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Spradling J, Garfinkel S, Edgecomb T, Chapman AJ, Pounders S, Burns K, Fisk CS, Stowe A, Hill E, Krech L. Venous Thromboembolism Rates in Trauma Patients Significantly Increase With Missed Prophylactic Enoxaparin Doses. Am Surg 2024; 90:2265-2272. [PMID: 39101941 DOI: 10.1177/00031348241269401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
Background: Current literature demonstrates prophylactic enoxaparin to be efficacious in reducing venous thromboembolism (VTE) rates without significantly increasing risk for bleeding complications. Despite this evidence, prophylactic enoxaparin doses are frequently withheld for surgery or procedures. This exploratory study aims to quantify the risk of a VTE event in trauma patients associated with missed doses of prophylactic enoxaparin. Methods: This retrospective cohort study evaluated trauma patients admitted to our Level 1 trauma center from January 1, 2012 to January 31, 2021. A 1:1 propensity match with ten variables was performed to compare patients receiving prophylactic enoxaparin that had a VTE and those that did not. The primary outcome was a VTE event. Results: 493 patients met inclusion criteria; 1:1 propensity score matching was performed resulting in a cohort of 184 patients. The percentage of patients that missed a prophylactic enoxaparin dose in the VTE group was higher than the no VTE group (34.8% vs 21.7%, P = 0.049). This is consistent when examining total missed doses (P = 0.038) and consecutively missed doses (P = 0.035). The odds of having a VTE for patients that missed at least one dose or more of enoxaparin are nearly two times greater (OR 1.92, 95% CI 0.997, 3.7). Conclusion: Missing enoxaparin doses significantly increases the risk of VTE in matched populations. Most prophylactic enoxaparin doses were held for procedures, and not for bleeding events. Trauma teams should carefully weigh the risk of bleeding complications associated with continuing enoxaparin prophylaxis against the significant thromboembolic risk of withholding it.
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Affiliation(s)
- Jess Spradling
- Butterworth Hospital, Corewell Health West, Grand Rapids, MI, USA
| | - Sophia Garfinkel
- Butterworth Hospital, Corewell Health West, Grand Rapids, MI, USA
| | - Taylor Edgecomb
- College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
| | - Alistair J Chapman
- Division Chief, Acute Care Surgery, Butterworth Hospital, Corewell Health West, Grand Rapids, MI, USA
| | - Steffen Pounders
- Trauma Research Institute, Corewell Health West, Grand Rapids, MI, USA
| | - Kelly Burns
- Trauma and Acute Care Surgery, Corewell Health West, Grand Rapids, MI, USA
| | - Chelsea S Fisk
- Trauma Research Institute, Corewell Health West, Grand Rapids, MI, USA
| | - Alicia Stowe
- Scholarly Activity and Scientific Support, Corewell Health West, Grand Rapids, MI, USA
| | - Emily Hill
- College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
| | - Laura Krech
- Trauma Research Institute, Corewell Health West, Grand Rapids, MI, USA
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Ratnasekera AM, Seng SS, Kim D, Ji W, Jacovides CL, Kaufman EJ, Sadek HM, Perea LL, Poloni CM, Shnaydman I, Lee AJ, Sharp V, Miciura A, Trevizo E, Rosenthal MG, Lottenberg L, Zhao W, Keininger A, Hunt M, Cull J, Balentine C, Egodage T, Mohamed AT, Kincaid M, Doris S, Cotterman R, Seegert S, Jacobson LE, Williams J, Moncrief M, Palmer B, Mentzer C, Tackett N, Hranjec T, Dougherty T, Morrissey S, Donatelli-Seyler L, Rushing A, Tatebe LC, Nevill TJ, Aboutanos MB, Hamilton D, Redmond D, Cullinane DC, Falank C, McMellen M, Duran C, Daniels J, Ballow S, Schuster KM, Ferrada P. Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study. Injury 2024; 55:111523. [PMID: 38614835 DOI: 10.1016/j.injury.2024.111523] [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: 10/27/2023] [Revised: 03/09/2024] [Accepted: 04/01/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI. METHODS Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest. RESULTS 984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant. CONCLUSION In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH. LEVEL OF EVIDENCE Level III, Therapeutic Care Management.
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Affiliation(s)
- Asanthi M Ratnasekera
- Department of Surgery, Division of Trauma and Surgical Critical Care, Associate Professor of Surgery, Drexel College of Medicine, Philadelphia, PA, United States; Crozer Health Upland PA, Currently at Christianacare Health, Newark, DE, United States.
| | - Sirivan S Seng
- Department of Surgery, Crozer Health, Upland, PA, United States
| | - Daniel Kim
- Department of Surgery, Crozer Health, Upland, PA, United States
| | - Wenyan Ji
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Polytechnic Institute and State University, Roanoke, VA, United States
| | - Christina L Jacovides
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States; Currently at Temple University, Philadelphia, PA, United States
| | - Elinore J Kaufman
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Hannah M Sadek
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - Lindsey L Perea
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, United States
| | - Christina Monaco Poloni
- Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States
| | - Ilya Shnaydman
- Department of Surgery, Medical Director, Surgical Intensive Care Unit, New York Medical College, West Chester Medical Center, Valhalla, NY, United States
| | | | - Victoria Sharp
- Department of Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, United States
| | - Angela Miciura
- Department of Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, United States
| | - Eric Trevizo
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Martin G Rosenthal
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Lawrence Lottenberg
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, FL, United States; Florida Atlantic University, Boca Raton, FL, United States
| | - William Zhao
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, FL, United States; Florida Atlantic University, Boca Raton, FL, United States
| | - Alicia Keininger
- Department of Surgery, Trinity Health Oakland, Pontiac, MI, United States
| | - Michele Hunt
- Department of Surgery, Trinity Health Oakland, Pontiac, MI, United States
| | - John Cull
- Department of Surgery, Prisma Health Upstate, Greenville, SC, United States
| | - Chassidy Balentine
- Department of Surgery, Prisma Health Upstate, Greenville, SC, United States
| | - Tanya Egodage
- Department of Surgery, Cooper University Hospital, Camden, NJ, United States
| | - Aleem T Mohamed
- Department of Surgery, Cooper University Hospital, Camden, NJ, United States
| | - Michelle Kincaid
- Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH, United States
| | - Stephanie Doris
- Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH, United States
| | - Robert Cotterman
- Department of Surgery, Promedica Toledo Hospital, Toledo, OH, United States
| | - Sara Seegert
- Department of Research, Promedica Toledo Hospital, Toledo, OH, United States
| | - Lewis E Jacobson
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, United States
| | - Jamie Williams
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, United States
| | - Melissa Moncrief
- Department of Trauma & Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, United States
| | - Brandi Palmer
- Department of Trauma & Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, United States
| | - Caleb Mentzer
- Department of Surgery, Spartanburg Medical Center, Spartanburg, SC, United States
| | - Nichole Tackett
- Department of Surgery, Spartanburg Medical Center, Spartanburg, SC, United States
| | - Tjasa Hranjec
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, United States
| | - Thomas Dougherty
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, United States
| | - Shawna Morrissey
- Department of Surgery, Conemaugh Memorial Medical Center, Johnstown, PA, United States
| | - Lauren Donatelli-Seyler
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Amy Rushing
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Leah C Tatebe
- Department of Surgery, Cook County Hospital, Chicago, IL, United States; Currently at Northwestern Memorial Hospital, Chicago, IL, United States
| | - Tiffany J Nevill
- Department of Surgery, Cook County Hospital, Chicago, IL, United States
| | - Michel B Aboutanos
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - David Hamilton
- Department of Surgery, Penrose Hospital, Colorado Springs, CO, United States
| | - Diane Redmond
- Department of Surgery, Penrose Hospital, Colorado Springs, CO, United States
| | - Daniel C Cullinane
- Department of Surgery, Maine Medical Center, Portland, ME, United States
| | - Carolyne Falank
- Department of Surgery, Maine Medical Center, Portland, ME, United States
| | - Mark McMellen
- Department of Surgery, St. Anthony Hospital, Lakewood, CO, United States
| | - Chris Duran
- Department of Surgery, St. Anthony Hospital, Lakewood, CO, United States
| | - Jennifer Daniels
- Department of Surgery, University of California San Francisco, Fresno, CA, United States
| | - Shana Ballow
- Department of Surgery, University of California San Francisco, Fresno, CA, United States
| | - Kevin M Schuster
- Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Paula Ferrada
- Department of Surgery, INOVA Fairfax Health System, Fairfax, VA, United States
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Tignanelli CJ, Shah S, Vock D, Siegel L, Serrano C, Haut E, Switzer S, Martin CL, Rizvi R, Peta V, Jenkins PC, Lemke N, Thyvalikakath T, Osheroff JA, Torres D, Vawdrey D, Callcut RA, Butler M, Melton GB. A pragmatic, stepped-wedge, hybrid type II trial of interoperable clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury. Implement Sci 2024; 19:57. [PMID: 39103955 DOI: 10.1186/s13012-024-01386-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Accepted: 07/14/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a preventable medical condition which has substantial impact on patient morbidity, mortality, and disability. Unfortunately, adherence to the published best practices for VTE prevention, based on patient centered outcomes research (PCOR), is highly variable across U.S. hospitals, which represents a gap between current evidence and clinical practice leading to adverse patient outcomes. This gap is especially large in the case of traumatic brain injury (TBI), where reluctance to initiate VTE prevention due to concerns for potentially increasing the rates of intracranial bleeding drives poor rates of VTE prophylaxis. This is despite research which has shown early initiation of VTE prophylaxis to be safe in TBI without increased risk of delayed neurosurgical intervention or death. Clinical decision support (CDS) is an indispensable solution to close this practice gap; however, design and implementation barriers hinder CDS adoption and successful scaling across health systems. Clinical practice guidelines (CPGs) informed by PCOR evidence can be deployed using CDS systems to improve the evidence to practice gap. In the Scaling AcceptabLE cDs (SCALED) study, we will implement a VTE prevention CPG within an interoperable CDS system and evaluate both CPG effectiveness (improved clinical outcomes) and CDS implementation. METHODS The SCALED trial is a hybrid type 2 randomized stepped wedge effectiveness-implementation trial to scale the CDS across 4 heterogeneous healthcare systems. Trial outcomes will be assessed using the RE2-AIM planning and evaluation framework. Efforts will be made to ensure implementation consistency. Nonetheless, it is expected that CDS adoption will vary across each site. To assess these differences, we will evaluate implementation processes across trial sites using the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework (a determinant framework) using mixed-methods. Finally, it is critical that PCOR CPGs are maintained as evidence evolves. To date, an accepted process for evidence maintenance does not exist. We will pilot a "Living Guideline" process model for the VTE prevention CDS system. DISCUSSION The stepped wedge hybrid type 2 trial will provide evidence regarding the effectiveness of CDS based on the Berne-Norwood criteria for VTE prevention in patients with TBI. Additionally, it will provide evidence regarding a successful strategy to scale interoperable CDS systems across U.S. healthcare systems, advancing both the fields of implementation science and health informatics. TRIAL REGISTRATION Clinicaltrials.gov - NCT05628207. Prospectively registered 11/28/2022, https://classic. CLINICALTRIALS gov/ct2/show/NCT05628207 .
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Affiliation(s)
- Christopher J Tignanelli
- Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA.
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.
- Center for Learning Health Systems Science, University of Minnesota, Minneapolis, MN, USA.
