Treatment of acute deep vein thrombosis in spinal cord injured patients with enoxaparin: a cost analysis

Venous thromboembolism after spinal cord injury

OBJECTIVE

To review systematically the published literature on the treatment of deep venous thromboembolism after spinal cord injury (SCI).

DATA SOURCES

MEDLINE/PubMed, CINAHL, EMBASE, and PsycINFO databases were searched for articles addressing the treatment of deep venous thromboembolism post-SCI. Randomized controlled trials (RCTs) were assessed for methodologic quality using the Physiotherapy Evidence Database Scale, while non-RCTs were assessed using the Downs and Black evaluation tool.

STUDY SELECTION

Studies included RCTs, non-RCTS, cohort, case-control, case series, pre-post, and postinterventional studies. Case studies were included only when no other studies were available.

DATA EXTRACTION

Data extracted included demographics, the nature of the study intervention, and study results.

DATA SYNTHESIS

Levels of evidence were assigned to the interventions using a modified Sackett scale.

CONCLUSIONS

Twenty-three studies met inclusion criteria. Thirteen studies examined various pharmacologic interventions for the treatment or prevention of deep venous thrombosis in patients with SCI. There was strong evidence to support the use of low-molecular-weight heparin in reducing venous thrombosis events, and a higher adjusted dose of unfractionated heparin was found to be more effective than 5000 units administered every 12 hours, although bleeding complications were more common. Nonpharmacologic treatments were also reviewed, but again limited evidence was found to support these treatments.

Prophylaxis of thromboembolism in spinal injuries--survey of practice in spinal units in the British Isles

AIM

Survey and discussion of the current thromboembolic prophylaxis practice in spinal injury units within the British Isles.

BACKGROUND

Deep vein thrombosis and pulmonary embolism are major causes of morbidity and mortality in patients with spinal injuries. A wide range of thromboprophylactic measures have been proposed. The optimum treatment and duration for thromboprophylaxis in spinal injuries is unknown. Different spinal units within the British Isles use different measures despite similar training backgrounds. The present study was performed to review practice and make suggestions on best practice using literature review.

METHODS

All the 13 regional and national spinal injury referral centres within the British Isles were contacted to find out their protocols for thromboembolic prophylaxis in patients with acute spinal injuries.

RESULTS

All units replied. A wide variation in methods used was found in different spinal units ranging from no chemical prophylaxis to oral anticoagulation with warfarin and contrasting views on the use of antithromboembolic stockings.

CONCLUSION

All units recognised the risk of thromboembolism after spinal injuries. A wide variety of thromboprophylactic measures are used.

Deep venous thrombosis and thromboembolism in patients with cervical spinal cord injuries

STANDARDS

Prophylactic treatment of thromboembolism in patients with severe motor deficits due to spinal cord injury is recommended. The use of low-molecular-weight heparins, rotating beds, adjusted dose heparin, or a combination of modalities is recommended as a prophylactic treatment strategy. Low-dose heparin in combination with pneumatic compression stockings or electrical stimulation is recommended as a prophylactic treatment strategy.

GUIDELINES

Low-dose heparin therapy alone is not recommended as a prophylactic treatment strategy. Oral anticoagulation alone is not recommended as a prophylactic treatment strategy.

OPTIONS

Duplex Doppler ultrasound, impedance plethysmography, and venography are recommended for use as diagnostic tests for deep venous thrombosis in the spinal cord-injured patient population. A 3-month duration of prophylactic treatment for deep venous thrombosis and pulmonary embolism is recommended. Vena cava filters are recommended for patients who do not respond to anticoagulation or who are not candidates for anticoagulation therapy and/or mechanical devices.

Prophylaxis of thromboembolism in spinal injuries--results of enoxaparin used in 276 patients

OBJECTIVE

To evaluate the results of thromboembolic prophylaxis using enoxaparin in acute spinal injury patients.

BACKGROUND

Deep vein thrombosis and pulmonary embolism are major causes of morbidity and mortality in patients with acute spinal injuries. A wide range of thromboprophylactic measures have been proposed. The present study describes the outcome of a regime of enoxaparin and antithromboembolic stockings in acute spinal injuries irrespective of neurological damage.

SETTING

Scotland, UK.

METHODS

Eighteen-month retrospective review of acute spinal injury patients admitted to a national spinal injuries unit. A thromboembolic prophylactic regimen of early mobilisation, use of antithromboembolic stockings, and subcutaneous administration of enoxaparin 40 mg once a day until patients could be mobilised for more than 4 h per day, was used. Patients with clinical suspicion of deep venous thrombosis or pulmonary embolism were investigated as appropriate.

RESULTS

Out of 146 (53% of total) patients with spinal injuries with no neurological deficit only one patient (0.4%) developed clinical evidence of pulmonary embolism and out of 130 (47% of total) with spinal cord injury two (0.7%) developed clinical evidence of deep venous thrombosis while still on enoxaparin. Four patients (1.5%) developed deep venous thrombosis and one (0.4%) pulmonary embolism after discontinuing enoxaparin. There were no fatal pulmonary emboli and one suspected intraspinal bleeding.

CONCLUSIONS

The present study suggests that, in addition to physical and mechanical measures, low molecular weight heparin in the form of enoxaparin 40 mg administered once daily compares favourably with previous studies for thromboprophylaxis in acute spinal injuries.