1
|
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.
Collapse
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
| |
Collapse
|
2
|
Jiang W, Yan Y, Huang T, Lin Z, Yang X, Luo Z, Ye L. Efficacy and safety of aspirin in venous thromboembolism prevention after total hip arthroplasty, total knee arthroplasty or fracture. VASA 2024. [PMID: 39052442 DOI: 10.1024/0301-1526/a001129] [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: 07/27/2024]
Abstract
Background: This study aims to analyse the efficacy and safety of aspirin in the prevention of venous thromboembolism (VTE) for patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA) or fracture. Patients and methods: Two independent investigators searched PubMed, Embase, Cochrane and ClinicalTrials.gov from January 2000 to June 2023 to retrieve randomized control trials (RCTs) about aspirin in VTE prevention after arthroplasty or fracture. Then, the relative risk (RR) was utilized to evaluate its efficiency and safety. Results: A total of 16 RCTs with 27,864 patients were included. There was no statistical difference in the incidence of deep-vein thrombosis (RR: 1.31, p = 0.100), pulmonary embolism (RR:1.05, p = 0.850), VTE (RR:1.28, p = 0.290), major bleeding (RR:0.96, p = 0.900), and death (RR:1.01, p = 0.960) between the aspirin group and the anticoagulants group. Subgroup analysis showed that a relatively higher incidence of deep-vein thrombosis in patients undergoing TKA (RR:1.49, p = 0.030), fracture (RR:1.48, p = 0.001), patients receiving 81 mg aspirin twice daily (RR:1.48, p = 0.001) and patients from North America (RR:1.57, p<0.001) when comparing aspirin with anticoagulants. Meanwhile, the incidence of VTE was higher in patients receiving 100 mg aspirin once daily (RR:1.82, p<0.001) compared with anticoagulants. Additionally, the incidence of all bleeding (RR:2.00, p = 0.030) was higher in patients receiving aspirin in Asia compared with anticoagulants. Conclusions: In terms of clinical effectiveness and safety, aspirin (antiplatelet agent) was generally not inferior to anticoagulants in the prevention of VTE after THA, TKA, or fracture. Notably, the clinical effectiveness of aspirin was affected by different surgical types, the doses of aspirin and races.
Collapse
Affiliation(s)
- Wei Jiang
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, Zhejiang, China
| | - Yici Yan
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Tongmin Huang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zhenyi Lin
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xinyan Yang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zhouqing Luo
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Lin Ye
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, Zhejiang, China
| |
Collapse
|
3
|
Kobzeva-Herzog AJ, Smith SM, Counihan DR, Kain MS, Richman AP, Scantling DR, Saillant NN, Sanchez SE, Torres CM. Timing of venous thromboembolism prophylaxis initiation and complications in polytrauma patients with high-risk bleeding orthopedic interventions: A nationwide analysis. J Trauma Acute Care Surg 2024; 97:96-104. [PMID: 38548689 DOI: 10.1097/ta.0000000000004331] [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: 06/26/2024]
Abstract
INTRODUCTION There are no clear recommendations for the perioperative timing and initiation of venous thromboembolism pharmacologic prophylaxis (VTEp) among polytrauma patients undergoing high-risk bleeding orthopedic operative intervention, leading to variations in VTEp administration. Our study examined the association between the timing of VTEp and VTE complications in polytrauma patients undergoing high-risk operative orthopedic interventions nationwide. METHODS We performed a retrospective cohort study of trauma patients 18 years or older who underwent high-risk bleeding operative orthopedic interventions for pelvic, hip, and femur fractures within 24 hours of admission at American College of Surgeons-verified trauma centers using the 2019-2020 American College of Surgeons Trauma Quality Improvement Program databank. We excluded patients with a competing risk of nonorthopedic surgical bleeding. We assessed operative orthopedic polytrauma patients who received VTEp within 12 hours of orthopedic surgical intervention compared with VTEp received beyond 12 hours of intervention. The primary outcome assessed was overall VTE events. Secondary outcomes were orthopedic reinterventions within 72 hours after primary orthopedic surgery, deep venous thromboembolism, and pulmonary embolism rates. RESULTS The study included 2,229 patients who underwent high-risk orthopedic operative intervention. The median time to VTEp initiation was 30 hours (interquartile range, 18-44 hours). After adjustment for baseline patient, injury, and hospital characteristics, VTEp initiated more than 12 hours from primary orthopedic surgery was associated with increased odds of VTE (adjusted odds ratio, 2.02; 95% confidence interval, 1.08-3.77). Earlier initiation of prophylaxis was not associated with an increased risk for surgical reintervention (hazard ratio, 0.90; 95% confidence interval, 0.62-1.34). CONCLUSION Administering VTEp within 24 hours of admission and within 12 hours of major orthopedic surgery involving the femur, pelvis, or hip demonstrated an associated decreased risk of in-hospital VTE without an accompanying elevated risk of bleeding-related orthopedic reintervention. Clinicians should reconsider delays in initiating or withholding perioperative VTEp for stable polytrauma patients needing major orthopedic intervention. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
Collapse
Affiliation(s)
- Anna J Kobzeva-Herzog
- From the Department of Surgery (A.J.K.-H., S.M.S., D.R.C., A.P.R., D.S., N.N.S., S.E.S., C.M.T.), and Department of Orthopedic Surgery (M.S.K.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Visconti L, Celi A, Carrozzi L, Tinelli C, Crocetti L, Daviddi F, De Caterina R, Madonna R, Pancani R. Inferior vena cava filters: Concept review and summary of current guidelines. Vascul Pharmacol 2024; 155:107375. [PMID: 38663572 DOI: 10.1016/j.vph.2024.107375] [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: 02/29/2024] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/05/2024]
Abstract
Anticoagulation is the first-line approach in the prevention and treatment of pulmonary embolism. In some instances, however, anticoagulation fails, or cannot be administered due to a high risk of bleeding. Inferior vena cava filters are metal alloy devices that mechanically trap emboli from the deep leg veins halting their transit to the pulmonary circulation, thus providing a mechanical alternative to anticoagulation in such conditions. The Greenfield filter was developed in 1973 and was later perfected to a model that could be inserted percutaneously. Since then, this model has been the reference standard. The current class I indication for this device includes absolute contraindication to anticoagulants in the presence of acute thromboembolism and recurrent thromboembolism despite adequate therapy. Additional indications have been more recently proposed, due to the development of removable filters and of progressively less invasive techniques. Although the use of inferior vena cava filters has solid theoretical advantages, clinical efficacy and adverse event profile are still unclear. This review analyzes the most important studies related to such devices, open issues, and current guideline recommendations.
Collapse
Affiliation(s)
- Luca Visconti
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Pulmonary Unit, Ospedale "Sacro Cuore di Gesù" Gallipoli, Azienda Sanitaria Locale Lecce, Italy
| | - Alessandro Celi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
| | - Laura Carrozzi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Camilla Tinelli
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Laura Crocetti
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Interventional Radiology Unit, University of Pisa, Pisa, Italy
| | - Francesco Daviddi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Interventional Radiology Unit, University of Pisa, Pisa, Italy
| | - Raffaele De Caterina
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Cardiology Unit, Cardio-Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Rosalinda Madonna
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Cardiology Unit, Cardio-Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Roberta Pancani
- Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| |
Collapse
|
5
|
Berndtson AE, Cross A, Yorkgitis BK, Kennedy R, Kochuba MP, Tignanelli C, Tominaga GT, Jacobs DG, Ashley DW, Ley EJ, Napolitano L, Costantini TW. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for postdischarge venous thromboembolism prophylaxis after trauma. J Trauma Acute Care Surg 2024; 96:980-985. [PMID: 38523134 DOI: 10.1097/ta.0000000000004307] [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: 03/26/2024]
Abstract
ABSTRACT Trauma patients are at an elevated risk for developing venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis. In the inpatient setting, prompt pharmacologic prophylaxis is utilized to prevent VTE. For patients with lower extremity fractures or limited mobility, VTE risk does not return to baseline levels postdischarge. Currently, there are limited data to guide postdischarge VTE prophylaxis in trauma patients. The goal of these postdischarge VTE prophylaxis guidelines are to identify patients at the highest risk of developing VTE after discharge and to offer pharmacologic prophylaxis strategies to limit this risk.
Collapse
Affiliation(s)
- Allison E Berndtson
- From the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (A.E.B., T.W.C.), UC San Diego School of Medicine, San Diego, California; University of Oklahoma Health Science Center (A.C.), Oklahoma City, Oklahoma; Division of Acute Care Surgery, Department of Surgery (B.K.Y., M.P.K.), University of Florida-Jacksonville, Jacksonville, Florida; Department of Surgery (R.K.), Baylor University Medical Center, Dallas, Texas; Department of Surgery (C.T.), University of Minnesota, Minneapolis, Minnesota; Trauma Services (G.T.T.), Scripps Memorial Hospital La Jolla, La Jolla, California; Division of Acute Care Surgery, Department of Surgery (D.G.J.), Atrium Health-Carolinas Medical Center, Charlotte, North Carolina; Mercer University School of Medicine (D.W.A.), Atrium Health Navicent, Macon, Georgia; Cedars-Sinai Medical Center (E.J.L.), Los Angeles, California; and Trauma and Surgical Critical Care, Department of Surgery (L.N.), University of Michigan Health System, Ann Arbor, Michigan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Haac BE, O'Hara NN, Haut ER, Manson TT, Slobogean GP, O'Toole RV, Stein DM. Venous thromboembolism testing practices after orthopaedic trauma: prophylaxis regimen does not influence testing patterns. OTA Int 2024; 7:e331. [PMID: 38623266 PMCID: PMC11013691 DOI: 10.1097/oi9.0000000000000331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 01/17/2024] [Accepted: 02/01/2024] [Indexed: 04/17/2024]
Abstract
Objectives To determine venous thromboembolism (VTE) testing patterns in an orthopaedic trauma population and to evaluate for differences in VTE surveillance by prophylaxis regimen through a secondary analysis of the ADAPT trial. Design Prospective randomized trial. Setting Level I trauma center. Patients Three hundred twenty-nine adult (18 years and older) trauma patients presenting with an operative extremity fracture proximal to the metatarsals/carpals or any pelvic or acetabular fracture requiring VTE prophylaxis. Intervention VTE imaging studies recorded within 90 days post injury. Main Outcome Measurements Percentage of patients tested for VTE were compared between treatment groups using Fisher's exact test. Subsequently, multivariable regression was used to determine patient factors significantly associated with risk of receiving a VTE imaging study. Results Sixty-seven patients (20.4%) had VTE tests ordered during the study period. Twenty (29.9%) of these 67 patients with ordered VTE imaging tests had a positive finding. No difference in proportion of patients tested for VTE by prophylaxis regimen (18.8% on aspirin vs. 22.0% on LMWH, P = 0.50) was observed. Factors associated with increased likelihood of VTE testing included White race (adjusted odds ratio [aOR]: 2.61, 95% CI: 1.26-5.42), increased Injury Severity Score (aOR for every 1-point increase: 1.10, 95% CI: 1.05-1.15), and lower socioeconomic status based on the Area Deprivation Index (aOR for every 10-point increase: 1.14, 95% CI: 1.00-1.30). Conclusions VTE surveillance did not significantly differ by prophylaxis regimen. Patient demographic factors including race, injury severity, and socioeconomic status were associated with differences in VTE surveillance. Level of Evidence Level I, Therapeutic.