- Center for Quality Outcomes, Discovery and Evaluation, University of Minnesota, Minneapolis, MN, USA.
| | - Surbhi Shah
- Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - David Vock
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis, MN, USA
| | - Lianne Siegel
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis, MN, USA
| | - Carlos Serrano
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis, MN, USA
| | - Elliott Haut
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Rubina Rizvi
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
- Center for Learning Health Systems Science, University of Minnesota, Minneapolis, MN, USA
| | - Vincent Peta
- Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
| | - Peter C Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas Lemke
- Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
| | - Thankam Thyvalikakath
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, USA
- Indiana University School of Dentistry, Indianapolis, IN, USA
| | | | - Denise Torres
- Department of Surgery, Geisinger Health, Danville, PA, USA
| | - David Vawdrey
- Department of Biomedical Informatics, Geisinger Health, Danville, PA, USA
| | - Rachael A Callcut
- Department of Surgery, UC Davis School of Medicine, Sacramento, CA, USA
| | - Mary Butler
- Center for Learning Health Systems Science, University of Minnesota, Minneapolis, MN, USA
- School of Publish Health, University of Minnesota, Minneapolis, MN, USA
| | - Genevieve B Melton
- Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
- Center for Learning Health Systems Science, University of Minnesota, Minneapolis, MN, USA
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4
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Vrettou CS, Dima E, Karela NR, Sigala I, Korfias S. Severe Traumatic Brain Injury and Pulmonary Embolism: Risks, Prevention, Diagnosis and Management. J Clin Med 2024; 13:4527. [PMID: 39124793 PMCID: PMC11313609 DOI: 10.3390/jcm13154527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/21/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
Severe traumatic brain injury (sTBI) is a silent epidemic, causing approximately 300,000 intensive care unit (ICU) admissions annually, with a 30% mortality rate. Despite worldwide efforts to optimize the management of patients and improve outcomes, the level of evidence for the treatment of these patients remains low. The concomitant occurrence of thromboembolic events, particularly pulmonary embolism (PE), remains a challenge for intensivists due to the risks of anticoagulation to the injured brain. We performed a literature review on sTBI and concomitant PE to identify and report the most recent advances on this topic. We searched PubMed and Scopus for papers published in the last five years that included the terms "pulmonary embolism" and "traumatic brain injury" in their title or abstract. Exclusion criteria were papers referring to children, non-sTBI populations, and post-acute care. Our search revealed 75 papers, of which 38 are included in this review. The main topics covered include the prevalence of and risk factors for pulmonary embolism, the challenges of timely diagnosis in the ICU, the timing of pharmacological prophylaxis, and the treatment of diagnosed PE.
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Affiliation(s)
- Charikleia S. Vrettou
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Effrosyni Dima
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Nina Rafailia Karela
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Ioanna Sigala
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Stefanos Korfias
- Department of Neurosurgery, Evaggelismos General Hospital of Athens, 10676 Athens, Greece
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Elkbuli A, Watts E, Patel H, Chin B, Wright DD, Inouye M, Nunez D, Rhodes HX. National Analysis of Outcomes for Adult Trauma Patients With Isolated Severe Blunt Traumatic Brain Injury Following Venous Thromboembolism Prophylaxis. J Surg Res 2024; 300:165-172. [PMID: 38815515 DOI: 10.1016/j.jss.2024.04.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 04/22/2024] [Accepted: 04/29/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION We aim to evaluate the association of early versus late venous thromboembolism (VTE) prophylaxis on in-hospital mortality among patients with severe blunt isolated traumatic brain injuries. METHODS Data from the American College of Surgeons Trauma Quality Program Participant Use File for 2017-2021 were analyzed. The target population included adult trauma patients with severe isolated traumatic brain injury (TBI). VTE prophylaxis types (low molecular weight heparin and unfractionated heparin) and their administration timing were analyzed in relation to in-hospital complications and mortality. RESULTS The study comprised 3609 patients, predominantly Caucasian males, with an average age of 48.5 y. Early VTE prophylaxis recipients were younger (P < 0.01) and more likely to receive unfractionated heparin (P < 0.01). VTE prophylaxis later than 24 h was associated with a higher average injury severity score and longer intensive care unit stays (P < 0.01). Logistic regression revealed that VTE prophylaxis later than 24 h was associated with significant reduction of in-hospital mortality by 38% (odds ratio 0.62, 95% confidence interval 0.40-0.94, P = 0.02). Additionally, low molecular weight heparin use was associated with decreased mortality odds by 30% (odds ratio 0.70, 95% confidence interval 0.55-0.89, P < 0.01). CONCLUSIONS VTE prophylaxis later than 24 h is associated with a reduced risk of in-hospital mortality in patients with severe isolated blunt TBI, as opposed to VTE prophylaxis within 24 h. These findings suggest the need for timely and appropriate VTE prophylaxis in TBI care, highlighting the critical need for a comprehensive assessment and further research concerning the safety and effectiveness of VTE prophylaxis in these patient populations.
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Affiliation(s)
- Adel Elkbuli
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, Florida; Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida.
| | - Emelia Watts
- NOVA Southeastern University, Kiran Patel College of Allopathic Medicine, Fort Lauderdale, Florida
| | - Heli Patel
- NOVA Southeastern University, Kiran Patel College of Allopathic Medicine, Fort Lauderdale, Florida
| | - Brian Chin
- University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii
| | - D-Dre Wright
- University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii
| | - Marissa Inouye
- University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii
| | - Denise Nunez
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, Arizona
| | - Heather X Rhodes
- Center for Clinical Epidemiology and Public Health, Marshfield Clinic Research Institute, Marshfield, Wisconsin
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Baucom MR, Price AD, Whitrock JN, Hanseman D, Smith MP, Pritts TA, Goodman MD. Need for Blood Transfusion Volume Is Associated With Increased Mortality in Severe Traumatic Brain Injury. J Surg Res 2024; 301:163-171. [PMID: 38936245 DOI: 10.1016/j.jss.2024.04.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/04/2024] [Accepted: 04/21/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Many patients suffering from isolated severe traumatic brain injury (sTBI) receive blood transfusion on hospital arrival due to hypotension. We hypothesized that increasing blood transfusions in isolated sTBI patients would be associated with an increase in mortality. METHODS We performed a trauma quality improvement program (TQIP) (2017-2019) and single-center (2013-2021) database review filtering for patients with isolated sTBI (Abbreviated Injury Scale head ≥3 and all other areas ≤2). Age, initial Glasgow Coma Score (GCS), Injury Severity Score (ISS), initial systolic blood pressure (SBP), mechanism (blunt/penetrating), packed red blood cells (pRBCs) and fresh frozen plasma (FFP) transfusion volume (units) within the first 4 h, FFP/pRBC ratio (4h), and in-hospital mortality were obtained from the TQIP Public User Files. RESULTS In the TQIP database, 9257 patients had isolated sTBI and received pRBC transfusion within the first 4 h. The mortality rate within this group was 47.3%. The increase in mortality associated with the first unit of pRBCs was 20%, then increasing approximately 4% per unit transfused to a maximum mortality of 74% for 11 or more units. When adjusted for age, initial GCS, ISS, initial SBP, and mechanism, pRBC volume (1.09 [1.08-1.10], FFP volume (1.08 [1.07-1.09]), and FFP/pRBC ratio (1.18 [1.08-1.28]) were associated with in-hospital mortality. Our single-center study yielded 138 patients with isolated sTBI who received pRBC transfusion. These patients experienced a 60.1% in-hospital mortality rate. Logistic regression corrected for age, initial GCS, ISS, initial SBP, and mechanism demonstrated no significant association between pRBC transfusion volume (1.14 [0.81-1.61]), FFP transfusion volume (1.29 [0.91-1.82]), or FFP/pRBC ratio (6.42 [0.25-164.89]) and in-hospital mortality. CONCLUSIONS Patients suffering from isolated sTBI have a higher rate of mortality with increasing amount of pRBC or FFP transfusion within the first 4 h of arrival.
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Affiliation(s)
- Matthew R Baucom
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Adam D Price
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jenna N Whitrock
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Dennis Hanseman
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Maia P Smith
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Timothy A Pritts
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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7
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Al Tannir AH, Golestani S, Tentis M, Murphy PB, Schramm AT, Peschman J, Dodgion C, Holena D, Miranda S, Carver TW, de Moya MA, Schellenberg M, Morris RS. Early venous thromboembolism chemoprophylaxis in traumatic brain injury requiring neurosurgical intervention: Safe and effective. Surgery 2024; 175:1439-1444. [PMID: 38388229 DOI: 10.1016/j.surg.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/25/2023] [Accepted: 01/17/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Traumatic brain injury patients who require neurosurgical intervention are at the highest risk of worsening intracranial hemorrhage. This subgroup of patients has frequently been excluded from prior research regarding the timing of venous thromboembolism chemoprophylaxis. This study aims to assess the efficacy and safety of early venous thromboembolism chemoprophylaxis in patients with traumatic brain injuries requiring neurosurgical interventions. METHODS This is a single-center retrospective review (2016-2020) of traumatic brain injury patients requiring neurosurgical intervention admitted to a level I trauma center. Interventions included intracranial pressure monitoring, subdural drain, external ventricular drain, craniotomy, and craniectomy. Exclusion criteria included neurosurgical intervention after chemoprophylaxis initiation, death within 5 days of admission, and absence of chemoprophylaxis. The total population was stratified into Early (≤72 hours of intervention) versus Late (>72 hours after intervention) chemoprophylaxis initiation. RESULTS A total of 351 patients met the inclusion criteria, of whom 204 (58%) had early chemoprophylaxis initiation. Overall, there were no significant differences in baseline and admission characteristics between cohorts. The Early chemoprophylaxis cohort had a statistically significant lower venous thromboembolism rate (5% vs 13%, P < .001) with no increased risk of worsening intracranial hemorrhage (10% vs 13%, P = .44) or neurosurgical reintervention (8% vs 10%, P = .7). On subgroup analysis, a total of 169 patients required either a craniotomy or a craniectomy before chemoprophylaxis. The Early chemoprophylaxis cohort had statistically significant lower venous thromboembolism rates (2% vs 11%, P < .001) with no increase in intracranial hemorrhage (8% vs 11%, P = .6) or repeat neurosurgical intervention (8% vs 10%, P = .77). CONCLUSION Venous thromboembolism prophylaxis initiation within 72 hours of neurosurgical intervention is safe and effective. Further prospective research is warranted to validate the results of this study.
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Affiliation(s)
- Abdul Hafiz Al Tannir
- Department of Surgery, Division of Trauma and Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI. https://twitter.com/tannir_abed
| | - Simin Golestani
- Department of Surgery, Division of Trauma and Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Morgan Tentis
- Department of Surgery, Division of Trauma and Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Patrick B Murphy
- Department of Surgery, Division of Trauma and Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Andrew T Schramm
- Department of Surgery, Division of Trauma and Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Jacob Peschman
- Department of Surgery, Division of Trauma and Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Christopher Dodgion
- Department of Surgery, Division of Trauma and Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Daniel Holena
- Department of Surgery, Division of Trauma and Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Stephen Miranda
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
| | - Thomas W Carver
- Department of Surgery, Division of Trauma and Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Marc A de Moya
- Department of Surgery, Division of Trauma and Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Morgan Schellenberg
- Department of Surgery, Division of Trauma and Critical Care Surgery, University of Southern California, Los Angeles, CA
| | - Rachel S Morris
- Department of Surgery, Division of Trauma and Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI.
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Borbas BZ, Whitfield P, King N. The safety of early pharmacological venous thromboembolism prophylaxis in patients with traumatic intracranial haemorrhage: a systematic review and meta-analysis. Br J Neurosurg 2024:1-11. [PMID: 38688329 DOI: 10.1080/02688697.2024.2339357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/01/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION In patients with traumatic intracranial haemorrhage (tICH) there is significant risk of both venous thromboembolism (VTE) and haemorrhage progression. There is a paucity of literature to inform the timing of pharmacological thromboprophylaxis (PTP) initiation. AIM This meta-analysis aims to summarise the current literature on the timing of PTP initiation in tICH. METHODS This meta-analysis followed the Methodological Expectations of Cochrane Intervention Reviews checklist and the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Following the literature search, studies were matched against the criteria for inclusion. Data from included studies was pooled, analysed using random-effect analysis and presented as forest plots of risk ratios, except one result reported as difference of means. The ROBINS-I tool was used to assess the risk of bias in the studies. The GRADE approach was taken to assess the quality of included studies. Heterogeneity of studies was assessed using Tau∧2. Funnel plots were generated and used in conjunction with Harbord's test and Rucker's arcsine to assess for small-study effect including publication bias. RESULTS A total of 9927 ICH patients who received PTP were included from 15 retrospective observational cohort studies, 4807 patients received early PTP, the remaining 5120 received late PTP. The definition of early was dependent on the study but no more than 72-hours after admission. The mean age of the included cohort was 45.3 (std dev ±9.5) years, and the proportion of males was 71%. Meta-analysis indicated that there was a significant difference between early and late groups for the rate of VTE (RR, 0.544; p = 0.000), pulmonary embolus (RR, 0.538; p = 0.004), deep vein thrombosis (RR, 0.484; p = 0.000) and the intensive care unit length of stay (difference of means, -2.021; 95% CI, -2.250, -1.792; p = 0.000; Tau∧2 = 0.000), favouring the early group. However, the meta-analysis showed no significant difference between the groups for the rate of mortality (RR, 1.008; p = 0.936), tICH progression (RR, 0.853; p = 0.157), and neurosurgical intervention (RR, 0.870; p = 0.480). CONCLUSION These findings indicated that early PTP appears to be safe and effective in patients with tICH.
