, p = 0.15) or PE (OR 0.48, p = 0.10) differences. In subgroup analysis, anti-Xa dose adjustment also suggested no VTE reduction (OR 0.68, p = 0.08).

CONCLUSIONS

Patients with higher anti-Xa levels are less likely to experience VTE, and anti-Xa guided chemoprophylaxis increases anti-Xa adequacy. However, dose adjustment, including anti-Xa guided dosing, may not reduce VTE.

LEVEL OF EVIDENCE

Level IV; Systematic Review Meta-Analysis.

Time is of the Essence: Impact of a More Aggressive Chemical Venous Thromboembolism Prophylaxis Regimen on Trauma Patients

BACKGROUND

Trauma patients are at high risk for venous thromboembolism (VTE). Opportunity for chemical VTE prophylaxis improvement was identified and practice was altered to start chemoprophylaxis on admission in most patients. The purpose of this study was to determine if early VTE prophylaxis is safe and reduces VTE.

METHODS

The trauma registry was queried over a 12-month period for patients admitted greater than 1 day for traumatic injury. The study spanned 6 months on either side of instituting aggressive chemoprophylaxis. Patients were risk adjusted on demographics, Injury Severity Score, transfusions, procedure type, length of stay, and mortality. Pre-intervention patients were then compared to patients in the aggressive cohort with the primary outcome of VTE. Secondary outcomes included transfusions, mortality, and length of stay (LOS).

RESULTS

1597 patients were identified over the study period with 754 (47%) patients in the aggressive period. There were no differences in age, sex, Injury Severity Score, transfusions, procedures, or LOS between cohorts. Pre-algorithm patients were more likely to have penetrating mechanism (9.3% vs 6.6%; P = .009) and longer time to VTE prophylaxis (23.3 vs 13.9 hours; P < .001). No differences were noted in anticoagulant, VTE rate (2.0% vs 1.2%; P = .195), or mortality. Linear regression analysis identified time to chemical prophylaxis as significant predictor of VTE (β = 43.9, P < .001).

CONCLUSIONS

Early aggressive chemical VTE prophylaxis is safe without increasing transfusions. Venous thromboembolism rates were decreased, but did not reach statistical significance.

Failure of internal fixation of the anterior ring for unstable pelvic fractures, the experience of a single institute

Background

This study aimed to share our experience of anterior ring fixation failure for unstable pelvic fractures and propose corresponding treatment strategies.

Materials

From January 2009 to December 2018, 93 charts of patients with pelvic fractures were retrospectively reviewed. Patients with failure of the anterior ring internal fixation within 3 months after initial surgery were analyzed. Quality of reduction was evaluated using the Majeed scoring system. Patients aging ≥ 18 years, with unstable pelvic fractures, Tile classification type B and type C pelvic fractures, combined injury of other organs that did not affect the operation and without important neurovascular damage were included. The exclusion criteria included: (1) pathological fracture, or combined with pelvic bone tumor or severe osteoporosis; (2) femoral fracture and thoracolumbar fracture; (3) open pelvic fracture; (4) Morel-Lavallée injury; (5) complicated acetabular fracture. The quality of the reduction of the anterior pelvic ring injury was evaluated on the x-ray film using the Majeed scoring system.

Results

According to the Tile classification of fracture, there were 23 cases of type B1, 17 cases of type B2, 11 cases of type B3, 28 cases of type C1, 6 cases of type C2, and 8 cases of type C3. The duration from injury to pelvic internal fixation ranged from 5 to 28 days. Seven out of 93 patients experienced failure of internal fixation of the anterior pelvic ring within 3 months, including 2 patients fixed with an external fixator and 5 patients fixed with a plate. Five patients undergoing revision surgery were followed up for 6–36 months with an average of 18 months. According to Majeed’s score at the last follow-up in the 5 patients undergoing revision surgery, there were 2 cases of excellent, 2 cases of good, 1 case of fair. The excellent and good rate reached 80%.

Conclusion

The treatment of complicated unstable pelvic fractures requires performing internal fixation surgery within 2 weeks. It is necessary to make a preoperative plan and stabilize the posterior ring first, avoiding a single steel plate crossing the pubic symphysis.