Collapse
Affiliation(s)
- Bryce E. Haac
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Nathan N. O'Hara
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Elliott R. Haut
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Theodore T. Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Gerard P. Slobogean
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Robert V. O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Deborah M. Stein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
7
|
De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [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: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
Collapse
Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
| |
Collapse
|
8
|
Pugliese ME, Battaglia R, Ursino M, Lucca LF, Quintieri M, Vatrano M, Tonin P, Cerasa A. Prevalence and Risk Factors of Deep Venous Thrombosis in Intensive Inpatient Neurorehabilitation Unit. Healthcare (Basel) 2024; 12:936. [PMID: 38727493 PMCID: PMC11082945 DOI: 10.3390/healthcare12090936] [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: 02/21/2024] [Revised: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Venous thromboembolism (VTE) (deep vein thrombosis and its complication, pulmonary embolism) is a major cause of morbidity and mortality in hospitalized patients and about 7% of these cases are due to immobility secondary to a neurological impairment. Acquired brain injury (ABI) has also been recognized as one of the main risk factors for VTE. Numerous epidemiological studies have been conducted to assess the risk factors for VTE in institutionalized polytrauma patients, although there is a lack of information about neurorehabilitation wards. Since VTE is often undiagnosed, this prospective study aimed to determine the prevalence and clinical characteristics of lower-limb deep venous thrombosis (DVT) in ABI patients at neurorehabilitation admission. METHODS ABI patients were screened for DVT on admission to the intensive rehabilitation unit (IRU) with compression ultrasonography and basal D-dimer assay and were daily clinically monitored until discharge. A total of 127 consecutive ABI patients (mean age: 60.1 ± 17.6 years; 63% male; time from event: 30.9 ± 22.1 days; rehabilitation time in IRU: 84.6 ± 58.4 days) were enrolled. RESULTS On admission to the IRU, the DVT prevalence was about 8.6%. The mean D-dimer level in patients with DVT was significantly higher than in patients without DVT (6 ± 0.9 vs. 1.97 ± 1.61, p-value = 0.0001). ABI patients with DVT did not show any significant clinical characteristics with respect to ABI without DVT, although a prevalence of hemorrhagic strokes and patients originating from the Intensive Care Unit and Neurosurgery ward was revealed. During the rehabilitation period, patients with DVT showed a significant difference in pharmacological DVT prophylaxis (high prevalence of nadroparin with 27.3% vs. 1.7%, p-value = 0.04) and a prevalence of transfers in critical awards (36% versus 9.5% of patients without DVT, p-value = 0.05). The mortality rate was similar in the two groups. CONCLUSIONS Our research offers a more comprehensive view of the clinical development of DVT patients and confirms the prevalence rate of DVT in ABI patients as determined upon IRU admission. According to our findings, screening these individuals regularly at the time of rehabilitation admission may help identify asymptomatic DVT quickly and initiate the proper treatment to avoid potentially fatal consequences. However, to avoid time-consuming general ultrasonography observation, a more precise selection of patients entering the rehabilitation ward is required.
Collapse
Affiliation(s)
- Maria Elena Pugliese
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Riccardo Battaglia
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Maria Ursino
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Lucia Francesca Lucca
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Maria Quintieri
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Martina Vatrano
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Paolo Tonin
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Antonio Cerasa
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy, 98164 Messina, Italy
- Pharmacotechnology Documentation and Transfer Unit, Preclinical and Translational Pharmacology, Department of Pharmacy, Health Science and Nutrition, University of Calabria, 87036 Rende, Italy
| |
Collapse
|
9
|
O'Hara NN, Frey KP, Stein DM, Levy JF, Slobogean GP, Castillo R, Firoozabadi R, Karunakar MA, Gary JL, Obremskey WT, Seymour RB, Cuschieri J, Mullins CD, O'Toole RV. Effect of Aspirin Versus Low-Molecular-Weight Heparin Thromboprophylaxis on Medication Satisfaction and Out-of-Pocket Costs: A Secondary Analysis of a Randomized Clinical Trial. J Bone Joint Surg Am 2024; 106:590-599. [PMID: 38381842 PMCID: PMC10980176 DOI: 10.2106/jbjs.23.00824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Current guidelines recommend low-molecular-weight heparin for thromboprophylaxis after orthopaedic trauma. However, recent evidence suggests that aspirin is similar in efficacy and safety. To understand patients' experiences with these medications, we compared patients' satisfaction and out-of-pocket costs after thromboprophylaxis with aspirin versus low-molecular-weight heparin. METHODS This study was a secondary analysis of the PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT) trial, conducted at 21 trauma centers in the U.S. and Canada. We included adult patients with an operatively treated extremity fracture or a pelvic or acetabular fracture. Patients were randomly assigned to receive 30 mg of low-molecular-weight heparin (enoxaparin) twice daily or 81 mg of aspirin twice daily for thromboprophylaxis. The duration of the thromboprophylaxis, including post-discharge prescription, was based on hospital protocols. The study outcomes included patient satisfaction with and out-of-pocket costs for their thromboprophylactic medication measured on ordinal scales. RESULTS The trial enrolled 12,211 patients (mean age and standard deviation [SD], 45 ± 18 years; 62% male), 9725 of whom completed the question regarding their satisfaction with the medication and 6723 of whom reported their out-of-pocket costs. The odds of greater satisfaction were 2.6 times higher for patients assigned to aspirin than those assigned to low-molecular-weight heparin (odds ratio [OR]: 2.59; 95% confidence interval [CI]: 2.39 to 2.80; p < 0.001). Overall, the odds of incurring any out-of-pocket costs for thromboprophylaxis medication were 51% higher for patients assigned to aspirin compared with low-molecular-weight heparin (OR: 1.51; 95% CI: 1.37 to 1.66; p < 0.001). However, patients assigned to aspirin had substantially lower odds of out-of-pocket costs of at least $25 (OR: 0.15; 95% CI: 0.12 to 0.18; p < 0.001). CONCLUSIONS Use of aspirin substantially improved patients' satisfaction with their medication after orthopaedic trauma. While aspirin use increased the odds of incurring any out-of-pocket costs, it protected against costs of ≥$25, potentially improving health equity for thromboprophylaxis. LEVEL OF EVIDENCE Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Nathan N O'Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Katherine P Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Deborah M Stein
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gerard P Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Renan Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Madhav A Karunakar
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Joseph Cuschieri
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - C Daniel Mullins
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
10
|
Chanas T, Gibson G, Langenstroer E, Herrmann DJ, Carver TW, Alexander K, Chui SHJ, Rein L, Ha M, Maynard KM, Bamberg K, O'Keefe M, O'Brien M, Gonzalez MC, Hobbs B, Pajoumand M, Peppard WJ. Multicenter study evaluating target attainment of anti-Factor Xa levels using various enoxaparin prophylactic dosing practices in adult trauma patients. Pharmacotherapy 2024; 44:258-267. [PMID: 38148134 DOI: 10.1002/phar.2904] [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: 08/08/2023] [Revised: 11/08/2023] [Accepted: 12/05/2023] [Indexed: 12/28/2023]
Abstract
STUDY OBJECTIVE Enoxaparin is standard of care for venous thromboembolism (VTE) prophylaxis in adult trauma patients, but fixed-dose protocols are suboptimal. Dosing based on body mass index (BMI) or total body weight (TBW) improves target prophylactic anti-Xa level attainment and reduces VTE rates. A novel strategy using estimated blood volume (EBV) may be more effective based on results of a single-center study. This study compared BMI-, TBW-, EBV-based, and hybrid enoxaparin dosing strategies at achieving target prophylactic anti-Factor Xa (anti-Xa) levels in trauma patients. DESIGN Multicenter, retrospective review. DATA SOURCE Electronic health records from participating institutions. PATIENTS Adult trauma patients who received enoxaparin twice daily for VTE prophylaxis and had at least one appropriately timed anti-Xa level (collected 3 to 6 hours after the previous dose after three consecutive doses) from January 2017 through December 2020. Patients were excluded if the hospital-specific dosing protocol was not followed or if they had thermal burns with > 20% body surface area involvement. INTERVENTION Dosing strategy used to determine initial prophylactic dose of enoxaparin. MEASUREMENTS The primary end point was percentage of patients with peak anti-Xa levels within the target prophylactic range (0.2-0.4 units/mL). MAIN RESULTS Nine hospitals enrolled 742 unique patients. The most common dosing strategy was based on BMI (43.0%), followed by EBV (29.0%). Patients dosed using EBV had the highest percentage of target anti-Xa levels (72.1%). Multiple logistic regression demonstrated EBV-based dosing was significantly more likely to yield anti-Xa levels at or above target compared to BMI-based dosing (adjusted odds ratio (aOR) 3.59, 95% confidence interval (CI) 2.29-5.62, p < 0.001). EBV-based dosing was also more likely than hybrid dosing to yield an anti-Xa level at or above target (aOR 2.30, 95% CI 1.33-3.98, p = 0.003). Other pairwise comparisons between dosing strategy groups were nonsignificant. CONCLUSIONS An EBV-based dosing strategy was associated with higher odds of achieving anti-Xa level within target range for enoxaparin VTE prophylaxis compared to BMI-based dosing and may be a preferred method for VTE prophylaxis in adult trauma patients.