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Affiliation(s)
| | - Peter Whitfield
- Neurosurgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Nicola King
- School of Biomedical Sciences, Faculty of Health, University of Plymouth, Plymouth, UK
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Van Gent JM, Clements TW, Lubkin DE, Kaminski CW, Bates JK, Sandoval M, Puzio TJ, Cotton BA. 'Door-to-prophylaxis' as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury. Trauma Surg Acute Care Open 2024; 9:e001297. [PMID: 38666014 PMCID: PMC11043729 DOI: 10.1136/tsaco-2023-001297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Objective Venous thromboembolism (VTE) risk reduction strategies include early initiation of chemoprophylaxis, reducing missed doses, weight-based dosing and dose adjustment using anti-Xa levels. We hypothesized that time to initiation of chemoprophylaxis would be the strongest modifiable risk for VTE, even after adjusting for competing risk factors. Methods A prospectively maintained trauma registry was queried for patients admitted July 2017-October 2021 who were 18 years and older and received emergency release blood products. Patients with deep vein thrombosis or pulmonary embolism (VTE) were compared to those without (no VTE). Door-to-prophylaxis was defined as time from hospital arrival to first dose of VTE chemoprophylaxis (hours). Univariate and multivariate analyses were then performed between the two groups. Results 2047 patients met inclusion (106 VTE, 1941 no VTE). There were no differences in baseline or demographic data. VTE patients had higher injury severity score (29 vs 24), more evidence of shock by arrival lactate (4.6 vs 3.9) and received more post-ED transfusions (8 vs 2 units); all p<0.05. While there was no difference in need for enoxaparin dose adjustment or missed doses, door-to-prophylaxis time was longer in the VTE group (35 vs 25 hours; p=0.009). On multivariate logistic regression analysis, every hour delay from time of arrival increased likelihood of VTE by 1.5% (OR 1.015, 95% CI 1.004 to 1.023, p=0.004). Conclusion The current retrospective study of severely injured patients with trauma who required emergency release blood products found that increased door-to-prophylaxis time was significantly associated with an increased likelihood for VTE. Chemoprophylaxis initiation is one of the few modifiable risk factors available to combat VTE, therefore early initiation is paramount. Similar to door-to-balloon time in treating myocardial infarction and door-to-tPA time in stroke, "door-to-prophylaxis time" should be considered as a hospital metric for prevention of VTE in trauma. Level of evidence Level III, retrospective study with up to two negative criteria.
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Affiliation(s)
- Jan-Michael Van Gent
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Thomas W Clements
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David E Lubkin
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Carter W Kaminski
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jonathan K Bates
- The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mariela Sandoval
- The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Thaddeus J Puzio
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bryan A Cotton
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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10
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Wu YT, Chien CY, Matsushima K, Schellenberg M, Inaba K, Moore EE, Sauaia A, Knudson MM, Martin MJ. Early venous thromboembolism prophylaxis in patients with trauma intracranial hemorrhage: Analysis of the prospective multicenter Consortium of Leaders in Traumatic Thromboembolism study. J Trauma Acute Care Surg 2023; 95:649-656. [PMID: 37314427 DOI: 10.1097/ta.0000000000004007] [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: 06/15/2023]
Abstract
BACKGROUND The optimal time to initiate venous thromboembolism prophylaxis (VTEp) for patients with intracranial hemorrhage (ICH) is controversial and must balance the risks of VTE with potential progression of ICH. We sought to evaluate the efficacy and safety of early VTEp initiation after traumatic ICH. METHODS This is a secondary analysis of the prospective multicenter Consortium of Leaders in the Study of Thromboembolism study. Patients with head Abbreviated Injury Scale score of > 2 and with immediate VTEp held because of ICH were included. Patients were divided into VTEp ≤ or >48 hours and compared. Outcome variables included overall VTE, deep vein thrombosis (DVT), pulmonary embolism, progression of intracranial hemorrhage (pICH), or other bleeding events. Univariate and multivariate logistic regressions were performed. RESULTS There were 881 patients in total; 378 (43%) started VTEp ≤48 hours (early). Patients starting VTEp >48 hours (late) had higher VTE (12.4% vs. 7.2%, p = 0.01) and DVT (11.0% vs. 6.1%, p = 0.01) rates than the early group. The incidence of pulmonary embolism (2.1% vs. 2.2%, p = 0.94), pICH (1.9% vs. 1.8%, p = 0.95), or any other bleeding event (1.9% vs. 3.0%, p = 0.28) was equivalent between early and late VTEp groups. On multivariate logistic regression analysis, VTEp >48 hours (odds ratio [OR], 1.86), ventilator days >3 (OR, 2.00), and risk assessment profile score of ≥5 (OR, 6.70) were independent risk factors for VTE (all p < 0.05), while VTEp with enoxaparin was associated with decreased VTE (OR, 0.54, p < 0.05). Importantly, VTEp ≤48 hours was not associated with pICH (OR, 0.75) or risk of other bleeding events (OR, 1.28) (both p = NS). CONCLUSION Early initiation of VTEp (≤48 hours) for patients with ICH was associated with decreased VTE/DVT rates without increased risk of pICH or other significant bleeding events. Enoxaparin is superior to unfractionated heparin as VTE prophylaxis in patients with severe TBI. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Yu-Tung Wu
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (Y.-T.W., C.-Y.C., K.M., M.S., K.I., M.J.M.), LAC+USC Medical Center, University of Southern California, Los Angeles, California; Department of Trauma and Emergency Surgery (Y.-T.W.), Chang Gung Memorial Hospital, Linkou; Department of General Surgery (C.-Y.C.), Chang Gung Memorial Hospital, Keelung, Taiwan; Department of Surgery (E.E.M.), Ernest E Moore Shock Trauma Center at Denver Health Center; School of Public Health (A.S.), University of Colorado, Denver, Colorado; and Department of Surgery (M.M.K.), University of California San Francisco, San Francisco, California
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11
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Filiberto DM, Byerly S, Lenart EK, Fischer PE, Kerwin AJ. Body Mass Index and Pharmacologic Venous Thromboembolism Prophylaxis in Traumatic Brain Injury. J Surg Res 2023; 291:245-249. [PMID: 37478648 DOI: 10.1016/j.jss.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/01/2023] [Accepted: 06/18/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION Patients with traumatic brain injury (TBI) are at risk for developing venous thromboembolic complications. Previous work suggests venous thromboembolism (VTE) prophylaxis with low molecular weight heparin (LMWH) is protective compared to unfractionated heparin (UH) in trauma patients. The purpose of this study was to evaluate the role of body mass index (BMI) and type of pharmacological VTE prophylaxis in patients who develop VTE with severe TBI. METHODS Patients with a severe TBI who received VTE prophylaxis were queried from the 2019 American College of Surgeons Trauma Quality Improvement Program database. Demographics, injury characteristics, timing of VTE prophylaxis, and BMI were collected. Outcome measures include VTE, mortality, and neurosurgical interventions. RESULTS Of the 39,520 patients with severe TBI included in the study, 25,671 received LMWH and 13,849 received UH. Multivariable logistic regression found patients with a BMI 25-29.9 kg/m2 (odds ratio [OR] 1.375; 95% confidence interval [CI] 1.180-1.603; P < 0.0001) and a BMI>30 kg/m2 (OR 1.831; 95% CI 1.570-2.137; P < 0.0001) were independent predictors of VTE. Patients with BMI of 25-29.9 kg/m2 (OR 1.145; 95% CI 1.016-1.289; P = 0.0265) have a higher risk of mortality. For every hour delay in initiation to VTE prophylaxis, patients were 0.2% more likely to develop VTE (OR 1.002; 95% CI 1.002-1.003; P < 0.0001). Patients treated with UH were more likely to develop VTE complications (OR 1.085; 95% CI 1.058-1.112; P < 0.0001) and have increased mortality (OR 1.116; 95% CI 1.094-1.139; P < 0.0001), regardless of BMI and time to initiation of prophylaxis, compared to patients treated with LMWH. CONCLUSIONS In patients with severe TBI, higher BMI was associated with an increased risk of VTE and death. Delay in VTE prophylaxis initiation was associated with an increased risk of VTE. LMWH had a protective association with VTE.
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Affiliation(s)
- Dina M Filiberto
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Emily K Lenart
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Peter E Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrew J Kerwin
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
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12
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D'Souza K, Norman M, Rebchuk AD, Samarasinghe N, Hounjet CD, Griesdale DE, Joos E, Field TS. Efficacy of Antithrombotic Therapy and Risk of Hemorrhagic Complication in Blunt Cerebrovascular Injury Patients with Concomitant Injury: A Systematic Review. J Am Coll Surg 2023; 237:663-672. [PMID: 37222430 DOI: 10.1097/xcs.0000000000000771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND The risk-benefit balance of antithrombotic therapy administration for blunt cerebrovascular injuries (BCVI) patients with concomitant injuries at high risk for bleeding is an ongoing therapeutic conundrum for trauma clinicians. We performed a systematic review to assess the reported efficacy and safety of treatment in this population with respect to prevention of ischemic stroke and risk of hemorrhagic complications. STUDY DESIGN A systematic electronic literature search of MEDLINE, EMBASE, Cochrane Library, and Web of Science databases was performed from January 1, 1996 to December 31, 2021. Studies were included if they reported treatment-stratified clinical outcomes after antithrombotic therapy in BCVI patients with concomitant injuries at high risk of bleeding into a critical site. Data were extracted from selected studies by two independent reviewers, including the main outcomes of interest were BCVI-related ischemic stroke rates and rates of hemorrhagic complications. RESULTS Of the 5,999 studies reviewed, 10 reported on the effects of treating BCVI patients with concurrent traumatic injuries and were included for review. In the pooled data, among patients with BCVI and concomitant injury who received any form of antithrombotic therapy, the BCVI-related stroke rate was 7.6%. The subgroup of patients who did not receive therapy had an overall BCVI-related stroke rate of 34%. The total rate of hemorrhagic complications in the treated population was 3.4%. CONCLUSIONS In BCVI patients with concomitant injuries at high risk for bleeding, antithrombotic use reduces the risk of ischemic strokes with a low reported risk of serious hemorrhagic complications.
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Affiliation(s)
- Karan D'Souza
- From the Section of Acute Care Surgery and Trauma, Division of General Surgery (D'Souza, Samarasinghe, Joos), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mathew Norman
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alexander D Rebchuk
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurosurgery, Department of Surgery (Rebchuk, Hounjet), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nadeesha Samarasinghe
- From the Section of Acute Care Surgery and Trauma, Division of General Surgery (D'Souza, Samarasinghe, Joos), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Celine D Hounjet
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurosurgery, Department of Surgery (Rebchuk, Hounjet), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald Eg Griesdale
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Critical Care Medicine (Griesdale), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Emilie Joos
- From the Section of Acute Care Surgery and Trauma, Division of General Surgery (D'Souza, Samarasinghe, Joos), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thalia S Field
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Stroke Program, Division of Neurology (Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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13
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Argandykov D, Proaño-Zamudio JA, Lagazzi E, Rafaqat W, Abiad M, Renne AM, Paranjape CN, Kaafarani HMA, Velmahos GC, Hwabejire JO. Low-molecular-weight heparin is superior to unfractionated heparin in lowering the risk of venous thromboembolism after traumatic lower extremity amputation. Surgery 2023; 174:1026-1033. [PMID: 37507306 DOI: 10.1016/j.surg.2023.06.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/30/2023] [Accepted: 06/18/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Patients undergoing lower extremity amputation after trauma are at high risk of venous thromboembolism. Practice variations persist regarding the optimal pharmacologic agent for venous thromboembolism prophylaxis in this patient population. We aimed to compare the efficacy of unfractionated heparin versus low-molecular-weight heparin in preventing venous thromboembolism. METHODS Using the 2013 to 2019 American College of Surgeons Pediatric Trauma Quality Improvement Program database, all trauma patients (≥18) who underwent lower limb amputation and received venous thromboembolism thromboprophylaxis in the form of unfractionated heparin or low-molecular-weight heparin were included. We excluded patients who died within 24 hours of admission or those who received no thromboprophylaxis. The primary outcome was the rate of venous thromboembolism. Multivariable logistic regression was used to evaluate the independent relationship between the type of pharmacologic prophylaxis and the risk of venous thromboembolism. RESULTS A total of 4,103 patients who underwent lower extremity amputation were identified. Patients were primarily young (median age 43 years) with blunt injuries (83%). The overall rate of venous thromboembolism was 8.6%. Most (77%) patients received low-molecular-weight heparin-based prophylaxis. Compared with patients without venous thromboembolism, the venous thromboembolism cohort had a greater injury severity score (19 vs 13, P < .001), had more patients undergoing above-the-knee amputation (48% vs 36%, P < .001), and less frequently received low-molecular-weight heparin (64% vs 78%, P < .001). Multivariable analysis showed that low-molecular-weight heparin was associated with a significantly lower venous thromboembolism rate than unfractionated heparin (odds ratio: 0.65 [0.51-0.83], P < .001). CONCLUSION Thromboprophylaxis with low-molecular-weight heparin was found to be superior to unfractionated heparin in lowering the risk of venous thromboembolism among traumatic amputees and should be the preferred pharmacologic agent in this patient population prone to venous thromboembolism.