Venous thromboembolic pharmacological prophylaxis in severe traumatic acute subdural hematomas: Early prophylaxis is effective and safe

BACKGROUND

The purpose of this study was to evaluate the optimal timing and type of pharmacological venous thromboembolism prophylaxis (VTEp) in patients with severe blunt head trauma with acute subdural hematomas (ASDH).

METHODS

Matched cohort study using ACS-TQIP database (2013-2016) including patients with isolated ASDH. Outcomes of matched patients receiving early prophylaxis (EP, ≤48 h) and late prophylaxis (LP, >48 h) were compared with univariable and multivariable regression analysis.

RESULTS

In 1,660 matched cases VTE complications (3.1% vs 0.5%, p < 0.001) were more common in the LP compared to the EP group. Multivariable regression analysis identified EP as an independent protective factor for VTE complications (OR 0.169, p < 0.001) but not mortality (p = 0.260). The adjusted risk for delayed craniectomy was not associated with EP compared to LP (p = 0.095). LMWH was independently associated with a lower mortality (OR 0.480, p = 0.008) compared to UH.

CONCLUSIONS

Early VTEp (≤48 h) does not increase the risk for craniectomies and is independently associated with fewer VTE complications in patients with isolated ASDH. LMWH was independently associated with a lower mortality compared to UH.

Association of timing of initiation of pharmacologic venous thromboembolism prophylaxis with outcomes in trauma patients

BACKGROUND

Patients are at a high risk for developing venous thromboembolism (VTE) following traumatic injury. We examined the relationship between timing of initiation of pharmacologic prophylaxis with VTE complications.

METHODS

Trauma quality collaborative data from 34 American College of Surgeons Committee on Trauma-verified levels I and II trauma centers were analyzed. Patients were excluded if they were on anticoagulant therapy at the time of injury, had hospitalization <48 hours, or received no or nonstandard pharmacologic VTE prophylaxis (heparin drip). Patient comparison groups were based on timing of initiation of VTE prophylaxis relative to hospital presentation (0 to <24 hours, 24 to <48 hours, ≥48 hours). Risk-adjusted rates of VTE events were calculated accounting for patient factors including type of pharmacologic agent in addition to standard trauma patient confounders. A sensitivity analysis was performed excluding patients who received blood in the first 4 hours and/or patients with a significant traumatic brain injury.

RESULTS

Within the 79,386 patients analyzed, there were 1,495 (1.9%) who experienced a VTE complication and 1,437 (1.8%) who died. After adjusting for type of prophylaxis and patient factors, the risk of a VTE event was significantly increased in the 24- to <48-hour (odds ratio, 1.26; 95% confidence interval, 1.09-1.47; p = 0.002) and ≥48-hour (odds ratio, 2.35; 95% confidence interval, 2.04-2.70; p < 0.001) cohorts relative to patients initiated at 0 to <24 hours. These VTE event findings remained significant after exclusion of perceived higher-risk patients in a sensitivity analysis.

CONCLUSION

Early initiation of pharmacologic VTE prophylaxis in stable trauma patients is associated with lower rates of VTE.

LEVEL OF EVIDENCE

Diagnostic, level III.

Impact of Chemoprophylaxis on Thromboembolism Following Operative Fixation of Pelvic Fractures

BACKGROUND

Venous thromboembolism (VTE) is a common cause of serious morbidity and mortality. While chemoprophylaxis decreases VTE, there is the theoretical risk of increased hemorrhagic complications. The purpose of this study was to evaluate the impact of preoperative anticoagulation on VTE and bleeding complications in patients with blunt pelvic fractures requiring operative fixation.

METHODS

Patients with blunt pelvic fractures requiring operative fixation over 10.5 years were identified. Patients were stratified by age, severity of shock, operative management, and timing and duration of anticoagulation. Outcomes were evaluated to determine risk factors for bleeding complications and VTE.