Collapse
Affiliation(s)
- Tyler Chanas
- ECU Health Medical Center, Greenville, North Carolina, USA
| | | | | | - David J Herrmann
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Thomas W Carver
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kaitlin Alexander
- University of Florida College of Pharmacy, Gainesville, Florida, USA
| | | | - Lisa Rein
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael Ha
- UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Kaylee M Maynard
- University of Rochester Medical Center, Rochester, New York, USA
| | | | - Mary O'Keefe
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marisa O'Brien
- UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | | | - Brandon Hobbs
- Orlando Regional Medical Center, Orlando, Florida, USA
| | | | - William J Peppard
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
11
|
Zhang D, Yang Y, Yi Y, Wang D, Jiang L, Huang H, Jin L, Meng H, Xia F, Guo G. Incidence and influence factors of venous thromboembolism in traumatic rib fracture patient: a multicenter study. J Orthop Surg Res 2024; 19:152. [PMID: 38395963 PMCID: PMC10893601 DOI: 10.1186/s13018-024-04622-1] [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: 11/01/2023] [Accepted: 02/11/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND This study aimed to determine the incidence and influencing factors of venous thromboembolism (VTE) in patients with traumatic rib fractures. METHODS The retrospective study analyzed medical records of patients with traumatic rib fractures from 33 hospitals. RESULTS The overall incidence of VTE in hospitalized patients with traumatic rib fractures was 8.1%. Patients with isolated traumatic rib fractures had a significantly lower incidence of VTE (4.4%) compared to patients with rib fractures combined with other injuries (12.0%). Multivariate analysis identified the number of rib fractures as an independent risk factor for thrombosis. Surgical stabilization of isolated rib fractures involving three or more ribs was associated with a lower VTE incidence compared to conservative treatment. CONCLUSIONS Patients with rib fractures have a higher incidence of VTE, positively correlated with the number of rib fractures. However, the occurrence of thrombosis is relatively low in isolated rib fractures. Targeted thromboprophylaxis strategies should be implemented for these patients, and surgical stabilization of rib fractures may be beneficial in reducing the risk of VTE.
Collapse
Affiliation(s)
- Dongsheng Zhang
- Department of Cardiothoracic Surgery, Shijiazhuang Third Hospital, Shijiazhuang, 050000, Hebei, China.
| | - Yi Yang
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Sixth People's Hospital, Shanghai, 200233, China.
| | - Yunfeng Yi
- Department of Cardiothoracic Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, 363000, Fujian, China
| | - Dongbin Wang
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin, 300211, China
| | - Lei Jiang
- The Second Department of Surgery (Thoracic and Breast Department), Foshan Hospital of Traditional Chinese Medicine, Foshan, 528000, Guangdong, China
| | - Hai Huang
- Department of Thoracic Surgery, Fuzhou Second Hospital, Fuzhou, 350007, Fujian, China
| | - Longyu Jin
- Department of Thoracic Surgery, The Third Xiangya Hospital of Central South University, Changsha, 410000, Hunan, China
| | - Hui Meng
- Department of Thoracic Surgery, The Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, 519100, Guangdong, China
| | - Fei Xia
- Department of Emergency Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550001, Guizhou, China
| | - Guangwei Guo
- Department of Cardiothoracic Surgery, Second Hospital of Shanxi Medical University, Taiyuan, 030000, Shanxi, China
| |
Collapse
|
12
|
Niziolek GM, Mangan L, Weaver C, Prendergast V, Lamore R, Zielke M, Martin ND. Inadequate prophylaxis in patients with trauma: anti-Xa-guided enoxaparin dosing management in critically ill patients with trauma. Trauma Surg Acute Care Open 2024; 9:e001287. [PMID: 38362006 PMCID: PMC10868176 DOI: 10.1136/tsaco-2023-001287] [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: 10/31/2023] [Accepted: 01/27/2024] [Indexed: 02/17/2024] Open
Abstract
Venous thromboembolism (VTE) causes significant morbidity in patients with trauma despite advances in pharmacologic therapy. Prior literature suggests standard enoxaparin dosing may not achieve target prophylactic anti-Xa levels. We hypothesize that a new weight-based enoxaparin protocol with anti-Xa monitoring for dose titration in critically injured patients is safe and easily implemented. Methods This prospective observational study included patients with trauma admitted to the trauma intensive care unit (ICU) from January 2021 to September 2022. Enoxaparin dosing was adjusted based on anti-Xa levels as standard of care via a performance improvement initiative. The primary outcome was the proportion of subtarget anti-Xa levels (<0.2 IU/mL) on 30 mg two times per day dosing of enoxaparin. Secondary outcomes included the dosing modifications to attain goal anti-Xa levels, VTE and bleeding events, and hospital and ICU lengths of stay. Results A total of 282 consecutive patients were included. Baseline demographics revealed a median age of 36 (26-55) years, and 44.7% with penetrating injuries. Of these, 119 (42.7%) achieved a target anti-Xa level on a starting dose of 30 mg two times per day. Dose modifications for subtarget anti-Xa levels were required in 163 patients (57.8%). Of those, 120 underwent at least one dose modification, which resulted in 78 patients (47.8%) who achieved a target level prior to hospital discharge on a higher dose of enoxaparin. Overall, only 69.1% of patients achieved goal anti-Xa level prior to hospital discharge. VTE occurred in 25 patients (8.8%) and major bleeding in 3 (1.1%) patients. Conclusion A majority of critically injured patients do not meet target anti-Xa levels with 30 mg two times per day enoxaparin dosing. This study highlights the need for anti-Xa-based dose modification and efficacy of a pharmacy-driven protocol. Further optimization is warranted to mitigate VTE events. Level of evidence Therapeutic/care management, level III.
Collapse
Affiliation(s)
| | - Lauren Mangan
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cassidi Weaver
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Raymond Lamore
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Megan Zielke
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
13
|
Carter C, Denny K, Carver TW, Jung B, Rein L, Peppard WJ. Evaluation of an Association Between Enoxaparin Dose per Estimated Blood Volume and Clinically Relevant Bleeding in Low-Weight Trauma Patients. Ann Pharmacother 2024; 58:118-125. [PMID: 37138511 DOI: 10.1177/10600280231169523] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND The optimal dosing for enoxaparin venous thromboembolism (VTE) prophylaxis in low-weight trauma patients is unknown. Estimated blood volume (EBV) has shown promise as a dose modifier. OBJECTIVE To characterize the association of enoxaparin dose per EBV with the prevalence of VTE and bleeding in low-weight trauma patients. METHODS This was a retrospective study of trauma patients admitted over a 4-year period. Included patients were adults weighing <60 kg who received a minimum of 3 consecutive doses of enoxaparin. The primary endpoint was a comparison of enoxaparin dose per EBV in patients experiencing bleeding and VTE. Secondary endpoints included comparisons of dose per body mass index (BMI) and total body weight (TBW) and the ability of dose per EBV to predict clinical endpoints. Subgroup analyses for patients weighing <50 kg were performed for all endpoints. RESULTS A total of 189 patients were included. Statistical comparisons for VTE were not performed because of low prevalence. The dose of enoxaparin per EBV was not statistically different between patients who did and did not bleed in all analyses. Doses per BMI and TBW were also not statistically different between the groups. In patients weighing <50 kg, numerically higher doses per EBV, BMI, and TBW were noted in patients that bled versus those that did not. Enoxaparin dose per EBV was not a statistically significant predictor of bleeding in logistic regression models. CONCLUSION AND RELEVANCE No significant associations between enoxaparin dose per EBV, BMI, or TBW and bleeding were noted in the study. Future analyses of EBV and other dose modifiers should consider inclusion of patients weighing <50 kg.
Collapse
Affiliation(s)
- Chris Carter
- Department of Pharmacy, SSM Health St. Clare Hospital-Fenton, Fenton, MO, USA
| | - Kailey Denny
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thomas W Carver
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benjamin Jung
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Division of Biostatistics, Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William J Peppard
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
14
|
Park G, Dhillon NK, Fierro NM, Drevets P, Stupinski J, Ley EJ. Creatinine clearance predicts the goal enoxaparin dose in traumatic brain injury. J Trauma Acute Care Surg 2024; 96:270-275. [PMID: 37335174 DOI: 10.1097/ta.0000000000004059] [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: 06/21/2023]
Abstract
BACKGROUND Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism (VTE). Recent guidelines recommend starting TBI patients on enoxaparin 30 mg twice daily and then considering weight-based dosing. Creatinine clearance may be better than weight for patients when considering high and low enoxaparin dose requirements. We hypothesize that creatinine clearance (CrCl) predicts goal enoxaparin dose better than weight-based dosing. METHODS A retrospective review was conducted on patients admitted to an urban, academic Level I trauma center from August 2017 to February 2020. Patients were included if greater than 18 years, admitted longer than 48 hours, and head and neck AIS ≥ 3. Patients were excluded if they did not have TBI, if they received deep vein thrombosis prophylaxis other than enoxaparin 12-hour dosing, if no anti-Xa levels were drawn, or if the goal anti-Xa level was not reached. Patients were grouped into dosing cohorts based on dose of enoxaparin required to reach goal. Pearson's correlation was used to compare mean CrCl and mean weight across dosing cohorts. RESULTS A total of 120 patients met inclusion and exclusion criteria, mean age was 47 years and 68% of patients were male. The mean hospital length of stay was 24 days. There were 5 (4.2%) deep vein thrombosis, no pulmonary embolism, and 5 (4.2%) patients died. Mean CrCl increased significantly with increased dosing of enoxaparin, Pearson's correlation coefficient of 0.484 ( p < 0.001). Weight on admission also increased with increasing enoxaparin dose requirements, with Pearson's correlation coefficient of 0.411 ( p < 0.001). CONCLUSION Creatine clearance predicts goal enoxaparin dose in TBI better than a weight-based dosing strategy. Further research with a larger patient population is required to validate CrCl values to guide enoxaparin dosing. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
Collapse
Affiliation(s)
- Greigory Park
- From the Division of Trauma and Critical Care, Department of Surgery (G.P., N.M.F., P.D., J.S., E.J.L.), Cedars-Sinai Medical Center, Los Angeles, California; and R Adams Cowley Shock Trauma Center (N.K.D.), University of Maryland, Baltimore Maryland
| | | | | | | | | | | |
Collapse
|
15
|
Li W, Ling H, Lu R, Huang Z, Su W. Nomogram based on high-density lipoprotein cholesterol for the occurrence of preoperative deep vein thrombosis in patients with intertrochanteric femur fracture: a retrospective study. J Orthop Surg Res 2024; 19:22. [PMID: 38167173 PMCID: PMC10763374 DOI: 10.1186/s13018-023-04497-8] [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: 11/13/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND This study aims to develop a nomogram and forecast the incidence of DVT in individuals suffering from an intertrochanteric femur fracture. METHOD This work created a nomogram using the R programming language and employed logistic regression to determine independent predicting features. An external validation dataset was used to validate the nomogram. RESULT The findings demonstrated the independence of LYM (0.02[0.01-0.09], p < 0.001), ALB (0.83[0.74, 0.94], p = 0.002), and HDL-C (0.18[0.04, 0.71], p = 0.014). Good prediction performance with modest errors was shown by the nomogram in both the training and validation groups. CONCLUSION In conclusion, the nomogram that was created using HDL-C, ALB, and LYM can assist medical professionals in determining the likelihood that DVT will occur.