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Affiliation(s)
- Dias Argandykov
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Emanuele Lagazzi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - May Abiad
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Angela M Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Charudutt N Paranjape
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA.
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14
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Tran A, Fernando SM, Gates RS, Gillen JR, Droege ME, Carrier M, Inaba K, Haut ER, Cotton B, Teichman A, Engels PT, Patel RV, Lampron J, Rochwerg B. Efficacy and Safety of Anti-Xa-Guided Versus Fixed Dosing of Low Molecular Weight Heparin for Prevention of Venous Thromboembolism in Trauma Patients: A Systematic Review and Meta-Analysis. Ann Surg 2023; 277:734-741. [PMID: 36413031 DOI: 10.1097/sla.0000000000005754] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE Trauma patients are at high risk of venous thromboembolism (VTE). We summarize the comparative efficacy and safety of anti-Xa-guided versus fixed dosing for low molecular weight heparin (LMWH) for the prevention of VTE in adult trauma patients. METHODS We searched Medline and Embase from inception through June 1, 2022. We included randomized controlled trials or observational studies comparing anti-Xa-guided versus fixed dosing of LMWH for thromboprophylaxis in adult trauma patients. We incorporated primary data from 2 large observational cohorts. We pooled effect estimates using a random-effects model. We assessed risk of bias using the ROBINS-I tool for observational studies and assessed certainty of findings using GRADE methodology. RESULTS We included 15 observational studies involving 10,348 patients. No randomized controlled trials were identified. determined that, compared to fixed LMWH dosing, anti-Xa-guided dosing may reduce deep vein thrombosis [adjusted odds ratio (aOR); 0.52, 95% CI: 0.40-0.69], pulmonary embolism (aOR: 0.48, 95% CI: 0.30-0.78) or any VTE (aOR: 0.54, 95% CI: 0.42-0.69), though all estimates are based on low certainty evidence. There was an uncertain effect on mortality (aOR: 1.06, 95% CI: 0.85-1.32) and bleeding events (aOR: 0.84, 95% CI: 0.50-1.39), limited by serious imprecision. We used several sensitivity and subgroup analyses to confirm the validity of our assumptions. CONCLUSION Anti-Xa-guided dosing may be more effective than fixed dosing for prevention of deep vein thrombosis, pulmonary embolism, and VTE for adult trauma patients. These promising findings justify the need for a high-quality randomized study with the potential to deliver practice changing results.
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Affiliation(s)
- Alexandre Tran
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Division of Critical Care, University of Ottawa, Ottawa, Canada
| | - Shannon M Fernando
- Division of Critical Care, University of Ottawa, Ottawa, Canada
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, Ontario, Canada
| | - Rebecca S Gates
- Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Jacob R Gillen
- Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Molly E Droege
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, OH
| | - Marc Carrier
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Elliott R Haut
- Division of Acute Care Surgery, Departments of Surgery, Anesthesiology and Critical Care, Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Bryan Cotton
- Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, TX
| | - Amanda Teichman
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Paul T Engels
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rakesh V Patel
- Division of Critical Care, University of Ottawa, Ottawa, Canada
| | - Jacinthe Lampron
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Bram Rochwerg
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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15
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Kuo YC, Li PH, Hsu TA, Fu CY, Bajani F, Mis J, Poulakidas S, Bokhari F. Does a time threshold exist for bladder repair after which outcomes worsen? A Trauma Quality Improvement Program study. Surgery 2023; 173:1296-1302. [PMID: 36759210 DOI: 10.1016/j.surg.2022.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/16/2022] [Accepted: 12/22/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND The appropriate timing of surgical intervention for bladder injuries is not well-defined. The effect of time to surgery on the outcomes of patients with a bladder injury was assessed using data from the Trauma Quality Improvement Program. METHODS Patients with dominant or isolated bladder injuries who underwent surgical repair from 2017 to 2019 were studied. Mortality, infection (surgical site infection or sepsis), acute kidney injury, overall length of stay, and length of stay after surgery were compared between patients who underwent bladder repair within and after 24 hours of arrival at the emergency department. The role of time to surgical repair in the outcomes of patients with a bladder injury was evaluated. RESULTS A total of 1,507 patients with a mean time to bladder repair of 14.0 hours were studied. In total, 233 (15.5%) patients with a bladder injury underwent bladder repair more than 1 day after emergency department arrival. These patients had significantly more infections (5.6% vs 2.5%, P = .011), more acute kidney injuries (7.8% vs 1.8%, P < .001), and a longer length of stay after surgery (16.0 vs 12.3 days, P = .001) than patients who underwent bladder repair within 1 day. A time to bladder repair longer than 24 hours after emergency department arrival did not significantly affect mortality (P = .075) but significantly increased the risk of infection/acute kidney injury (odds = 1.823, P = .040). However, the infection/acute kidney injury risk did not increase with increasing time to surgery in patients who underwent bladder repair within 24 hours (P = .120). CONCLUSION Patients with dominant or isolated bladder injuries may have a poor outcome (ie, increased infection rate, acute kidney injury, longer overall length of stay, and longer length of stay after bladder repair) if they undergo surgical repair more than 24 hours after arrival at the emergency department.
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Affiliation(s)
- Yu-Chi Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Pei-Hua Li
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Ting-An Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan; Department of Trauma and Burn Surgery, John H. Stroger Jr Hospital of Cook County, Chicago, IL.
| | - Francesco Bajani
- Department of Trauma and Burn Surgery, John H. Stroger Jr Hospital of Cook County, Chicago, IL
| | - Justin Mis
- Department of Trauma and Burn Surgery, John H. Stroger Jr Hospital of Cook County, Chicago, IL
| | - Stathis Poulakidas
- Department of Trauma and Burn Surgery, John H. Stroger Jr Hospital of Cook County, Chicago, IL
| | - Faran Bokhari
- Department of Trauma and Burn Surgery, John H. Stroger Jr Hospital of Cook County, Chicago, IL
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Lier H, Gooßen K, Trentzsch H. [The chapters "Stop the bleed-prehospital" and "Coagulation management and volume therapy (emergency departement)" in the new S3 guideline "Polytrauma/severe injury treatment"]. Notf Rett Med 2023; 26:259-268. [PMID: 37261335 PMCID: PMC10117256 DOI: 10.1007/s10049-023-01147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 06/02/2023]
Abstract
The S3 guideline on the treatment of patients with severe/multiple injuries by the German Association of the Scientific Medical Societies was updated between 2020 and 2022. This article describes the essence of the new chapter "Stop the bleed-prehospital" and the revised chapter "Coagulation management and volume therapy".
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Affiliation(s)
- H. Lier
- Medizinische Fakultät und Uniklinik Köln, Klinik für Anästhesiologie und Operative Intensivmedizin, Universität zu Köln, Kerpener Straße 62, 50937 Köln, Deutschland
- Sektion „Klinische Hämotherapie und Hämostasemanagement“ der Deutschen Gesellschaft für Intensiv- und Notfallmedizin (DIVI), Schumannstr. 2, 10117, Berlin, Deutschland
| | - K. Gooßen
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke, Ostmerheimer Straße 200, 51109 Köln, Deutschland
| | - H. Trentzsch
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336 München, Deutschland
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Haut ER, Byrne JP, Price MA, Bixby P, Bulger EM, Lake L, Costantini T. Proceedings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma. J Trauma Acute Care Surg 2023; 94:461-468. [PMID: 36534056 PMCID: PMC9974764 DOI: 10.1097/ta.0000000000003843] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
ABSTRACT On May 4 and 5, 2022, a meeting of multidisciplinary stakeholders in the prevention and treatment of venous thromboembolism (VTE) after trauma was convened by the Coalition for National Trauma Research, funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health, and hosted by the American College of Surgeons in Chicago, Illinois. This consensus conference gathered more than 40 in-person and 80 virtual attendees, including trauma surgeons, other physicians, thrombosis experts, nurses, pharmacists, researchers, and patient advocates. The objectives of the meeting were twofold: (1) to review and summarize the present state of the scientific evidence regarding VTE prevention strategies in injured patients and (2) to develop consensus on future priorities in VTE prevention implementation and research gaps.To achieve these objectives, the first part of the conference consisted of talks from physician leaders, researchers, clinical champions, and patient advocates to summarize the current state of knowledge of VTE pathogenesis and prevention in patients with major injury. Video recordings of all talks and accompanying slides are freely available on the conference website ( https://www.nattrauma.org/research/research-policies-templates-guidelines/vte-conference/ ). Following this curriculum, the second part of the conference consisted of a series of small-group breakout sessions on topics potentially requiring future study. Through this process, research priorities were identified, and plans of action to develop and undertake future studies were defined.The 2022 Consensus Conference to Implement Optimal VTE Prophylaxis in Trauma answered the National Trauma Research Action Plan call to define a course for future research into preventing thromboembolism after trauma. A multidisciplinary group of clinical champions, physicians, scientists, and patients delineated clear objectives for future investigation to address important, persistent key knowledge gaps. The series of papers from the conference outlines the consensus based on the current literature and a roadmap for research to answer these unanswered questions.
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Affiliation(s)
- Elliott R Haut
- From the Division of Acute Care Surgery, Department of Surgery (E.R.H., J.P.B.), Department of Anesthesiology and Critical Care Medicine (E.R.H.), and Department of Emergency Medicine (E.R.H.), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (E.R.H.), Johns Hopkins Medicine; Department of Health Policy and Management (E.R.H.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Coalition for National Trauma Research (M.A.P., P.B.), San Antonio, Texas; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington, DC; National Blood Clot Alliance (L.L.), Philadelphia, Pennsylvania; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (T.C.), University of California San Diego School of Medicine, San Diego, California
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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: 13] [Impact Index Per Article: 13.0] [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.
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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
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Trauma Quality Improvement and Team Education: How Can We Better Optimize Our Training? CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00351-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Age-dependent thrombin generation predicts 30-day mortality and symptomatic thromboembolism after multiple trauma. Sci Rep 2023; 13:1681. [PMID: 36717730 PMCID: PMC9886925 DOI: 10.1038/s41598-023-28474-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/19/2023] [Indexed: 01/31/2023] Open
Abstract
Trauma-induced coagulopathy (TIC) is a risk factor for death and is associated with deviations in thrombin generation. TIC prevalence and thrombin levels increase with age. We assayed in vivo and ex vivo thrombin generation in injured patients (n = 418) to specifically investigate how age impacts thrombin generation in trauma and to address the prognostic ability of thrombin generation. Biomarkers of thrombin generation were elevated in young (< 40 years) and older (≥ 40 years) trauma patients. In vivo thrombin generation was associated with Injury Severity Score (ISS) and this association was stronger in young than older patients. In vivo thrombin generation decreased faster after trauma in the young than the older patients. Across age groups, in vivo thrombin generation separated patients dying/surviving within 30 days at a level comparable to the ISS score (AUC 0.80 vs. 0.82, p > 0.76). In vivo and ex vivo thrombin generation also predicted development of thromboembolic events within the first 30 days after the trauma (AUC 0.70-0.84). In conclusion, younger trauma patients mount a stronger and more dynamic in vivo thrombin response than older patients. Across age groups, in vivo thrombin generation has a strong ability to predict death and/or thromboembolic events 30 days after injury.