RESULTS

310 patients were identified: 212 patients received at least one dose of preoperative anticoagulation and 98 received no preoperative anticoagulation. 68% were male with a mean injury severity score and Glasgow Coma Scale of 26 and 13, respectively. Bleeding complications occurred in 24 patients and 21 patients suffered VTE. Patients with VTE had a greater initial severity of shock (resuscitation transfusions, 4 vs. 2 units, P = .02). Despite longer time to mobilization (4 vs. 3 days, P = .001), patients who received their scheduled preoperative doses within 48 hours of arrival had no significant differences in the number of deep vein thrombosis events (5.2% vs. 5.7%, P = .99), but fewer episodes of pulmonary embolism (PE) (1.5% vs. 6.8%, P = .03) with no difference in bleeding complications (7.5% vs. 8%, P = .87) compared to either patients who had their doses held until after 48 hours of arrival or received no preoperative anticoagulation.

DISCUSSION

Preoperative anticoagulation prior to pelvic fixation reduced the risk of PE without increasing bleeding complications. Preoperative anticoagulation is safe and beneficial in this group of patients.

Timing and Type of Venous Thromboembolic Prophylaxis in Isolated Severe Liver Injury Managed Non-Operatively

BACKGROUND

The optimal timing and type of pharmacological venous thromboembolic prophylaxis (VTEp) after severe liver injury selected for nonoperative management (NOM) are controversial. The aim of this study was to assess the effect of timing and type of VTEp in severe liver injuries selected for NOM.

METHODS

ACS-TQIP database study (2013-17) including patients with blunt isolated severe liver injuries (AIS ≥ 3), selected for NOM, who received VTEp with either unfractionated heparin (UH) or low-molecular-weight heparin (LMWH). Patients who underwent laparotomy or angiointervention within 24 h or prior to the initiation of VTEp were excluded. The study population was stratified according to the timing of VTEp ≤ 48 h (EP) and > 48 h (LP) groups. Univariate and multivariate analyses were used to identify differences between the groups.

RESULTS

A total of 4074 patients was included in the study. 2004 (49.2%) received EP and 2070 (50.8%) LP. Patients with more severe injuries were more likely to receive LP than an EP [ISS 24 (19-29) vs 22 (17-27), p < 0.001]. On multivariate analysis (correcting for age, gender, comorbidities, blood pressure, GCS, ISS, type of VTEp), LP was identified as an independent risk factor for thromboembolic events (OR 1.52, p = 0.032) and mortality (OR 2.49, p = 0.031). LMWH was independently associated with lower mortality (OR 0.36, p = 0.007), compared to UH. EP did not increase the risk of laparotomy or angiointervention after starting VTEp, compared to LP (p = 0.992).

CONCLUSION

Early VTEp (≤ 48 h) is safe and independently associated with fewer thromboembolic events and a lower mortality after isolated severe liver injuries managed nonoperatively. LMWH was independently associated with improved outcomes when compared with UH.

Guidelines for the prevention of venous thromboembolism in hospitalized patients with pelvi-acetabular trauma

BACKGROUND

Venous thromboembolism is a dreaded complication leading to increased morbidity and mortality in patients having pelvi-acetabular fractures.

OBJECTIVES

These evidence based guidelines aim to provide the decision making ability in the prevention of venous thromboembolism in patients with pelvi-acetabular trauma planned for operative or non operative treatment.

METHODS

The patients were subclassified into 5 categories. The PICO framework was used to devise research questions in each category. The systematic reviews were performed for each research question. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess outcomes of critical interest. The guideline panel consisting of expert members of different subspecialties, analyzed the evidence and made recommendations.

RESULTS

The guideline panel proposed 21 recommendations. There are five recommendations in category 1 to 3, two recommendations in category 4 and four recommendations in category 5.

CONCLUSION

In pelvi-acetabular fractures there is strong evidence to suggest that thromboprophylaxis should be given. It should be initiated as early as possible after control of hemorrhage. The chemical prophylaxis is the preferred mode and LMWH is the preferred agent of choice. The mechanical methods can be used as an adjunct. The routine prophylactic use of IVC filters is not recommended. However, the use of retrievable IVC filters in high risk patients with established VTE in preoperative period can be considered. The use of newer directly acting oral anticoagulants is gaining importance.

Management and outcomes of severe pelvic fractures in level I and II ACS verified trauma centers

BACKGROUND

The aim of this study was to evaluate the management strategies and outcomes of isolated severe pelvic fractures in level I and II ACS verified trauma centers.