Collapse
Affiliation(s)
- Wencai Li
- Dept. Orthopedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530022, China
- Huizhou Central People's Hospital, Huizhou, 516001, Guangdong, China
| | - He Ling
- Dept. Orthopedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530022, China
| | - Rongbin Lu
- Dept. Orthopedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530022, China
| | - Zhao Huang
- Dept. Orthopedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530022, China
| | - Wei Su
- Dept. Orthopedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530022, China.
- Guangxi Collaborative Innovation Center for Biomedicine, Guangxi Medical University, Nanning, 530022, Guangxi, China.
| |
Collapse
|
16
|
Lv B, Wang H, Zhang Z, Li W, Han G, Liu X, Zhang C. Nomogram for predicting postoperative deep vein thrombosis in patients with spinal fractures caused by high-energy injuries. Arch Orthop Trauma Surg 2024; 144:171-177. [PMID: 37792059 DOI: 10.1007/s00402-023-05085-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 09/18/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVE Deep venous thrombosis (DVT) is a common complication in patients with spinal fractures caused by high-energy injuries. Early identification of patients at high risk of postoperative DVT is essential for the prevention of thrombosis. This study aimed to develop and validate a prediction model based on a nomogram to predict DVT in patients with spinal fractures caused by high-energy injuries. METHODS Clinical data were collected from 936 patients admitted to our hospital between January 2016 and December 2021 with spinal fractures caused by high-energy injuries. Multivariate logistic regression analysis was used to identify the risk factors for postoperative DVT and to develop a nomogram. The predictive performance of the nomogram was evaluated by the receiver operating characteristic (ROC) curve and calibration curve. RESULTS The incidence of preoperative DVT was 15.38% (144/936). The postoperative incidence of DVT was 20.5% (192/936). The multivariate analysis revealed that age, operation time, blood transfusion, duration of bed rest, American Spinal Injury Association (ASIA) score and D-dimer were risk factors for postoperative DVT. The area under the ROC curve of the nomogram was 0.835 and the calibration curve showed good calibration. CONCLUSIONS The nomogram showed a good ability to predict postoperative DVT in patients with spinal fractures caused by high-energy injuries, which may benefit pre- and postoperative DVT prophylaxis strategy development.
Collapse
Affiliation(s)
- Bing Lv
- Department of Ultrasound Medicine, Baoding No.1 Central Hospital, Baoding, 071000, People's Republic of China
| | - Haiying Wang
- Department of Orthopaedic Surgery, Baoding No.1 Central Hospital, 320 Changcheng North Street, Baoding, 071000, Hebei, People's Republic of China.
| | - Zipeng Zhang
- Department of Orthopaedic Surgery, Baoding No.1 Central Hospital, 320 Changcheng North Street, Baoding, 071000, Hebei, People's Republic of China
| | - Weifeng Li
- Department of Orthopaedic Surgery, Baoding No.1 Central Hospital, 320 Changcheng North Street, Baoding, 071000, Hebei, People's Republic of China
| | - Gefeng Han
- Department of Orthopaedic Surgery, Baoding No.1 Central Hospital, 320 Changcheng North Street, Baoding, 071000, Hebei, People's Republic of China
| | - Xiangdong Liu
- Department of Orthopaedic Surgery, Baoding No.1 Central Hospital, 320 Changcheng North Street, Baoding, 071000, Hebei, People's Republic of China
| | - Cheng Zhang
- Department of Orthopaedic Surgery, Baoding No.1 Central Hospital, 320 Changcheng North Street, Baoding, 071000, Hebei, People's Republic of China
| |
Collapse
|
17
|
Ryce AL, Lee SJ, Ahmed O, Majdalany BS, Kokabi N. Contemporary Use of Prophylactic Inferior Vena Cava Filters in Patients With Severe Traumatic Injuries and High Thromboembolic Event Risk. J Am Coll Radiol 2023:S1546-1440(23)01039-6. [PMID: 38157951 DOI: 10.1016/j.jacr.2023.12.020] [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: 10/14/2023] [Revised: 12/15/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE The aim of this study was to evaluate the relationship between prophylactic inferior vena cava filter (IVCF) implantation and in-hospital deep vein thrombosis (DVT), pulmonary embolism (PE), and mortality among adults with intracranial, pelvic or lower extremity, and spinal cord injuries. METHODS Patients 18 years and older with severe intracranial, pelvic or lower extremity, or spinal cord injuries captured by the Trauma Quality Improvement Program (2010-2019) were identified. IVCFs implanted ≤72 hours after hospital presentation and before performance of lower extremity ultrasonography were defined as prophylactic. Patients were stratified by pharmacologic venous thromboembolism (VTE) prophylaxis status. Logistic regression models estimated prophylactic inferior vena cava (IVC) filtration's effect on selected outcomes and identified attributes associated with prophylactic IVCF implantation. RESULTS Of 544,739 included patients, 1.3% (n = 7,247) underwent prophylactic IVCF implantation. Among patients who received pharmacologic VTE prophylaxis, prophylactic IVC filtration compared with expectant management was positively associated with DVT (odds ratio [OR], 4.30; P < .001) and PE (OR, 4.30; P < .001) but not associated with mortality (OR, 0.92; P = .43). Among patients who received no pharmacologic prophylaxis, prophylactic IVC filtration was positively associated with DVT (OR, 4.63; P < .001) and PE (OR, 5.02; P < .001) but negatively associated with mortality (OR, 0.43; P < .001). CONCLUSIONS Prophylactic IVC filtration was associated with increased likelihood of VTE among all adults with severe intracranial, pelvic or lower extremity, and spinal cord injuries. In patients who received no pharmacologic VTE prophylaxis, prophylactic IVC filtration was associated with decreased likelihood of in-hospital mortality.
Collapse
Affiliation(s)
- Arrix L Ryce
- Wellstar Kennestone Regional Medical Center, Marietta, Georgia. https://twitter.com/A_Ryce
| | - Scott J Lee
- Department of Radiology, University of Michigan Medical School, Ann Arbor, Michigan. https://twitter.com/scottlee_md
| | - Osman Ahmed
- Division of Interventional Radiology, Department of Radiology, University of Chicago Medical Center, Chicago, Illinois. https://twitter.com/TheRealDoctorOs
| | - Bill S Majdalany
- Division of Interventional Radiology, Department of Radiology, University of Vermont, Burlington, Vermont. https://twitter.com/billmajdalany
| | - Nima Kokabi
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| |
Collapse
|
18
|
Li X, Ruff C, Rafailidis V, Grozinger G, Cokkinos D, Kirksey L, Levitin A, Gadani S, Partovi S. Noninvasive and invasive imaging of lower-extremity acute and chronic venous thrombotic disease. Vasc Med 2023; 28:592-603. [PMID: 37792749 DOI: 10.1177/1358863x231198069] [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: 10/06/2023]
Abstract
The spectrum of venous thromboembolic (VTE) disease encompasses both acute deep venous thrombosis (DVT) and chronic postthrombotic changes (CPC). A large percentage of acute DVT patients experience recurrent VTE despite adequate anticoagulation, and may progress to CPC. Further, the role of iliocaval venous obstruction (ICVO) in lower-extremity VTE has been increasingly recognized in recent years. Imaging continues to play an important role in both acute and chronic venous disease. Venous duplex ultrasound remains the gold standard for diagnosing acute VTE. However, imaging of CPC is more complex and may involve computed tomography, magnetic resonance, contrast-enhanced ultrasound, or intravascular ultrasound. In this narrative review, we aim to discuss the full spectrum of venous disease imaging for both acute and chronic venous thrombotic disease.
Collapse
Affiliation(s)
- Xin Li
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Christer Ruff
- Department of Diagnostic and Interventional Radiology, University of Tubingen, Tubingen, Germany
- Department of Diagnostic and Interventional Neuroradiology, University of Tubingen, Tubingen, Germany
| | - Vasileios Rafailidis
- Department of Clinical Radiology, AHEPA University Hospital of Thessaloniki, Thessaloniki, Greece
| | - Gerd Grozinger
- Department of Diagnostic and Interventional Radiology, University of Tubingen, Tubingen, Germany
| | | | - Levester Kirksey
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Abraham Levitin
- Division of Interventional Radiology, The Cleveland Clinic Imaging Institute, Cleveland, OH, USA
| | - Sameer Gadani
- Division of Interventional Radiology, The Cleveland Clinic Imaging Institute, Cleveland, OH, USA
| | - Sasan Partovi
- Division of Interventional Radiology, The Cleveland Clinic Imaging Institute, Cleveland, OH, USA
| |
Collapse
|
19
|
Fu BS, Zheng ZH. Surgical Treatments for Femoral Shaft Fractures: A Narrative Review. Malays Orthop J 2023; 17:5-8. [PMID: 38107348 PMCID: PMC10723005 DOI: 10.5704/moj.2311.002] [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: 06/22/2023] [Accepted: 08/21/2023] [Indexed: 12/19/2023] Open
Abstract
Femoral shaft fractures are increasingly common due to various traumatic injuries. Intramedullary nail (IMN) is considered the gold standard treatment for these fractures, but comorbidities often require thorough trauma life support and intensive care. The primary goal of treatment is rigid fixation, early mobilisation, and long-term functional recovery. This article reviews current concepts in the treatment of femoral shaft fractures, including the effects of early or delayed operation, differences between antegrade or retrograde intramedullary nailing, alternative methods to using a fracture table, methods to predict nail length before operation, assessing femoral rotation during an operation, and complications.