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The Risk Assessment Profile is suboptimal for guiding duplex ultrasound surveillance in trauma patients. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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22
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Ang D, Pierre K, Armstrong J, Dunne J, Flaherty S, Gonzalez E, McKenney M, Offner P, Plurad D, Liu H, Ziglar M. Timing and Type of Venous Thromboembolic Chemoprophylaxis Is Associated with Acute Traumatic Brain Injury Outcomes. Neurotrauma Rep 2022; 3:511-521. [DOI: 10.1089/neur.2022.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Darwin Ang
- Department of Trauma, HCA Florida Ocala Hospital, Ocala, Florida, USA
- Department of Surgery, University of South Florida, Tampa, Florida, USA
- College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Kevin Pierre
- Department of Trauma, HCA Florida Ocala Hospital, Ocala, Florida, USA
- College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - John Armstrong
- Department of Surgery, University of South Florida, Tampa, Florida, USA
| | - James Dunne
- Department of Surgery, Medical Center, Memorial Health University, Savannah, Georgia, USA
| | - Stephen Flaherty
- Department of Trauma, Del Sol Medical Center, El Paso, Texas, USA
| | - Ernest Gonzalez
- Department of Trauma, South Austin Medical Center, Austin, Texas, USA
| | - Mark McKenney
- Department of Trauma, Kendall Regional Medical Center, Miami, Florida, USA
| | - Patrick Offner
- Department of Trauma, Sky Ridge Medical Center, Lone Tree, Colorado, USA
| | - David Plurad
- Department of Trauma, Riverside Community Hospital, Riverside, California, USA
| | - Huazhi Liu
- Department of Trauma, HCA Florida Ocala Hospital, Ocala, Florida, USA
| | - Michele Ziglar
- Clinical Services Group, Hospital Corporation of America, Nashville, Tennessee, USA
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Park HS, Hyun SY, Choi WS, Cho JS, Jang JH, Choi JY. Epidemiology and clinical characteristics of posttraumatic hospitalized patients with symptoms related to venous thromboembolism: a single-center retrospective study. JOURNAL OF TRAUMA AND INJURY 2022. [DOI: 10.20408/jti.2021.0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose: The aim of this study was to investigate the epidemiology of trauma inpatients with venous thromboembolism (VTE) symptoms diagnosed using computed tomographic angiography (CTA) in KoreaMethods: In total, 7,634 patients admitted to the emergency department of Gachon University Gil Medical Center, a tertiary hospital, and hospitalized between July 1, 2018 and December 31, 2020 were registered for this study. Of these patients, 278 patients who underwent CTA were enrolled in our study. Results: VTE was found in 120 of the 7,634 patients (1.57%), and the positive diagnosis rate of the 278 patients who underwent CTA was 43.2% (120 of 278). The incidence of VTE was statistically significantly higher among those with severe head and neck injuries (Abbreviated Injury Scale, 3–5) than among those with nonsevere head and neck injuries (Abbreviated Injury Scale, 0–2; P=0.038). In a subgroup analysis, the severe and nonsevere head and neck injury groups showed statistically significant differences in known independent risk factors for VTE. In logistic regression analysis, the adjusted odds ratio of severe head and neck injury (Abbreviated Injury Scale, 3–5) for VTE was 1.891 (95% confidence interval, 1.043–3.430). Conclusions: Trauma patients with severe head and neck injuries are more susceptible to VTE than those with nonsevere head and neck injuries. Thus, physicians must consider CTA as a priority for the diagnosis of VTE in trauma patients with severe head and neck injuries who show VTE-associated symptoms.
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Tang CC, Huang JF, Kuo LW, Cheng CT, Liao CH, Hsieh CH, Fu CY. The highest troponin I level during admission is associated with mortality in blunt cardiac injury patients. Injury 2022; 53:2960-2966. [PMID: 35750532 DOI: 10.1016/j.injury.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/28/2022] [Accepted: 06/08/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cardiac troponin I (cTnI) levels are usually measured in primary evaluations of blunt cardiac injury (BCI) patients. We evaluated the associations of cTnI levels with the outcomes of BCI patients at different times. METHODS From 2015 to 2019, blunt chest trauma patients with elevated cTnI levels were compared with patients without elevated cTnI levels using propensity score matching (PSM) to minimize selection bias. The cTnI levels at different times in the survivors and nonsurvivors were compared. RESULTS A total of 2,287 blunt chest trauma patients were included, and 57 (2.5%) of the patients had BCIs. PSM showed that patients with and without elevated cTnI levels had similar mortality rates (13.0% vs. 11.1%, p-value = 0.317], hospital lengths of stay (LOSs) [17.3 (14.4) vs. 15.5 (22.2) days, p-value = 0.699] and intensive care unit (ICU) LOSs [7.7 (12.1) vs. 6.4 (15.4) days, p-value = 0.072]. Among the BCI patients, nonsurvivors had a significantly higher highest cTnI level during the observation period than survivors. Additionally, patients who needed surgical intervention had significantly higher highest cTnI levels than patients who did not. CONCLUSIONS An elevated cTnI level is insufficient for the evaluation of BCI and the determination of the need for further treatment. The highest cTnI level during the observation period may be related to mortality and the need for surgery in BCI patients.
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Affiliation(s)
- Chia-Chun Tang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Jen-Fu Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Ling-Wei Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan.
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25
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Maragkos GA, Cho LD, Legome E, Wedderburn R, Margetis K. Delayed Cranial Decompression Rates After Initiation of Unfractionated Heparin versus Low-Molecular-Weight Heparin in Traumatic Brain Injury. World Neurosurg 2022; 164:e1251-e1261. [PMID: 35691523 DOI: 10.1016/j.wneu.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Both unfractionated heparin (UH) and low-molecular-weight heparin (LMWH) are routinely used prophylactically after traumatic brain injury (TBI) to prevent deep vein thrombosis (DVT). Their comparative risk for development or worsening of intracranial hemorrhage necessitating cranial decompression is unclear. Furthermore, the absence of a specific antidote for LMWH may lead to UH being used more often for high-risk patients. This study aims to compare the incidence of delayed cranial decompression occurring after initiation of prophylactic UH versus LMWH using the National Trauma Data Bank. METHODS Cranial decompression procedures included craniotomy and craniectomy. Multiple imputation was used for missing data. Propensity score matching was used to account for selection bias between UH and LMWH. The 1:1 matched groups were compared using logistic regression for the primary outcome of postprophylaxis cranial decompression. RESULTS A total of 218,594 patients with TBI were included, with 61,998 (28.3%) receiving UH and 156,596 (71.7%) receiving LMWH as DVT prophylaxis. The UH group had higher patient age, body mass index, comorbidity rates, Injury Severity Score, and worse motor Glasgow Coma Scale score. After the UH and LMWH groups were matched for these factors, logistic regression showed lower rates of postprophylaxis cranial decompression for the LMWH group (odds ratio, 0.13; 95% confidence interval, 0.11-0.16; P < 0.001). CONCLUSIONS Despite the absence of a specific antidote, LMWH was associated with lower rates of need for post-DVT-prophylaxis in craniotomy/craniectomy. This finding questions the notion of UH being safer for patients with TBI because it can be readily reversed. Randomized studies are needed to elucidate causality.
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Affiliation(s)
- Georgios A Maragkos
- Department of Neurosurgery, Mount Sinai Morningside Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Logan D Cho
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric Legome
- Department of Emergency Medicine, Mount Sinai West and Mount Sinai Morningside Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raymond Wedderburn
- Department of Surgery, Mount Sinai Morningside Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Konstantinos Margetis
- Department of Neurosurgery, Mount Sinai Morningside Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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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.
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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.
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Li PH, Hsu TA, Kuo YC, Fu CY, Bajani F, Bokhari M, Mis J, Poulakidas S, Bokhari F. The application of the WSES classification system for open pelvic fractures-validation and supplement from a nationwide data bank. World J Emerg Surg 2022; 17:29. [PMID: 35624457 PMCID: PMC9145531 DOI: 10.1186/s13017-022-00434-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Open pelvic fractures are rare but complex injuries. Concomitant external and internal hemorrhage and wound infection-related sepsis result in a high mortality rate and treatment challenges. Here, we validated the World Society Emergency Society (WSES) classification system for pelvic injuries in open pelvic fractures, which are quite different from closed fractures, using the National Trauma Data Bank (NTDB). Methods Open pelvic fracture patients in the NTDB 2015 dataset were retrospectively queried. The mortality rates associated with WSES minor, moderate and severe injuries were compared. A multivariate logistic regression model (MLR) was used to evaluate independent factors of mortality. Patients with and without sepsis were compared. The performance of the WSES classification in the prediction of mortality was evaluated by determining the discrimination and calibration. Results A total of 830 open pelvic fracture patients were studied. The mortality rates of the mild, moderate and severe WSES classes were 3.5%, 11.2% and 23.8%, respectively (p < 0.001). The MLR analysis showed that the presence of sepsis was an independent factor of mortality (odds of mortality 9.740, p < 0.001). Compared with patients without sepsis, those with sepsis had significantly higher mortality rates in all WSES classes (minor: 40.0% vs. 3.1%, p < 0.001; moderate: 50.0% vs. 9.1%, p < 0.001; severe: 66.7% vs. 22.2%, p < 0.001). The receiver operating characteristic (ROC) curve showed an acceptable discrimination of the WSES classification alone for evaluating the mortality of open pelvic fracture patients [area under curve (AUC) = 0.717]. Improved discrimination with an increased AUC was observed using the WSES classification plus sepsis (AUC = 0.767). Conclusions The WSES guidelines can be applied to evaluate patients with open pelvic fracture with accurate evaluation of outcomes. The presence of sepsis is recommended as a supplement to the WSES classification for open pelvic fractures.
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Affiliation(s)
- Pei-Hua Li
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Ting-An Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Yu-Chi Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan. .,Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA.
| | - Francesco Bajani
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Marissa Bokhari
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Justin Mis
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Stathis Poulakidas
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Faran Bokhari
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
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Shulkosky MM, Han EJ, Wahl WL, Hecht JP. Effects of Early Chemoprophylaxis in Traumatic Brain Injury and Risk of Venous Thromboembolism. Am Surg 2022:31348221102604. [PMID: 35575013 DOI: 10.1177/00031348221102604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The optimal timing to initiate venous thromboembolism (VTE) prophylaxis in patients with a traumatic brain injury (TBI) is still unknown. We designed a study to determine the effect that timing of initiation of VTE prophylaxis has on VTE rates in TBI patients. METHODS Patient records were obtained from 32 level 1 and 2 trauma centers in the Michigan Trauma Quality Improvement Program from 2008 to 2018. Overall, 5589 patients with a TBI were included and split into cohorts based on VTE prophylaxis initiation time. Outcomes included rate of VTE, mortality, and serious in-hospital complications. RESULTS There were nine patients (1.3%) in the <24 hour group with a VTE as compared to 36 (2.6%) in the 24-48 hour group, 51 (4.1%) in the 48-72 hour group, and 181 (8.1%) in the >72 hour group (P < .001). The adjusted odds of VTE were significantly greater in patients initiated within 48-72 hours (AOR 2.861, 95% CI 1.271-6.439) and >72 hours (AOR 3.963, 95% CI 1.824-8.612) compared to <24 hours. Patients that received VTE prophylaxis within 24 hours had similar rates of serious in-hospital complication as patients initiated within 24-48 hours (AOR .956, 95% CI .637-1.434) and 48-72 hour (AOR 1.132, 95% CI .757-1.692) but less than the >72 hour group (AOR 1.662, 95% CI 1.154-2.393) groups. DISCUSSION Patients initiated on VTE prophylaxis within 48 hours of presentation had lower incidence of VTE without a significant increase in serious complications.