METHODS

ACS-TQIP database study, including patients with blunt, isolated severe pelvic facture (AIS 3-5).

RESULTS

2629 level I and 1277 level II patients were included. Early blood product transfusion was significantly higher, pharmacological VTE prophylaxis significantly lower and ICU length of stay significantly longer in level II centers (p < 0.001). On multivariate analysis, treatment at level II centers was independently associated with increased overall complications, specifically ARDS, but not mortality.

CONCLUSIONS

In isolated severe pelvic fractures there was a significantly higher use of early blood products, less VTE pharmacological prophylaxis, longer ICU length of stay and higher overall complications and ARDS in level II centers. Blood product utilization and pharmacological VTE prophylaxis are potential areas of quality improvement in level II centers.

When Is It Safe to Start Pharmacologic Venous Thromboembolism Prophylaxis After Pelvic Fractures? A Prospective Study From a Level I Trauma Center

BACKGROUND

The ideal time for pharmacologic venous thromboembolism (VTE) prophylaxis initiation after pelvic fracture is controversial. This prospective study evaluated the safety and efficacy of early VTE prophylaxis after blunt pelvic trauma.

METHODS

Patients presenting to our American College of Surgeons-verified level I trauma center (between December 1, 2016 and November 30, 2017) with blunt pelvic fracture were prospectively screened. Exclusion criteria were emergency department death, immediate operative intervention, transfers, home anticoagulation, pregnancy, and patients receiving no pharmacologic VTE prophylaxis during hospitalization. Patients were dichotomized into study groups based on VTE prophylaxis initiation time ≤48 h (early prophylaxis [EP]) versus >48 h (late prophylaxis [LP]) after emergency department arrival. Demographics, injury data, clinical data, VTE prophylaxis agent and initiation time, and outcomes were compared.

RESULTS

After exclusions, 146 patients were identified: 74 (51%) patients in EP group and 72 (49%) patients in LP group. Pelvic fracture severity was comparable between groups (Abbreviated Injury Scale extremity score 2 [2-3] versus 2 [2-3]; P = 0.610). On univariate analysis, deep vein thrombosis rates were higher after LP (n = 5, 7% versus 0, 0%; P = 0.027). Pulmonary embolism rates were similar (n = 2, 3% versus n = 3, 4%; P = 1.000). No patient required delayed intervention for bleeding, and postprophylaxis blood transfusion was comparable between groups (P > 0.05). On multivariate analysis, timing of pharmacologic VTE prophylaxis initiation was not associated with VTE development (odds ratio, 0.647; P = 0.999). Pelvic angioembolization was independently associated with VTE (odds ratio, 1.296; P = 0.044).

CONCLUSIONS

Early initiation of pharmacologic VTE prophylaxis after blunt pelvic fracture is safe. Although EP initiation did not reduce the rate of VTE, these data identify angioembolization as an independent risk factor for VTE. Patients with blunt pelvic fracture who undergo angioembolization may therefore represent a high-risk population who may especially benefit from EP.

Worth looking! venous thromboembolism in patients who undergo preperitoneal pelvic packing warrants screening duplex

BACKGROUND

Venous thromboembolism (VTE) in patients with major pelvic fractures who undergo preperitoneal pelvic packing (PPP) has not been investigated. We hypothesized that patients who undergo PPP are at high risk for VTE, thus early prophylactic anticoagulation and screening duplex are warranted.

STUDY DESIGN

All patients requiring PPP from 2015 to 2019 were reviewed. Management and outcomes were analyzed.

RESULTS

During the study period, 79 patients underwent PPP. Excluding the early deaths, 17 patients had deep venous thrombosis (DVT) and 6 had pulmonary emboli (PE); 4 patients had both DVT/PE. Overall mortality was 15%. Thirty-two patients underwent screening duplex within 72 h of admission and 10 were positive for DVT.

CONCLUSION

Patients with complex pelvic trauma undergoing PPP have a 23% incidence of DVT and an additional 8% incidence of PE. 31% of screening ultrasounds are positive. The overall mortality was 15%. With a high incidence of VTE in this patient population, we recommend screening duplex ultrasounds.