Collapse
Affiliation(s)
- B S Fu
- Department of Orthopedic Surgery, Zuoying Branch of Kaohsiung Armed Force General Hospital, Kaohsiung City, Taiwan
| | - Z H Zheng
- Department of Orthopedic Surgery, Hualien Armed Forces General Hospital, Hualien City, Taiwan
| |
Collapse
|
20
|
Huang JF, Liao CH, Wang CC, Hsu CP, Cheng CT, Chan SY, Kuo LW, Liao CA, Yang CHO, Fu CY. Accelerated fixation is associated with fewer pulmonary embolism in patients with isolated and unilateral femoral shaft fractures: A TQIP analysis. Injury 2023; 54:111010. [PMID: 37729812 DOI: 10.1016/j.injury.2023.111010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/29/2023] [Accepted: 08/28/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION The optimal time to intramedullary internal fixation for patients with isolated and unilateral femoral shaft fractures was investigated by the American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP). MATERIAL AND METHODS Adult patients from the TQIP between 2017 and 2019 were eligible for inclusion. The associations between time to fixation and target outcomes (pulmonary embolism [PE], deep vein thrombosis [DVT], acute respiratory distress syndrome [ARDS], and mortality) were assessed. Maximization of the sum of sensitivity and specificity was used to determine the optimal cut point. The patients were divided into three groups according to different time to fixation intervals. A multinomial propensity scores weighting using generalized boosted models was performed for all unbiased pre-treatment factors between the groups. Multivariate logistic regression was used to clarify the outcomes predictors. RESULTS The univariate and multivariate analysis before weighting showed that only PE was significantly associated with time to fixation (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.09; p = 0.012). The optimal cut point of time to fixation was 13.88 h. The patients were divided into accelerated (≤ 13.88 h), standard (> 13.88 and ≤ 24 h), and delayed (> 24 and < 36 h) groups. After weighting for all unbiased pre-treatment factors between the groups, multivariate logistic regression showed that standard group significantly increased the risk of PE compared with accelerated group (OR, 4.436; 95% CI, 1.844-10.672; p = 0.001). CONCLUSION Accelerated intramedullary internal fixation within 13.88 h was associated with a significantly decreased risk of PE compared with standard fixation in patients with isolated and unilateral femoral shaft fractures without additional mortality risks.
Collapse
Affiliation(s)
- Jen-Fu Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Chia-Cheng Wang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Chih-Po Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan.
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Sheng-Yu Chan
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Ling-Wei Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Chien-An Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan; Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taiwan
| | - Chun-Hsiang Ou Yang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| |
Collapse
|
21
|
Heye T, Thind T, Jenkins A, Reif R, Jensen HK, Sexton K, Kalkwarf K, Bhavaraju A. Weight-Based Dosing for Venous Thromboembolism Prophylaxis in Spinal Trauma Patients Appears Safe. J Surg Res 2023; 290:209-214. [PMID: 37285702 DOI: 10.1016/j.jss.2023.04.019] [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: 11/03/2022] [Revised: 04/18/2023] [Accepted: 04/30/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a substantial cause of morbidity and mortality in trauma patients. VTE prophylaxis (VTEP) initiation is often delayed in certain patients due to the perceived risk of bleeding complications. Our VTEP guideline was changed from fixed-dosing to a weight-based dosing strategy using enoxaparin in June 2019. We investigated the rate of postoperative bleeding complications with a weight-based and a standard dosing protocol in traumatic spine injury patients requiring surgical stabilization. METHODS A retrospective pre-post cohort study using an institutional trauma database was conducted, comparing bleeding complications between fixed and weight-based VTEP protocols. Patients undergoing surgical stabilization of a spine injury were included. The preintervention cohort received fixed-dose thromboprophylaxis (30 mg twice daily or 40 mg daily); the postcohort received weight-based thromboprophylaxis (0.5 mg/kg q12 h with anti-factor Xa monitoring). All patients received VTEP 24-48 h after surgery. International Classification of Diseases codes were used to identify bleeding complications. RESULTS There were 68 patients in the pregroup and 68 in the postgroup with comparable demographics. Incidence of bleeding complications in the pre- and postgroups were 2.94% and 0% respectively. CONCLUSIONS VTEP initiated 24-48 h after surgical stabilization of a spine fracture using a weight-based dosing strategy and has a similar rate of bleeding complications as a standard dose protocol. Our study is limited by the low overall incidence of bleeding complications and small sample size. These findings could be validated by a larger multicenter trial.
Collapse
Affiliation(s)
- Thomas Heye
- University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas
| | - Tarendeep Thind
- University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas
| | - Allison Jenkins
- Department of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Rebecca Reif
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Hanna K Jensen
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Kevin Sexton
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Biomedical Informatics, UAMS College of Medicine, Little Rock, Arkansas; Department of Health Policy and Management, UAMS Fay. W. Boozman College of Public Health, Little Rock, Arkansas; Division of Pharmaceutical Evaluation & Policy, Department of Pharmacy Practice, UAMS College of Pharmacy, Little Rock, Arkansas
| | - Kyle Kalkwarf
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Avi Bhavaraju
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| |
Collapse
|
22
|
Hsiao PM, Liao SC, Chen IJ, Chou YC, Hsu YH, Wang SM, Yu YH. Incidence of deep vein thrombosis and symptomatic pulmonary embolism in Taiwanese patients with pelvic and/or acetabular fractures: a retrospective study. Sci Rep 2023; 13:16352. [PMID: 37770539 PMCID: PMC10539495 DOI: 10.1038/s41598-023-43449-4] [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: 02/21/2023] [Accepted: 09/24/2023] [Indexed: 09/30/2023] Open
Abstract
Venous thromboembolism (VTE) is common in patients with trauma, and thromboprophylaxis has been advocated. However, conflicting results regarding VTE rates in the Asian population following orthopaedic procedures have been presented. We aimed to investigate the VTE incidence in Taiwanese patients with pelvic and/or acetabular fractures and identify the associated risk factors. We included 402 patients who underwent surgery for pelvic and/or acetabular fractures. All patients received mechanical thromboprophylaxis with graduated compression stockings. Duplex scanning was performed postoperatively or during follow-up when signs or symptoms of deep vein thrombosis (DVT) developed. Variables with a significance level of ≤ 0.1 in the univariate analyses were introduced into the multivariate logistic regression analysis to identify DVT risk factors. The overall DVT and symptomatic pulmonary embolism (PE) rate was 3.48% (14/402 patients). Among patients with DVT, 46.1% were asymptomatic. Patients with VTE were significantly older than those without. Multivariate logistic regression analysis revealed that age was a VTE risk factor. The incidence of DVT and symptomatic PE in our cohort was low. Advanced age was a risk factor for VTE. These findings could help clinicians develop appropriate prevention and treatment strategies for VTE in Taiwanese patients with pelvic and/or acetabular fractures.
Collapse
Affiliation(s)
- Po-Meng Hsiao
- Department of Orthopaedics, New Taipei Municipal TuCheng Hospital, No. 6, Sec. 2, Jincheng Rd., Tucheng Dist., New Taipei City, 236, Taiwan
- Chang Gung University, No. 259, Wenhua 1St Rd., Guishan Dist., Taoyuan City, 33302, Taiwan
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsin St. Kweishan, 33302, Taoyuan, Taiwan
| | - Shu-Chen Liao
- Department of Orthopaedics, New Taipei Municipal TuCheng Hospital, No. 6, Sec. 2, Jincheng Rd., Tucheng Dist., New Taipei City, 236, Taiwan
- Chang Gung University, No. 259, Wenhua 1St Rd., Guishan Dist., Taoyuan City, 33302, Taiwan
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsin St. Kweishan, 33302, Taoyuan, Taiwan
| | - I-Jung Chen
- Chang Gung University, No. 259, Wenhua 1St Rd., Guishan Dist., Taoyuan City, 33302, Taiwan
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsin St. Kweishan, 33302, Taoyuan, Taiwan
| | - Ying-Chao Chou
- Chang Gung University, No. 259, Wenhua 1St Rd., Guishan Dist., Taoyuan City, 33302, Taiwan
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsin St. Kweishan, 33302, Taoyuan, Taiwan
| | - Yung-Heng Hsu
- Chang Gung University, No. 259, Wenhua 1St Rd., Guishan Dist., Taoyuan City, 33302, Taiwan
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsin St. Kweishan, 33302, Taoyuan, Taiwan
| | - Shu-Mei Wang
- Chang Gung University, No. 259, Wenhua 1St Rd., Guishan Dist., Taoyuan City, 33302, Taiwan
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, No. 5, Fu-Hsin St. Kweishan, 33302, Taoyuan, Taiwan
| | - Yi-Hsun Yu
- Chang Gung University, No. 259, Wenhua 1St Rd., Guishan Dist., Taoyuan City, 33302, Taiwan.
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Hsin St. Kweishan, 33302, Taoyuan, Taiwan.
| |
Collapse
|
23
|
Taniguchi T, Furukawa K, Ishii H, Kawagoe K, Sakaguchi S, Meiri R. Single-Stage Surgical Treatment of Acute Type A Aortic Dissection and Blunt Abdominal Trauma: A Case Report. Ann Vasc Dis 2023; 16:238-241. [PMID: 37779648 PMCID: PMC10539120 DOI: 10.3400/avd.cr.23-00017] [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: 02/21/2023] [Accepted: 08/05/2023] [Indexed: 10/03/2023] Open
Abstract
A 53-year-old man suddenly developed chest and back pain while driving, resulting in an accident. Computed tomography revealed acute type A aortic dissection with malperfusion of the left lower extremity, retroperitoneal extravasation, hematoma in the anterior mediastinum, and ascites in the rectovesical pouch. Exploratory laparotomy before aortic repair revealed intestinal perforation and retroperitoneal bleeding, which were repaired, and an ascending aortic replacement was performed. Visceral trauma with active bleeding should be treated with priority, even if the need for systemic heparinization accompanies acute type A aortic dissection during surgery for aortic dissection.
Collapse
Affiliation(s)
- Tomoaki Taniguchi
- Department of Cardiovascular Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Koji Furukawa
- Department of Cardiovascular Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Hirohito Ishii
- Department of Cardiovascular Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Katsuya Kawagoe
- Department of Cardiovascular Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Shuhei Sakaguchi
- Department of Cardiovascular Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Risa Meiri
- Department of Cardiovascular Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Miyazaki, Japan
| |
Collapse
|
24
|
Liu YB, Liu Y, Zhang L, Zhou XC, Ren BY, Zheng C, Hao CH, Wang WT, Xia X, Zhou GQ, Wu CT, Jin JD. Recombinant Neorudin for the Prevention of Deep-Vein Thrombosis After Spinal-Cord Injury. Drug Des Devel Ther 2023; 17:2523-2535. [PMID: 37641688 PMCID: PMC10460582 DOI: 10.2147/dddt.s408078] [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] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 07/28/2023] [Indexed: 08/31/2023] Open
Abstract
Background Whether anticoagulant therapy should be used after spinal-cord injury (SCI) surgery was controversial. The anticoagulation characteristics of a newly developed anticoagulant, recombinant neorudin (EPR-hirudin (EH)), were explored using a rat model of SCI to provide a basis for clinical anticoagulation therapy of SCI. Methods A rat model of SCI was developed by Allen's method. Then, thrombosis in the inferior vena cava was induced by ligation. The low-bleeding characteristics of EH were explored by investigating dose-response and time-effect relationships, as well as multiple administration of EH, on thrombus formation complicated with SCI. Results EH inhibited thrombosis in a dose-dependent manner by reducing the wet weight and dry weight of the thrombus. An inhibiting action of EH on thrombosis was most evident in the group given EH 2 h after SCI. After multiple intravenous doses of EH, thrombosis inhibition was improved to that observed with low molecular weight heparin (LMWH) (87% vs 90%). EH administration after SCI neither increased bleeding in the injured spine nor damaged to nerve function. Bleeding duration and activated partial thromboplastin time were increased in the high-dose EH group compared with that in the normal-saline group, but were lower than those in the LMWH group. Conclusion EH can reduce thrombus formation in a rat model of SCI, and bleeding is decreased significantly compared with that using LMWH. EH may prevent thrombosis after SCI or spinal surgery.