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Affiliation(s)
- Megan M Shulkosky
- Department of Pharmacy, 2569Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Emily J Han
- Department of Pharmacy, 21614University of Michigan, Ann Arbor, MI, USA
| | - Wendy L Wahl
- Department of Surgery, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jason P Hecht
- Department of Pharmacy, 159837St. Joseph Mercy Hospital, Ann Arbor, MI, USA
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Miles MVP, Brown CNH, Webster CC, Armistead C, Gilchrist SA, Everett H, Wilson A, Maxwell R. Routine Lower Extremity Screening Ultrasound Protocols in Trauma Patients Are Not Cost Effective. Am Surg 2022; 88:1490-1495. [PMID: 35437039 DOI: 10.1177/00031348221082283] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite prophylaxis, deep vein thrombosis (DVT) and pulmonary embolism remain dreaded complications following traumatic injury and are associated with significant morbidity and mortality. Screening ultrasound (US) protocols have been employed in trauma centers for early detection of lower extremity (LE) deep venous thrombosis. We hypothesized that screening lower extremity venous duplex US would not prove cost effective in our trauma population who receives early pharmacologic prophylaxis. METHODS Data was collected for one year on all adult trauma patients admitted to the trauma service from December 2019 to 2020. DVT screening US was obtained at 3 days after admission for patients with long bone or pelvic fracture, spinal cord injury, immobility, and/or spinal fracture requiring surgery. Screening US was obtained at 7 days for all others and repeated weekly until discharge. Data was retrospectively collected and analyzed. RESULTS Exactly 1365 patients met inclusion criteria with median ISS 12 (IQR, 9-17), median age 56 (IQR, 36-73 years), and with majority blunt injuries (90.7%). A total of 1369 screening US were performed finding 27 DVTs (2%). The total cost of screening for the year analyzed amounted to over $270,000 with 50.7 screening US needed to detect 1 DVT. This resulted in an average screening cost of over $10,000 for the detection of a single DVT. DISCUSSION In trauma patients receiving early pharmacologic prophylaxis, routine LE screening US protocols to detect LE DVT are not cost effective.
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Affiliation(s)
- M Victoria P Miles
- Department of Surgery, 70274University of Tennessee College of Medicine, Chattanooga, TN, USA
| | | | | | - Charles Armistead
- Department of Surgery, 70274University of Tennessee College of Medicine, Chattanooga, TN, USA
| | - S Austin Gilchrist
- Department of Surgery, 70274University of Tennessee College of Medicine, Chattanooga, TN, USA
| | - Hayley Everett
- Department of Surgery, 70274University of Tennessee College of Medicine, Chattanooga, TN, USA
| | - Andrew Wilson
- Department of Orthopedic Surgery, 70274University of Tennessee College of Medicine, Chattanooga, TN, USA
| | - Robert Maxwell
- Department of Surgery, 70274University of Tennessee College of Medicine, Chattanooga, TN, USA
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Ng IC, Barnes C, Biswas S, Wright D, Dagal A. When is it safe to resume anticoagulation in traumatic brain injury? Curr Opin Anaesthesiol 2022; 35:166-171. [PMID: 35131968 DOI: 10.1097/aco.0000000000001117] [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: 11/26/2022]
Abstract
PURPOSE OF REVIEW When to resume or initiate anticoagulation therapy following traumatic brain injury (TBI) is controversial. This summary describes the latest evidence to guide best practice. RECENT FINDINGS Following trauma, prophylactic, and therapeutic anticoagulation (TAC) have been widely encouraged to prevent major comorbidities such as pulmonary embolism and deep venous thrombosis. Increased rebleeding risk and potentially catastrophic outcome from initiation of anticoagulation treatment in TBI are mainly influenced by institutional guidelines or physician preference in the absence of level I or II recommendations. In recent years, there has been an increasing number of TBI in the elderly population on anticoagulation for other medical conditions; this complicates the decision and timing to restart anticoagulation after the injury. SUMMARY Strategies and timing to start prophylactic and TAC differ significantly between institutions and physicians. Each TBI patient should be evaluated on a case-by-case basis on when to start anticoagulation. More investigation is required to guide best practice.
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Affiliation(s)
- Ireana C Ng
- Harborview Medical Center, UW Medicine, Seattle, Washington
| | | | - Subarna Biswas
- Keck School of Medicine of USC, Health Sciences Campus, Los Angeles, California, USA
| | - David Wright
- Harborview Medical Center, UW Medicine, Seattle, Washington
| | - Arman Dagal
- Harborview Medical Center, UW Medicine, Seattle, Washington
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Waqar M, Chadwick A, Kersey J, Horner D, Kearney T, Karabatsou K, Gnanalingham KK, Pathmanaban ON. Venous thromboembolism chemical prophylaxis after endoscopic trans-sphenoidal pituitary surgery. Pituitary 2022; 25:267-274. [PMID: 34843070 PMCID: PMC8894148 DOI: 10.1007/s11102-021-01195-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE There is no compelling outcome data or clear guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using low molecular weight heparin (chemoprophylaxis) in patients undergoing pituitary surgery. Here we describe our experience of early chemoprophylaxis (post-operative day 1) following trans-sphenoidal pituitary surgery. METHODS Single-centre review of a prospective surgical database and VTE records. Adults undergoing first time trans-sphenoidal pituitary surgery were included (2009-2018). VTE was defined as either deep vein thrombosis and/or pulmonary embolism within 3 months of surgery. Postoperative haematomas were those associated with a clinical deterioration together with radiological evidence. RESULTS 651 Patients included with a median age of 55 years (range 16-86 years). Most (99%) patients underwent trans-sphenoidal surgery using a standard endoscopic single nostril or bi-nostril trans-sphenoidal technique. More than three quarters had pituitary adenomas (n = 520, 80%). Postoperative chemoprophylaxis to prevent VTE was administered in 478 patients (73%). Chemoprophylaxis was initiated at a median of 1 day post-procedure (range 1-5 days postoperatively; 92% on postoperative day 1). Tinzaparin was used in 465/478 patients (97%) and enoxaparin was used in 14/478 (3%). There were no cases of VTE, even in 78 ACTH-dependent Cushing's disease patients. Six patients (1%) developed postoperative haematomas. Chemoprophylaxis was not associated with a significantly higher rate of postoperative haematoma formation (Fisher's Exact, p = 0.99) or epistaxis (Fisher's Exact, p > 0.99). CONCLUSIONS Chemoprophylaxis after trans-sphenoidal pituitary surgery on post-operative day 1 is a safe strategy to reduce the risk of VTE without significantly increasing the risk of postoperative bleeding events.
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Affiliation(s)
- Mueez Waqar
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
| | - Annabel Chadwick
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- School of Medicine, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
| | - James Kersey
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- Department of Neurocritical Care, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Daniel Horner
- Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
- Department of Neurocritical Care, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- School of Medicine, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
| | - Tara Kearney
- Department of Endocrinology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Konstantina Karabatsou
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Kanna K Gnanalingham
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK.
- Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK.
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Use of Pharmacologic Prophylaxis Against Venous Thromboembolism in Hospitalized Injured Children. J Pediatr Hematol Oncol 2022; 44:e349-e357. [PMID: 33885041 DOI: 10.1097/mph.0000000000002167] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/19/2021] [Indexed: 11/26/2022]
Abstract
Despite a practice management guideline and risk prediction model for venous thromboembolism (VTE), pediatric-specific evidence on pharmacologic prophylaxis is lacking. In a retrospective study, we characterized receipt of prophylaxis and explored its effectiveness in hospitalized injured patients below 18 years old using data from the Trauma Quality Improvement Program. Concordance of receipt of prophylaxis with guideline and predicted risk of VTE was estimated using κ statistic. Effectiveness was explored using cohorts matched based on the risk prediction model. A total of 11,165 (6.2%) of 180,932 patients received prophylaxis. Those who received prophylaxis were more commonly post-pubertal and more severely injured. Receipt of prophylaxis was fairly concordant with the guideline (κ=0.32) and predicted risk of VTE (κ=0.29). Receipt of prophylaxis was associated with higher rates of VTE likely due to confounding by indication. Low molecular weight heparin seemed more effective against VTE than unfractionated heparin (incidence rate ratio: 0.52; 95% confidence interval: 0.36, 0.75), but less effective when received ≥72 hours after admission to the hospital. We showed that hospitalized injured children did not commonly receive prophylaxis. We also showed that prophylaxis may be effective in hospitalized injured children, but it needs to be proven definitively in a randomized clinical trial.
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Relationship Between Anti-Xa Level Achieved with Prophylactic Low-Molecular Weight Heparin and Venous Thromboembolism in Trauma Patients: A Systematic Review and Meta-Analysis. J Trauma Acute Care Surg 2022; 93:e61-e70. [PMID: 35195094 DOI: 10.1097/ta.0000000000003580] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Alabboudi YH, Salman AH, El Tayeb YH, Yammahi AK. Therapeutic Anticoagulation in the Presence of a High-Grade Abdominal Solid Organ Injury: A Challenging Case to Manage – Case Report and Literature Review. DUBAI MEDICAL JOURNAL 2022. [DOI: 10.1159/000521636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
There are well-established protocols for venous thromboembolism prophylaxis in many patients with a variety of medical and surgical conditions. However, no studies have been published regarding therapeutic anticoagulation in polytrauma patients, who usually present with multiple injuries including vascular injuries and solid organ injuries, which would require therapeutic anticoagulation that increases the risk of bleeding from abdominal solid organ injuries. Here, we present the case of a 45-year-old male, who had a motor vehicle collision and was found to have a grade III splenic injury and had to be started on therapeutic anticoagulation due to popliteal artery injury repair. Our patient was anticoagulated with low-molecular-weight heparin. He had no bleeding complications, and his splenic injury was successfully managed nonoperatively.
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Fletcher-Sandersjöö A, Tatter C, Tjerkaski J, Bartek J, Svensson M, Thelin EP, Bellander BM. Clinical Significance of Vascular Occlusive Events following Moderate-to-Severe Traumatic Brain Injury: An Observational Cohort Study. Semin Thromb Hemost 2022; 48:301-308. [PMID: 34991168 DOI: 10.1055/s-0041-1740567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Preventing hemorrhage progression is a potential therapeutic opportunity in traumatic brain injury (TBI) management, but its use has been limited by fear of provoking vascular occlusive events (VOEs). However, it is currently unclear whether VOE actually affects outcome in these patients. The aim of this study was to determine incidence, risk factors, and clinical significance of VOE in patients with moderate-to-severe TBI. A retrospective observational cohort study of adults (≥15 years) with moderate-to-severe TBI was performed. The presence of a VOE during hospitalization was noted from hospital charts and radiological reports. Functional outcome, using the Glasgow Outcome Scale (GOS), was assessed at 12 months posttrauma. Univariate and multivariate logistic regressions were used for endpoint assessment. In total, 848 patients were included, with a median admission Glasgow Coma Scale of 7. A VOE was detected in 54 (6.4%) patients, of which cerebral venous thrombosis was the most common (3.2%), followed by pulmonary embolism (1.7%) and deep vein thrombosis (1.3%). Length of ICU stay (p < 0.001), body weight (p = 0.002), and skull fracture (p = 0.004) were independent predictors of VOE. VOE development did not significantly impact 12-month GOS, even after adjusting for potential confounders using propensity score matching. In conclusion, VOE in moderate-to-severe TBI patients was relatively uncommon, and did not affect 12-month GOS. This suggests that the potential benefit of treating bleeding progression might outweigh the risks of VOE.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Charles Tatter
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Jonathan Tjerkaski
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Mikael Svensson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Upper Extremity Deep Venous Thrombosis Risk Factors, Associated Morbidity and Mortality in Trauma Patients. World J Surg 2022; 46:561-567. [PMID: 34981151 DOI: 10.1007/s00268-021-06383-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The literature on upper extremity deep venous thrombosis (UEDVT) is not as abundant as that on lower extremities. This study aimed to identify the risk factors for UEDVT, associated mortality and morbidity in trauma patients and the impact of pharmacological prophylaxis therein. METHODS A 3-year retrospective review of patients admitted to a Level 1 trauma center was conducted. Patients aged 18 years or older who had experienced a traumatic event and had undergone an upper extremity ultrasound (UEUS) were included in the study. Multiple logistic regression was used to identify independent risk factors that contributed to UEDVT. RESULTS A total of 6,607 patients were admitted due to traumatic injuries during the study period, of whom 5.6% (373) had at least one UEUS during their hospitalization. Fifty-six (15%) were diagnosed with an UEDVT, as well as three non-fatal pulmonary emboli (PE) and four (7.1%) deaths, p = 0.03. Pharmacological prophylaxis with low-molecular-weight heparin (LMWH) or unfractionated heparin showed a protective effect against UEDVT; among the patients positive for UEDVT, 14 of 186 patients (7.5%) received LMWH, while 42 of 195 (21.5%) did not receive LMWH (p < 0.001). Multiple logistic regression revealed that the presence of upper extremity fractures, peripherally inserted central catheter (PICC) lines, and traumatic brain injury (TBI) were independent risk factors for UEDVT. CONCLUSIONS UEDVT are associated with a higher mortality. The presence of upper extremity fractures, PICC lines, and TBI were independent risk factors for UEDVTs. Further, pharmacological prophylaxis reduces the risk of UEDVT.