Collapse
Affiliation(s)
- Yu-Bin Liu
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, People’s Republic of China
- Division of (Bio) Pharmaceutics, Institute of Zhejiang University - Quzhou, Zhejiang, People’s Republic of China
| | - Yun Liu
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, People’s Republic of China
- School of Medicine, Guizhou University, Guiyang, People’s Republic of China
| | - Lin Zhang
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, People’s Republic of China
| | - Xing-Chen Zhou
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, People’s Republic of China
| | - Bo-Yuan Ren
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, People’s Republic of China
| | - Can Zheng
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, People’s Republic of China
| | - Chun-Hua Hao
- Center for Pharmacodynamic Research, Tianjin Institute of Pharmaceutical Research, Tianjin, People’s Republic of China
| | - Wei-Ting Wang
- Center for Pharmacodynamic Research, Tianjin Institute of Pharmaceutical Research, Tianjin, People’s Republic of China
| | - Xia Xia
- Beijing SH Biotechnology Co., Ltd., Beijing, People’s Republic of China
| | - Gang-Qiao Zhou
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, People’s Republic of China
- School of Medicine, Guizhou University, Guiyang, People’s Republic of China
| | - Chu-Tse Wu
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, People’s Republic of China
| | - Ji-De Jin
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, People’s Republic of China
| |
Collapse
|
25
|
Langenstroer EA, Carver TW, Herrmann DJ, O'Keefe MM, Hubbard S, Holschbach L, Rein L, Peppard WJ. Evaluation of a novel blood volume-based enoxaparin dosing guideline for venous thromboembolism prophylaxis in trauma patients. Am J Health Syst Pharm 2023; 80:1137-1146. [PMID: 37256752 DOI: 10.1093/ajhp/zxad119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Indexed: 06/02/2023] Open
Abstract
PURPOSE Fixed-dose and body mass index (BMI)-based enoxaparin regimens provide inadequate venous thromboembolism (VTE) prophylaxis for many trauma patients. The purpose of this study was to evaluate the effectiveness of a novel blood volume (BV)-based enoxaparin guideline vs a historical BMI-based guideline for VTE prophylaxis in trauma patients. METHODS This was a retrospective pre/post study completed at a large academic level 1 trauma center. All adult trauma patients admitted from October through December 2019 and August through October 2020 who received prophylactic enoxaparin per guideline were included. The BV dosing was as follows: patients with a BV of 3 to 4.9 L received enoxaparin 30 mg every 12 hours, those with a BV of 5 to 6.9 L received 40 mg every 12 hours, and those with a BV of ≥7 L received 60 mg every 12 hours. The primary outcome was the percentage of patients who attained a target anti-factor Xa (anti-Xa) postdosing level at the first steady-state assessment (0.2 to 0.5 IU/mL). RESULTS A total of 241 patients (99 for the BMI group and 142 for the BV group) were included. The study groups had a median age of 38 vs 42 years, a mean BMI of 27.4 vs 27.7 kg/m2, and a mean BV of 5.1 vs 5.1 L, respectively. A total of 63 patients (62.6%) in the BMI group attained target anti-Xa levels compared to 115 patients (81%) in the BV group (P = 0.008). In multivariate regression, the BV-based guideline was the only variable associated with attainment of target anti-Xa levels (adjusted odds ratio, 2.02; P = 0.01). Clinically relevant bleeding and VTE rates were similar between the groups. CONCLUSION Dosing prophylactic enoxaparin using a BV-based dosing guideline significantly increased attainment of target anti-Xa levels.
Collapse
Affiliation(s)
| | - Thomas W Carver
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - David J Herrmann
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mary M O'Keefe
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara Hubbard
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - Leah Holschbach
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | |
Collapse
|
26
|
Park G, Dhillon NK, Fierro NM, Drevets P, Stupinski J, Ley EJ. Creatinine Clearance May Predict Goal Enoxaparin Dose in Trauma. J Am Coll Surg 2023; 237:94-100. [PMID: 36942874 DOI: 10.1097/xcs.0000000000000689] [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: 03/23/2023]
Abstract
BACKGROUND Guidelines for enoxaparin dosing after trauma recommend an initial dose of 40 mg twice daily for most patients and then adjusting by anti-Xa levels. Previous studies indicated higher enoxaparin doses are necessary with higher levels of creatinine clearance (CrCl). We sought to determine if the goal enoxaparin dose correlates with the admission CrCl to reduce the reliance on measuring anti-Xa levels. STUDY DESIGN A retrospective review was conducted of patients admitted to an urban, academic Level 1 trauma center from April 2017 to February 2020. Patients started on enoxaparin who reached goal anti-Xa trough levels were included, and patients were excluded if they did not reach goal anti-Xa levels. Data collection included patient demographics, injury characteristics, admission CrCl, and final enoxaparin dose. CrCl was then correlated with the final enoxaparin dose. RESULTS Of 421 patients included, the mean age was 46.6 years and 73% were male. The median goal enoxaparin dose was 40 mg twice daily. The mean CrCl significantly increased with increasing twice-daily doses of enoxaparin (20 mg: 69.2 mL/min; 30 mg: 89 mL/min; 40 mg: 112.8 mL/min; 50 mg: 140.5mL/min; 60 mg: 147.4 mL/min; and 70 mg: 140 mL/min; p < 0.01). CONCLUSIONS Admission CrCl may predict the enoxaparin dose required to achieve adequate anti-Xa levels. Our data indicate that CrCls of approximately 70, 90, 110, 140, and 150 mL/min may predict the twice-daily enoxaparin doses of 20, 30, 40, 50, and 60 mg, respectively. CrCl dosing guidance may reduce the time to goal anti-Xa levels and the frequency of anti-Xa measurements. Further research is necessary, and enoxaparin dosing should continue to be monitored by anti-Xa levels.
Collapse
Affiliation(s)
- Greigory Park
- From the Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA (Park, Fierro, Drevets, Stupinski, Ley)
| | - Navpreet K Dhillon
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD (Dhillon)
| | - Nicole M Fierro
- From the Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA (Park, Fierro, Drevets, Stupinski, Ley)
| | - Peter Drevets
- From the Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA (Park, Fierro, Drevets, Stupinski, Ley)
| | - John Stupinski
- From the Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA (Park, Fierro, Drevets, Stupinski, Ley)
| | - Eric J Ley
- From the Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA (Park, Fierro, Drevets, Stupinski, Ley)
| |
Collapse
|
27
|
Draganich C, Park A, Sevigny M, Charlifue S, Coons D, Makley M, Fenton J, Alvarez R, Berliner J. Venous thromboembolism: Exploring incidence and utility of screening in spinal cord injury. J Spinal Cord Med 2023:1-8. [PMID: 37162305 DOI: 10.1080/10790268.2023.2207063] [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] [Indexed: 05/11/2023] Open
Abstract
OBJECTIVE To assess the incidence and possible risk factors for venous thromboembolism (VTE) in patients admitted to a SCI rehabilitation center. DESIGN Retrospective review. SETTING Acute neurorehabilitation hospital specializing in SCI. METHODS Records of 228 consecutive admissions were reviewed. All patients received screening four limb ultrasounds on admission. Charts were reviewed to determine whether VTE was diagnosed at the acute care hospital or in the rehabilitation center; either on admission screening or later in the rehabilitation stay. Charts were reviewed to identify potential risk factors for VTE as well as the incidence of bleeding complications in patients on full anticoagulation. RESULTS In this cohort, 115 deep venous thromboses (DVTs) were identified in the following settings: 27% in acute care [n = 31], 70% on admission to rehabilitation [n = 80], and 24% during the rehabilitation stay [n = 28]. Of those on therapeutic anticoagulation due to admission diagnosis of VTE [n = 63], 12.7% developed recurrent DVT and 9.5% had bleeding complications. Of those who were initiated and continued on therapeutic anticoagulation, there was zero incidence of PE. Risk factors for the development of VTE included age, body mass index (BMI), rehabilitation length of stay, injury etiology, spinal cord-related surgery, and history of inferior vena cava filter. CONCLUSIONS DVT was identified in 70% of this cohort with screening ultrasound on admission to rehabilitation and of those initiated and continued on therapeutic anticoagulation, none developed PE, while 9.5% had bleeding complications. Given the findings of this study, prospective research in noninvasive vascular ultrasound screening for VTE should be considered.
Collapse
Affiliation(s)
- Christina Draganich
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
| | - Andrew Park
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
- Craig Hospital, Englewood, CO, USA
| | | | | | - David Coons
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
- VHA Spinal Cord Injury & Disorders, Aurora, CO, USA
| | - Michael Makley
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
- Craig Hospital, Englewood, CO, USA
| | | | - Raul Alvarez
- Colorado Blood and Cancer Care, LLC, Denver, CO, USA
| | - Jeffrey Berliner
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
- Craig Hospital, Englewood, CO, USA
| |
Collapse
|
28
|
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.