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Tran A, Fernando SM, Carrier M, Siegal DM, Inaba K, Vogt K, Engels PT, English SW, Kanji S, Kyeremanteng K, Lampron J, Kim D, Rochwerg B. Efficacy and Safety of Low Molecular Weight Heparin Versus Unfractionated Heparin for Prevention of Venous Thromboembolism in Trauma Patients: A Systematic Review and Meta-analysis. Ann Surg 2022; 275:19-28. [PMID: 34387202 DOI: 10.1097/sla.0000000000005157] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Trauma patients are at high risk of VTE. We summarize the efficacy and safety of LMWH versus UFH for the prevention of VTE in trauma patients. METHODS We searched 6 databases from inception through March 12, 2021. We included randomized controlled trials (RCTs) or observational studies comparing LMWH versus UFH for thromboprophylaxis in adult trauma patients. We pooled effect estimates across RCTs and observational studies separately, using random-effects model and inverse variance weighting. We assessed risk of bias using the Cochrane tool for RCTs and the Risk of Bias in Non-Randomized Studies (ROBINS)-I tool for observational studies and assessed certainty of findings using Grading of Recommendations, Assessment, Development and Evaluations methodology. RESULTS We included 4 RCTs (879 patients) and 8 observational studies (306,747 patients). Based on pooled RCT data, compared to UFH, LMWH reduces deep vein thrombosis (RR 0.67, 95% CI 0.50 to 0.88, moderate certainty) and VTE (RR 0.68, 95% CI 0.51 to 0.90, moderate certainty). As compared to UFH, LMWH may reduce pulmonary embolism [adjusted odds ratio from pooled observational studies 0.56 (95% CI 0.50 to 0.62)] and mortality (adjusted odds ratio from pooled observational studies 0.54, 95% CI 0.45 to 0.65), though based on low certainty evidence. There was an uncertain effect on adverse events (RR from pooled RCTs 0.80, 95% CI 0.48 to 1.33, very low certainty) and heparin induced thrombocytopenia [RR from pooled RCTs 0.26 (95% CI 0.03 to 2.38, very low certainty)]. CONCLUSIONS Among adult trauma patients, LMWH is superior to UFH for deep vein thrombosis and VTE prevention and may additionally reduce pulmonary embolism and mortality. The impact on adverse events and heparin induced thrombocytopenia is uncertain.
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Affiliation(s)
- Alexandre Tran
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - Marc Carrier
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Deborah M Siegal
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles
| | - Kelly Vogt
- Division of General Surgery, Department of Surgery, Western University, London, Canada
| | - Paul T Engels
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada
| | - Shane W English
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Salmaan Kanji
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jacinthe Lampron
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Dennis Kim
- Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Bulger EM. Optimizing Venous Thromboembolism Prophylaxis After Injury: An Evidence-based Approach. Ann Surg 2022; 275:29-30. [PMID: 34596075 DOI: 10.1097/sla.0000000000005235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, WA
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Al-Dorzi H, Al-Yami G, Al-Daker F, Alqirnas M, Alhamadh M, Khan R. The association of timing of pharmacological prophylaxis and venous thromboembolism in patients with moderate-to-severe traumatic brain injury: A retrospective cohort study. Ann Thorac Med 2022; 17:102-109. [PMID: 35651893 PMCID: PMC9150664 DOI: 10.4103/atm.atm_174_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 05/12/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES: Patients with traumatic brain injury (TBI) have an increased risk for venous thromboembolism (VTE). The current guidelines recommend pharmacologic prophylaxis, but its timing remains unclear. METHODS: In this retrospective cohort study, patients with moderate-to-severe TBI admitted to a tertiary care intensive care unit between 2016 and 2019 were categorized into two groups according to the timing of pharmacologic prophylaxis: early if prophylaxis was given within 72 h from hospital admission and late if after 72 h. RESULTS: Of the 322 patients in the cohort, 46 (14.3%) did not receive pharmacological prophylaxis, mainly due to early brain death; 152 (47.2%) received early pharmacologic prophylaxis and 124 (38.5%) received late prophylaxis. Predictors of late pharmacologic prophylaxis were lower body mass index, intracerebral hemorrhage (odds ratio [OR], 3.361; 95% confidence interval [CI], 1.269–8.904), hemorrhagic contusion (OR, 3.469; 95% CI, 1.039–11.576), and lower platelet count. VTE was diagnosed in 43 patients on a median of 10 days after trauma (Q1, Q3: 5, 15): 6.6% of the early prophylaxis group and 26.6% of the late group (P < 0.001). On multivariable logistic regression analysis, the predictors of VTE were Acute Physiology and Chronic Health Evaluation II score, subarachnoid hemorrhage, and late versus early pharmacologic prophylaxis (OR, 3.858; 95% CI, 1.687–8.825). The late prophylaxis group had higher rate of tracheostomy, longer duration of mechanical ventilation and stay in the hospital, lower discharge Glasgow coma scale, but similar survival, compared with the early group. CONCLUSIONS: Late prophylaxis (>72 h) was associated with higher VTE rate in patients with moderate-to-severe TBI, but not with higher mortality.
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Byrne JP, Witiw CD, Schuster JM, Pascual JL, Cannon JW, Martin ND, Reilly PM, Nathens AB, Seamon MJ. Association of Venous Thromboembolism Prophylaxis After Neurosurgical Intervention for Traumatic Brain Injury With Thromboembolic Complications, Repeated Neurosurgery, and Mortality. JAMA Surg 2021; 157:e215794. [PMID: 34910096 DOI: 10.1001/jamasurg.2021.5794] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance There is a lack of evidence regarding the effectiveness and safety of pharmacologic venous thromboembolism (VTE) prophylaxis among patients who undergo neurosurgical interventions for traumatic brain injury (TBI). Objective To measure the association between timing of VTE prophylaxis after urgent neurosurgical intervention for TBI and thromboembolic and intracranial complications. Design, Setting, and Participants This retrospective cohort study included adult patients (aged ≥16 years) who underwent urgent neurosurgical interventions (craniotomy/craniectomy or intracranial monitor/drain insertion within 24 hours after admission) for TBI at level 1 and 2 trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program between January 1, 2012, and December 31, 2016. Data were analyzed from January to August 2020. Exposures Timing of pharmacologic VTE prophylaxis initiation after urgent neurosurgical intervention (prophylaxis delay) measured in days (24-hour periods). Main Outcomes and Measures The primary outcome was VTE (deep vein thrombosis or pulmonary embolism). Secondary outcomes were repeated neurosurgery (neurosurgical reintervention after initiation of VTE prophylaxis) and mortality. Hierarchical logistic regression models were used to evaluate the association between prophylaxis delay and each outcome at the patient level and were adjusted for patient baseline and injury characteristics. Results The study included 4951 patients (3676 [74%] male; median age, 50 years [IQR, 31-64 years]) who underwent urgent neurosurgical intervention for TBI at 304 trauma centers. The median prophylaxis delay was 3 days (IQR, 1-5 days). After adjustment for patient baseline and injury characteristics, prophylaxis delay was associated with increased odds of VTE (adjusted odds ratio [aOR], 1.08 per day; 95% CI, 1.04-1.12). Earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. During the first 3 days, each additional day of prophylaxis delay was associated with a 28% decrease in odds of repeated neurosurgery (aOR, 0.72 per day; 95% CI, 0.59-0.88). After 3 days, each additional day of prophylaxis delay was associated with an additional 15% decrease in odds of repeated neurosurgery (aOR, 0.85 per day; 95% CI, 0.80-0.90). Earlier prophylaxis was associated with greater mortality among patients who initially underwent intracranial monitor/drain procedures, such that each additional day of prophylaxis delay was associated with decreased odds of death (aOR, 0.94 per day; 95% CI, 0.89-0.99). Conclusions and Relevance In this cohort study of patients who underwent urgent neurosurgical interventions for TBI, early pharmacologic VTE prophylaxis was associated with reduced risk of thromboembolism. However, earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. These findings suggest that although timely initiation of prophylaxis should be prioritized, caution should be used particularly during the first 3 days after the index procedure, when this risk appears to be highest.
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Affiliation(s)
- James P Byrne
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Christopher D Witiw
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - James M Schuster
- Department of Neurosurgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Jose L Pascual
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark J Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Schroeppel TJ, Clement LP, Douville AA, Schmoekel NH, Stassinopoulos J, Decker C, Stillman ZE, Rodriquez J, Brockman VP, Hennessy E, Heise H, Khan AD. Time is of the Essence: Impact of a More Aggressive Chemical Venous Thromboembolism Prophylaxis Regimen on Trauma Patients. Am Surg 2021; 88:455-462. [PMID: 34797198 DOI: 10.1177/00031348211050839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Thomas J Schroeppel
- Department of Surgery, 2604UCHealth-Memorial Hospital, Colorado Springs, CO, USA
| | - Lesley P Clement
- Department of Pharmacy, 2604UCHealth-Memorial Hospital, Colorado Springs, CO, USA
| | - Alyssa A Douville
- Department of Pharmacy, 2604UCHealth-Memorial Hospital, Colorado Springs, CO, USA
| | - Nathan H Schmoekel
- Department of Surgery, 2604UCHealth-Memorial Hospital, Colorado Springs, CO, USA
| | - Jerry Stassinopoulos
- Department of Surgery, 2604UCHealth-Memorial Hospital, Colorado Springs, CO, USA
| | - Cassandra Decker
- Department of Trauma Research, 2604UCHealth-Memorial Hospital, Colorado Springs, CO, USA
| | - Zachery E Stillman
- Department of Trauma Research, 2604UCHealth-Memorial Hospital, Colorado Springs, CO, USA
| | - Jennifer Rodriquez
- Department of Trauma Research, 2604UCHealth-Memorial Hospital, Colorado Springs, CO, USA
| | - Valerie P Brockman
- Department of Trauma Research, 2604UCHealth-Memorial Hospital, Colorado Springs, CO, USA
| | - Elizabeth Hennessy
- Department of Trauma Research, 2604UCHealth-Memorial Hospital, Colorado Springs, CO, USA
| | - Holly Heise
- Department of Trauma Research, 2604UCHealth-Memorial Hospital, Colorado Springs, CO, USA
| | - Abid D Khan
- Department of Surgery, 2604UCHealth-Memorial Hospital, Colorado Springs, CO, USA
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Timing of venous thromboembolic pharmacological prophylaxis in traumatic combined subdural and subarachnoid hemorrhage. Am J Surg 2021; 223:1194-1199. [PMID: 34809908 DOI: 10.1016/j.amjsurg.2021.11.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/13/2021] [Accepted: 11/15/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The combination of subdural and subarachnoid hemorrhage is the most common intracranial bleeding. The present study evaluated the timing and type of venous thromboembolic chemoprophylaxis (VTEp) for efficacy and safety in patients with blunt head trauma with combined acute subdural and subarachnoid hemorrhage. METHODS Patients with isolated combined acute subdural and subarachnoid hemorrhage were extracted from the ACS-TQIP database (2013-2017). After 1:1 cohort matching of patients receiving early prophylaxis (EP, ≤48 h) versus late prophylaxis (LP, >48 h) outcomes were compared with univariable and multivariable regression analysis. RESULTS Multivariable regression analysis identified EP as an independent protective factor for VTE complications (OR 0.468, CI 0.293-0.748) but not mortality (p = 0.485). The adjusted risk for delayed craniectomy was not associated with EP compared to LP (p = 0.283). The type of VTEp was not associated with VTE complications (p = 0.301), mortality (p = 0.391) or delayed craniectomy (p = 0.126). CONCLUSIONS Early VTEp (≤48 h) was associated with fewer VTE complications in patients and did not increase the risk for craniectomies in patients with combined acute subdural and subarachnoid hemorrhage.