Collapse
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
| |
Collapse
|
29
|
Bhanushali A, Ravichandran B, Stretton B, Kovoor JG, Bacchi S, Hewitt JN, Ovenden CD, Gupta AK, Jaarsma RL, Maddern GJ. Direct oral anticoagulants for venous thromboembolism prophylaxis in orthopaedic trauma: a clear first choice? ANZ J Surg 2023; 93:815-816. [PMID: 36732907 DOI: 10.1111/ans.18305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/11/2022] [Accepted: 01/20/2023] [Indexed: 02/04/2023]
Affiliation(s)
- Ameya Bhanushali
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
- Flinders Medical Centre, Department of Orthopaedics and Trauma, Adelaide, South Australia, Australia
| | - Bhuvanesh Ravichandran
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
| | - Brandon Stretton
- Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
| | - Joshua G Kovoor
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
| | - Joseph N Hewitt
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Christopher D Ovenden
- Discipline of Surgery, Women and Children's Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
| | - Ruurd L Jaarsma
- Flinders Medical Centre, Department of Orthopaedics and Trauma, Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Guy J Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
30
|
Alshaqaq HM, Al-Sharydah AM, Alshahrani MS, Alqahtani SM, Amer M. Prophylactic Inferior Vena Cava Filters for Venous Thromboembolism in Adults With Trauma: An Updated Systematic Review and Meta-Analysis. J Intensive Care Med 2023; 38:491-510. [PMID: 36939472 DOI: 10.1177/08850666231163141] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Background: Trauma is an independent risk factor for venous thromboembolism (VTE). Due to contraindications or delay in starting pharmacological prophylaxis among trauma patients with a high risk of bleeding, the inferior vena cava (IVC) filter has been utilized as alternative prevention for pulmonary embolism (PE). Albeit, its clinical efficacy has remained uncertain. Therefore, we performed an updated systematic review and meta-analysis on the effectiveness and safety of prophylactic IVC filters in severely injured patients. Methods: Three databases (MEDLINE, EMBASE, and Cochrane) were searched from August 1, 2012, to October 27, 2021. Independent reviewers performed data extraction and quality assessment. Relative risk (RR) at 95% confidence interval (CI) pooled in a randomized meta-analysis. A parallel clinical practice guideline committee assessed the certainty of evidence using the GRADE approach. The outcomes of interest included VTE, PE, deep venous thrombosis, mortality, and IVC filter complications. Results: We included 10 controlled studies (47 140 patients), of which 3 studies (310 patients) were randomized controlled trials (RCTs) and 7 were observational studies (46 830 patients). IVC filters demonstrated no significant reduction in PE and fatal PE (RR, 0.27; 95% CI, 0.06-1.28 and RR, 0.32; 95% CI, 0.01-7.84, respectively) by pooling RCTs with low certainty. However, it demonstrated a significant reduction in the risk of PE and fatal PE (RR, 0.25; 95% CI, 0.12-0.55 and RR, 0.09; 95% CI, 0.011-0.81, respectively) by pooling observational studies with very low certainty. IVC filter did not improve mortality in both RCTs and observational studies (RR, 1.44; 95% CI, 0.86-2.43 and RR, 0.63; 95% CI, 0.3-1.31, respectively). Conclusion: In trauma patients, moderate risk reduction of PE and fatal PE was demonstrated among observational data but not RCTs. The desirable effect is not robust to outweigh the undesirable effects associated with IVC filter complications. Current evidence suggests against routinely using prophylactic IVC filters.
Collapse
Affiliation(s)
- Hassan M Alshaqaq
- Emergency Medicine Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Abdulaziz M Al-Sharydah
- Diagnostic and Interventional Radiology Department, King Fahd Hospital of the University, 48023Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammed S Alshahrani
- Department of Emergency and Critical Care, King Fahd Hospital of the University, 48023Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Saad M Alqahtani
- Department of Orthopedics surgery, 48102King Fahd Hospital of the University, 48023Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Marwa Amer
- Medical/Critical Pharmacy Division, 37852King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,College of Medicine, 101686Alfaisal University, Riyadh, Saudi Arabia
| |
Collapse
|
31
|
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.
Collapse
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
| | | | | | | | | | | | | |
Collapse
|
32
|
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.
Collapse
Affiliation(s)
- Morgan Schellenberg
- Division of Acute Care Surgery, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA
| | - Todd Costantini
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona College of Medicine, Tucson, AZ
| | | | - Andrew C. Bernard
- Division of Acute Care Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Elliott R. Haut
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
33
|
Mirzamohammadi F, Nnamani Silva ON, Leaf RK, Eberlin KR, Valerio IL. Chemoprophylaxis and Management of Venous Thromboembolism in Microvascular Surgery. Semin Plast Surg 2023; 37:57-72. [PMID: 36776808 PMCID: PMC9911223 DOI: 10.1055/s-0042-1760381] [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: 02/11/2023]
Abstract
This review aims to highlight the common pharmacological and nonpharmacological interventions utilized for thromboprophylaxis as well as flap salvage in microsurgery. A literature review was conducted in PubMed/National Center for Biotechnology Information, Scopus, Web of Science, and MEDLINE databases. Articles with a focus on thromboprophylaxis in microsurgical procedures spanning head and neck surgery, breast and extremity microvascular reconstruction, deep venous thrombosis/pulmonary embolus in microvascular surgery, and flap thrombosis and salvage were included in this review. The majority of available evidence supports mechanical venous thromboembolism (VTE) prophylaxis in all patients undergoing microsurgery given the presence of multiple risk factors for VTE within this particular patient population. Based on the literature review, addition of VTE chemoprophylactic agents is beneficial and an algorithmic approach to thromboprophylaxis in microsurgery patients and management of patients with thrombosis based on literature review and senior authors' experience is recommended and outlined.
Collapse
Affiliation(s)
- Fatemeh Mirzamohammadi
- Wright State University Plastic Surgery Residency Program, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | | | - Rebecca K. Leaf
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kyle R. Eberlin
- Division of Plastic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ian L. Valerio
- Division of Plastic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
34
|
Liasidis P, Benjamin ER, Jakob D, Ding L, Lewis M, Demetriades D. Race does matter: venous thromboembolism in trauma patients with isolated severe pelvic fractures. Eur J Trauma Emerg Surg 2023; 49:241-251. [PMID: 35836009 DOI: 10.1007/s00068-022-02044-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/30/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Studies in non-trauma populations have shown that Black patients have a higher risk of venous thromboembolism (VTE) compared to other races. We sought to determine whether this association exists in trauma patients. The incidence of VTE is particularly high following severe pelvic fractures. To limit confounding factors associated with additional injuries, we examined patients with isolated blunt severe pelvic fractures. METHODS The TQIP database (2013-2017) was queried for all patients who sustained isolated blunt severe pelvic fractures (AIS ≥ 3) and received VTE prophylaxis (VTEp) with either unfractionated heparin or low molecular weight heparin. The study groups were Asian, Black, and White race as defined by TQIP. The primary outcome was differences in the rate of thromboembolic events. RESULTS A total of 9491 patients were included in the study. Of these, 232 (2.4%) were Asian, 1238 (13.0%) Black, and 8021 (84.5%) White. There was no significant difference in the distribution of pelvis AIS 3,4,5 between the groups. Black patients had a significantly higher incidence of VTE, DVT and PE compared to Asians and Whites. After adjusting for differences between the groups, Black patients had higher odds of developing pulmonary embolism (OR 1.887, 95% CI 1.101-3.232, p = 0.021) compared to White patients. CONCLUSIONS In this nationwide study of trauma patients with severe pelvic fractures, Black patients were more likely to develop pulmonary embolism compared to White patients. Further research to identify the determinants of racial disparities in trauma-related VTE is warranted, to target interventions that can improve VTE outcomes for all patients.
Collapse
Affiliation(s)
- Panagiotis Liasidis
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Elizabeth R Benjamin
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA, USA.
- Department of Surgery, Grady Memorial Hospital, Emory University, Glenn Memorial Building, 3rd Flr, 69 Jesse Hills Jr Dr SE, Atlanta, GA, 30303, USA.
| | - Dominik Jakob
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Li Ding
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Meghan Lewis
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
35
|
Anteby R, Allar BG, Broekhuis JM, Patel PB, Marcaccio CL, Papageorge MV, Papatheodorou S, Mendoza AE. Thromboprophylaxis Timing After Blunt Solid Organ Injury: A Systematic Review and Meta-analysis. J Surg Res 2023; 282:270-279. [PMID: 36332306 DOI: 10.1016/j.jss.2022.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/29/2022] [Accepted: 10/08/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Trauma patients with blunt abdominal solid organ injuries are at high risk for venous thromboembolism (VTE), but the optimal time to safely administer chemical thromboprophylaxis is controversial, especially for patients who are managed nonoperatively due to increased risk of hemorrhage. We sought to compare failure of nonoperative management (NOM) and VTE events based on timing of chemical thromboprophylaxis initiation. METHODS A systematic review was conducted in PubMed and Embase databases. Studies were included if they evaluated timing of initiation of chemical thromboprophylaxis in trauma patients who underwent NOM of blunt solid organ injuries. Outcomes included failure of NOM and incidence of VTE. A random-effects meta-analysis was performed comparing patients who received late (>48 h) versus early thromboprophylaxis initiation. RESULTS Twelve retrospective cohort studies, comprising 21,909 patients, were included. Three studies, including 6375 patients, provided data on adjusted outcomes. Pooled adjusted analysis demonstrated no difference in failure of NOM in patients receiving late versus early thromboprophylaxis (odds ratio [OR] 0.92, 95% confidence interval [CI]:0.4-2.14). When including all unadjusted studies, even those at high risk of bias, there remained no difference in failure of NOM (OR 1.16, 95% CI:0.72-1.86). In the adjusted analysis for VTE events, which had 6259 patients between two studies, patients receiving late chemical thromboprophylaxis had a higher risk of VTE compared with those who received early thromboprophylaxis (OR 1.89, 95% CI:1.15-3.12). CONCLUSIONS Based on current observational evidence, initiation of prophylaxis before 48 h is associated with lower VTE rates without higher risk of failure of NOM.