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Inpatient compliance with venous thromboembolism prophylaxis after orthopaedic trauma: results from a randomized controlled trial of aspirin versus low molecular weight heparin. OTA Int 2021; 4:e150. [PMID: 34765900 PMCID: PMC8575420 DOI: 10.1097/oi9.0000000000000150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/10/2021] [Indexed: 12/21/2022]
Abstract
Objectives: To compare inpatient compliance with venous thromboembolism prophylaxis regimens. Design: A secondary analysis of patients enrolled in the ADAPT (A Different Approach to Preventing Thrombosis) randomized controlled trial. Setting: Level I trauma center. Patients/Participants: Patients with operative extremity or any pelvic or acetabular fracture requiring venous thromboembolism prophylaxis. Intervention: We compared patients randomized to receive either low molecular weight heparin (LMWH) 30 mg or aspirin 81 mg BID during their inpatient admission. Main Outcome Measurements: The primary outcome measure was the number of doses missed compared with prescribed number of doses. Results: A total of 329 patients were randomized to receive either LMWH 30 mg BID (164 patients) or aspirin 81 mg BID (165 patients). No differences observed in percentage of patients who missed a dose (aspirin: 41.2% vs LMWH: 43.3%, P = .7) or mean number of missed doses (0.6 vs 0.7 doses, P = .4). The majority of patients (57.8%, n = 190) did not miss any doses. Missed doses were often associated with an operation. Conclusions: These data should reassure clinicians that inpatient compliance is similar for low molecular weight heparin and aspirin regimens.
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Dhillon NK, Hashim YM, Conde G, Phillips G, Fierro NM, Yong F, Berezin N, Ley EJ. Early Propranolol Is Associated With Lower Risk of Venous Thromboembolism After Traumatic Brain Injury. Am Surg 2021; 87:1556-1560. [PMID: 34704840 DOI: 10.1177/00031348211051693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) results in an elaborate systemic cascade of secondary injury elicited in part by an intrinsic catecholamine response, which ultimately leads to changes in inflammation and coagulopathy. Attenuation of this catecholamine response with agents such as propranolol confers a survival advantage. The related impact of propranolol on venous thromboembolism (VTE) after TBI is largely unknown. STUDY DESIGN A single institution retrospective review was conducted of all TBI patients requiring intensive care unit (ICU) admission with an injury severity scale (ISS) ≥ 25 from January 2013 to May 2015. Patients who received at least one dose of propranolol within 24 hours of admission (PROP) were compared to patients who did not receive any doses of propranolol (NPROP) during their hospitalization. RESULTS Of the 131 patients analyzed, 31 (23.7%) patients received propranolol. The PROP cohort was more severely injured overall (ISS 29 vs 26.5, P = .02). While unadjusted VTE rates were similar (16.1% vs 19.0%, P = .72), the adjusted VTE rate was lower in the PROP cohort (AOR 0.20 (95% CI 0.04-0.97), adjusted P-value < .05). CONCLUSION Propranolol use in TBI patients who have sustained critical injuries may mitigate the risk of VTE. The mechanism by which this outcome is achieved requires further investigation.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Division of Trauma and Critical Care, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yassar M Hashim
- Department of Surgery, Division of Trauma and Critical Care, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Geena Conde
- Department of Surgery, Division of Trauma and Critical Care, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - George Phillips
- Department of Surgery, Division of Trauma and Critical Care, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nicole M Fierro
- Department of Surgery, Division of Trauma and Critical Care, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Felix Yong
- Department of Surgery, Division of Trauma and Critical Care, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Naomi Berezin
- Department of Surgery, Division of Trauma and Critical Care, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Accuracy of the WSES classification system for pelvic ring disruptions: an international validation study. World J Emerg Surg 2021; 16:54. [PMID: 34656156 PMCID: PMC8520313 DOI: 10.1186/s13017-021-00399-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
Abstract
Background In 2017, a novel classification for pelvic injuries was established by the World Society of Emergency Surgery (WSES). We validated its effectiveness using nationwide real-world data. The roles of associated vascular injury and open fracture in this system were also evaluated. Methods Patients with pelvic fractures in the National Trauma Data Bank 2015 dataset were retrospectively studied. First, the mortality rates were compared by WSES classification. Second, independent predictors of mortality were evaluated using a multivariate logistic regression model. Patients with and without associated vascular injuries and the same hemodynamic and pelvic ring stability statuses were compared. Patients with associated vascular injuries were compared to the proportion of nonsurvivors and survivors with unstable pelvic ring injuries. Third, the outcomes were compared between patients with open pelvic fracture and closed pelvic fracture in the mild, moderate and severe WSES classes. Results During the 12-month study period, 44,163 blunt pelvic fracture patients were included. The mortality rates were 1.8%, 3.8% and 10.6% for the mild, moderate and severe WSES classes, respectively (p < 0.001). MLR analysis showed that unstable pelvic ring injury did not significantly affect mortality (p = 0.549), whereas open pelvic fracture and associated vascular injury were independent predictors of mortality (odds of mortality: open pelvic fracture 1.630, p < 0.001; associated vascular injury 1.602, p < 0.001). Patients with associated vascular injuries showed that there was no significant difference in the proportion of patients with unstable pelvic ring injuries between survivors and nonsurvivors (37.2% vs. 32.7%, p = 0.323). In all three classes, patients with open pelvic fractures had significantly higher mortality rates and infection rates than patients with closed fractures (mortality rates: minor 3.5% vs. 1.8%, p = 0.009, moderate 11.2% vs. 3.3%, p < 0.001, severe 23.8% vs. 9.8%, p < 0.001; infection rates: minor 3.3% vs. 0.7%, p < 0.001, moderate 6.7% vs. 2.1%, p < 0.001, severe 7.9% vs. 2.8%, p < 0.001). Conclusions Based on this nationwide study, the WSES guideline provides an accurate and reproducible classification of pelvic fractures. It is recommended that open/closed fractures and associated vascular injuries be evaluated as supplements of the WSES classification.
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Venous Thromboembolism Chemoprophylaxis in Trauma and Emergency General Surgery Patients: A Systematic Review. J Trauma Nurs 2021; 28:323-331. [PMID: 34491950 DOI: 10.1097/jtn.0000000000000606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Appropriate venous thromboembolism (VTE) chemoprophylaxis in trauma and emergency general surgery (EGS) patients is crucial. OBJECTIVE The purpose of this study is to review the recent literature and offer recommendations for VTE chemoprophylaxis in trauma and EGS patients. METHODS We conducted a literature search from 2000 to 2021 for articles investigating VTE chemoprophylaxis in adult trauma and EGS patients. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. RESULTS Our search resulted in 34 articles. Most studies showed low-molecular-weight heparin (LMWH) is similar to unfractionated heparin (UFH) for VTE prevention; however, LMWH was more commonly used. Adjusted chemoprophylaxis dosing did not change the VTE rate but the timing did. Direct oral anticoagulants (DOACs) have been shown to be safe and effective in trauma and traumatic brain injury (TBI)/spinal cord injury (SCI). Studies showed VTE prophylaxis in EGS can be inconsistent and improves with guidelines that lower VTE events. CONCLUSIONS There may be no benefit to receiving LMWH over UFH in trauma patients. In addition, different drugs under the class of LMWH do not change the incidence of VTE. Adjusted dosing of enoxaparin does not seem to affect VTE incidence. The use of DOACs in the trauma TBI and SCI setting has been shown to be safe and effective in reducing VTE. One important consideration with VTE prophylaxis may be the timing of prophylaxis initiation, specifically as it relates to TBI, with a higher likelihood of developing VTE as time progresses. EGS patients are at a high risk of VTE. Improved compliance with clinical guidelines in this population is correlated with decreased thrombotic events.
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Jakob DA, Benjamin ER, Recinos G, Cremonini C, Lewis M, Demetriades D. Venous thromboembolic pharmacological prophylaxis in severe traumatic acute subdural hematomas: Early prophylaxis is effective and safe. Am J Surg 2021; 223:1004-1009. [PMID: 34364655 DOI: 10.1016/j.amjsurg.2021.07.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Dominik A Jakob
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Elizabeth R Benjamin
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Gustavo Recinos
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Camilla Cremonini
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Meghan Lewis
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Demetrios Demetriades
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
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Fu CY, Bajani F, Bokhari M, Wang SH, Cheng CT, Mis J, Poulakidas S, Bokhari F. How long of a postponement in surgery can a blunt hollow viscus injury patient tolerate? A retrospective study from the National Trauma Data Bank. Surgery 2021; 171:526-532. [PMID: 34266649 DOI: 10.1016/j.surg.2021.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 06/02/2021] [Accepted: 06/15/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND In the management of patients with blunt abdominal trauma, delayed diagnosis and treatment of hollow viscus injury can occur. We assessed the effect of the time to surgery on the outcomes of blunt hollow viscus injury patients. METHODS The National Trauma Data Bank was queried from 2012 to 2015 to identify patients with blunt hollow viscus injury for inclusion. Patients with unstable hemodynamics, concomitant intra-abdominal organ injuries, or other severe extra-abdominal injuries were excluded. Inverse probability of treatment weighting and multivariate logistic regression were used to evaluate the effect of the time to surgery on the outcomes. RESULTS In total, 2,997 patients with blunt hollow viscus injury were studied; the mean time to abdominal surgery was 6.7 hours. Twenty-two hours was selected as a cutoff value for further analyses because of an observed transition zone at that time in the distribution of mortality and severe sepsis rates. After adjustment, patients who underwent surgery within 22 hours had a significantly lower mortality rate (1.2% vs 4.2%), lower sepsis rate (0.9% vs 4.5%), shorter hospital length of stay (8.7 vs 12.0 days), and shorter intensive care unit length of stay (1.4 vs 3.3 days). In patients who underwent surgery within 22 hours, neither mortality nor sepsis were affected significantly by the time to surgery. CONCLUSION In the management of patients with blunt hollow viscus injury, early surgical treatment is needed. Patients with isolated blunt hollow viscus injury may have a poor outcome if they undergo abdominal surgery more than 22 hours after arrival in the emergency department.
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Affiliation(s)
- Chih-Yuan Fu
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, IL; Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan. https://twitter.com/PeterFu24437602
| | - Francesco Bajani
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, IL
| | - Marissa Bokhari
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, IL
| | - Szu-Han Wang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan; Institute of Biomedical Informatics, National Yang-Ming University, Taipei, Taiwan.
| | - Justin Mis
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, IL
| | - Stathis Poulakidas
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, IL
| | - Faran Bokhari
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, Chicago, IL
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Hamilton J, Cocco A, Shakerian R, Wu M, Wang J, Gumm K, Read DJ. Venous thromboembolism prophylaxis practices and outcomes at an Australian level-one trauma service. TRAUMA-ENGLAND 2021. [DOI: 10.1177/14604086211019535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major cause of potentially preventable morbidity and mortality amongst trauma patients. Venous thromboembolism prevalence varies from 1 to 58%, and traditionally, compliance with prophylaxis protocols is low in major trauma cohorts. This study aimed to describe VTE prevalence, prophylaxis practices and outcomes amongst VTE cases at an Australian level-one trauma centre. Methods A retrospective review of all VTE cases occurring in acute, major trauma admissions between 1 January 2010 and 30 June 2019 was conducted using prospectively collected registry data. Data regarding demographics, time to diagnosis, VTE prophylaxis, VTE risk assessment tool (RAT) usage and all-cause mortality were collected. Chemoprophylaxis was considered adequate if administered for 48 h prior to diagnosis. VTE cases diagnosed within 48 h of admission were excluded from prophylaxis compliance analysis. A subgroup analysis of patients with intracranial haemorrhage (ICH) was also completed. Results During the study period, 238 VTE events occurred in 237 patients from 7482 major trauma admissions, giving a VTE prevalence of 3.18%. The all-cause mortality rate was 8.0%. VTE chemoprophylaxis was administered for 109 of 211 eligible patients (51.7%). Of the remaining 102 VTE cases, 75 (73.5%) did not receive prophylaxis due to a documented contraindication, while 27 (26.5%) did not receive prophylaxis with no contraindication recorded. The VTE RAT was completed in 49.0% of cases. Conclusion Venous thromboembolism prevalence at our institution was consistent with published figures for comparable institutions. A review of compliance with prophylaxis protocols showed several potential areas for improvement.
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Affiliation(s)
- Jordan Hamilton
- Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Annelise Cocco
- Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rose Shakerian
- Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Michael Wu
- Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jennifer Wang
- Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kellie Gumm
- Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David J Read
- Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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