Collapse
Affiliation(s)
- Roi Anteby
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of General Surgery, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Benjamin G Allar
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Jordan M Broekhuis
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Priya B Patel
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of General Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Christina L Marcaccio
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Marianna V Papageorge
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Stefania Papatheodorou
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - April E Mendoza
- Department of Surgery, University of California San Francisco - East Bay, Oakland, California
| |
Collapse
|
36
|
Deremiah E, Franco-Martinez C, Gamboa C, Sponhaltz K, Rippee L, Reveles K, Foster D. Effectiveness and Safety of High-Dose Thromboprophylaxis in Morbidly Obese Major Trauma Patients. Hosp Pharm 2023; 58:92-97. [PMID: 36644743 PMCID: PMC9837326 DOI: 10.1177/00185787221111740] [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: 01/18/2023]
Abstract
BACKGROUND Trauma increases risk for venous thromboembolism (VTE) and obesity is a known independent risk factor for VTE development. Currently, no consensus on an optimal prophylactic dosing strategy for morbidly obese trauma patients exists. The objective of this study is to evaluate the effectiveness and safety of a BMI-stratified dosing strategy for VTE prophylaxis in morbidly obese trauma patients. METHODS This was a single center, retrospective cohort study of adult major trauma patients with a body mass index (BMI) of ≥40 kg/m2 admitted to the surgical-trauma intensive care unit from April 2014 to July 2020. Patients included were those who received enoxaparin 40 mg subcutaneously (SQ) every 12 hours (Q12H) for BMI of 40 to 49.9 kg/m2 or 60 mg SQ Q12H BMI ≥ 50 kg/m2 (per protocol), or enoxaparin 40 mg SQ Q12H for BMI of 40 to 49.9 kg/m2 (non-protocol). The primary endpoint was confirmed incidence of VTE. Secondary endpoints included occurrence of deep vein thrombosis (DVT) or pulmonary embolism (PE) during hospitalization, bleeding events, intensive care unit (ICU) and hospital length of stay (LOS) and hospital mortality. RESULTS One hundred forty-five morbidly obese major trauma patients were included, with 123 patients (84.8%) in the per-protocol group. The primary outcome of in-hospital VTE did not occur in any patients in this group. Bleeding events occurred in 3 patients (2.7%) with a BMI of 40 to 49.9 kg/m2 and in 2 patients (16.7%) with a BMI of ≥50 kg/m2 (P = .064). Twenty-two patients in the non-protocol group were reviewed. One VTE event (4.5%) and no bleeding events occurred in this group. Median ICU LOS was 5 days, and hospital LOS was 11 days for the entire study group. CONCLUSIONS Administration of enoxaparin 40 mg SQ Q12H to morbidly obese major trauma patients with a BMI of 40 to 49.9 kg/m2 and enoxaparin 60 mg SQ Q12H in those with a BMI of ≥50 kg/m2 resulted in low rates of VTE and bleeding events in the current study. However, future larger studies using this BMI-stratified dosing strategy are necessary to confirm these findings.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Dana Foster
- University Health System, San Antonio, TX, USA
| |
Collapse
|
37
|
Draganich C, Park A, Sevigny M, Charlifue S, Coons D, Makley M, Alvarez R, Fenton J, Berliner J. Venous Thromboembolism: Exploring Incidence and Utility of Screening in Individuals With Brain Injury. Arch Phys Med Rehabil 2023:S0003-9993(23)00087-4. [PMID: 36736807 DOI: 10.1016/j.apmr.2023.01.012] [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: 08/08/2022] [Revised: 12/07/2022] [Accepted: 01/05/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine the incidence of VTE in the population with brain injuries (BIs) using ultrasonography, and to assess the risk of pulmonary embolism (PE) development and/or bleeding complications related to anticoagulation. DESIGN Retrospective study. SETTING Acute rehabilitation hospital. PARTICIPANTS 238 individuals with moderate to severe BI who were routinely screened for VTE with ultrasonography on admission to rehabilitation (N=238). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Retrospective chart review was performed to identify individuals who were diagnosed with VTE at the following 3 time points: in acute care prior to admission to rehabilitation, at the time of admission diagnosed via screening examination, and after admission to rehabilitation. Additionally, risk factors for VTE, PE, and incidence of bleeding complications related to therapeutic anticoagulation were assessed. RESULTS 123 deep vein thromboses (DVTs) were identified with 38.2% in acute care (n=47), 69.1% on admission to rehabilitation (n=85), and 7.3% during the course of rehabilitation stay (n=9). Risk factors for development of VTE included age at injury, body mass index, injury etiology, history of neurosurgical procedure, and surgery during inpatient rehabilitation. Of those who were placed on therapeutic anticoagulation due to admission diagnosis of VTE (n=50), 2% developed recurrent DVT and 2% had bleeding complications. There was zero incidence of PE. CONCLUSION We demonstrated a high prevalence of VTEs identified on screening ultrasonography on admission to inpatient rehabilitation among individuals with moderate to severe BIs, and low complications related to anticoagulation. Given the findings of this study, prospective research in ultrasonography screening for VTE in moderate to severe BI is needed.
Collapse
Affiliation(s)
- Christina Draganich
- University of Colorado Department of Physical Medicine and Rehabilitation, Aurora, CO.
| | - Andrew Park
- University of Colorado Department of Physical Medicine and Rehabilitation, Aurora, CO; Craig Hospital, Englewood, CO
| | | | | | - David Coons
- University of Colorado Department of Physical Medicine and Rehabilitation, Aurora, CO; VHA Spinal Cord Injury & Disorders, Aurora, CO
| | - Michael Makley
- University of Colorado Department of Physical Medicine and Rehabilitation, Aurora, CO; Craig Hospital, Englewood, CO
| | | | | | - Jeffrey Berliner
- University of Colorado Department of Physical Medicine and Rehabilitation, Aurora, CO; Craig Hospital, Englewood, CO
| |
Collapse
|
38
|
Costa M. Thromboprophylaxis after Extremity Fracture - Time for Aspirin? N Engl J Med 2023; 388:274-275. [PMID: 36652359 DOI: 10.1056/nejme2214045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Matthew Costa
- From Oxford Trauma and Emergency Care, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
39
|
O'Toole RV, Stein DM, O'Hara NN, Frey KP, Taylor TJ, Scharfstein DO, Carlini AR, Sudini K, Degani Y, Slobogean GP, Haut ER, Obremskey W, Firoozabadi R, Bosse MJ, Goldhaber SZ, Marvel D, Castillo RC. Aspirin or Low-Molecular-Weight Heparin for Thromboprophylaxis after a Fracture. N Engl J Med 2023; 388:203-213. [PMID: 36652352 DOI: 10.1056/nejmoa2205973] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Clinical guidelines recommend low-molecular-weight heparin for thromboprophylaxis in patients with fractures, but trials of its effectiveness as compared with aspirin are lacking. METHODS In this pragmatic, multicenter, randomized, noninferiority trial, we enrolled patients 18 years of age or older who had a fracture of an extremity (anywhere from hip to midfoot or shoulder to wrist) that had been treated operatively or who had any pelvic or acetabular fracture. Patients were randomly assigned to receive low-molecular-weight heparin (enoxaparin) at a dose of 30 mg twice daily or aspirin at a dose of 81 mg twice daily while they were in the hospital. After hospital discharge, the patients continued to receive thromboprophylaxis according to the clinical protocols of each hospital. The primary outcome was death from any cause at 90 days. Secondary outcomes were nonfatal pulmonary embolism, deep-vein thrombosis, and bleeding complications. RESULTS A total of 12,211 patients were randomly assigned to receive aspirin (6101 patients) or low-molecular-weight heparin (6110 patients). Patients had a mean (±SD) age of 44.6±17.8 years, 0.7% had a history of venous thromboembolism, and 2.5% had a history of cancer. Patients received a mean of 8.8±10.6 in-hospital thromboprophylaxis doses and were prescribed a median 21-day supply of thromboprophylaxis at discharge. Death occurred in 47 patients (0.78%) in the aspirin group and in 45 patients (0.73%) in the low-molecular-weight-heparin group (difference, 0.05 percentage points; 96.2% confidence interval, -0.27 to 0.38; P<0.001 for a noninferiority margin of 0.75 percentage points). Deep-vein thrombosis occurred in 2.51% of patients in the aspirin group and 1.71% in the low-molecular-weight-heparin group (difference, 0.80 percentage points; 95% CI, 0.28 to 1.31). The incidence of pulmonary embolism (1.49% in each group), bleeding complications, and other serious adverse events were similar in the two groups. CONCLUSIONS In patients with extremity fractures that had been treated operatively or with any pelvic or acetabular fracture, thromboprophylaxis with aspirin was noninferior to low-molecular-weight heparin in preventing death and was associated with low incidences of deep-vein thrombosis and pulmonary embolism and low 90-day mortality. (Funded by the Patient-Centered Outcomes Research Institute; PREVENT CLOT ClinicalTrials.gov number, NCT02984384.).
Collapse
Affiliation(s)
- Robert V O'Toole
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Deborah M Stein
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Nathan N O'Hara
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Katherine P Frey
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Tara J Taylor
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Daniel O Scharfstein
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Anthony R Carlini
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Kuladeep Sudini
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Yasmin Degani
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Gerard P Slobogean
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Elliott R Haut
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - William Obremskey
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Reza Firoozabadi
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Michael J Bosse
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Samuel Z Goldhaber
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Debra Marvel
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Renan C Castillo
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| |
Collapse
|
40
|
Alexander KM, Butts CC, Lee YLL, Kutcher ME, Polite N, Haut ER, Spain D, Berndtson AE, Costantini TW, Simmons JD. Survey of venous thromboembolism prophylaxis in trauma patients: current prescribing practices and concordance with clinical practice guidelines. Trauma Surg Acute Care Open 2023; 8:e001070. [PMID: 37205274 PMCID: PMC10186479 DOI: 10.1136/tsaco-2022-001070] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/25/2023] [Indexed: 05/21/2023] Open
Abstract
Objectives Pharmacological venous thromboembolism (VTE) prophylaxis is recommended in the vast majority of trauma patients. The purpose of this study was to characterize current dosing practices and timing of initiation of pharmacological VTE chemoprophylaxis at trauma centers. Methods This was an international, cross-sectional survey of trauma providers. The survey was sponsored by the American Association for the Surgery of Trauma (AAST) and distributed to AAST members. The survey included 38 questions about practitioner demographics, experience, level and location of trauma center, and individual/site-specific practices regarding the dosing, selection, and timing of initiation of pharmacological VTE chemoprophylaxis in trauma patients. Results One hundred eighteen trauma providers responded (estimated response rate 6.9%). Most respondents were at level 1 trauma centers (100/118; 84.7%) and had >10 years of experience (73/118; 61.9%). While multiple dosing regimens were used, the most common dose reported was enoxaparin 30 mg every 12 hours (80/118; 67.8%). The majority of respondents (88/118; 74.6%) indicated adjusting the dose in patients with obesity. Seventy-eight (66.1%) routinely use antifactor Xa levels to guide dosing. Respondents at academic institutions were more likely to use guideline-directed dosing (based on the Eastern Association of the Surgery of Trauma and the Western Trauma Association guidelines) of VTE chemoprophylaxis compared with those at non-academic centers (86.2% vs 62.5%; p=0.0158) and guideline-directed dosing was reported more often if the trauma team included a clinical pharmacist (88.2% vs 69.0%; p=0.0142). Wide variability in initial timing of VTE chemoprophylaxis after traumatic brain injury, solid organ injury, and spinal cord injuries was found. Conclusions A high degree of variability exists in prescribing and monitoring practices for the prevention of VTE in trauma patients. Clinical pharmacists may be helpful on trauma teams to optimize dosing and increase prescribing of guideline-concordant VTE chemoprophylaxis.
Collapse
Affiliation(s)
- Kaitlin M Alexander
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
- Pharmacy, UF Health Shands Hospital, Gainesville, Florida, USA
| | | | | | - Matthew E Kutcher
- Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Nathan Polite
- Surgery, University of South Alabama, Mobile, Alabama, USA
| | - Elliott R Haut
- Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Spain
- Surgery, Stanford University, Stanford, California, USA
| | | | - Todd W Costantini
- Surgery, UC San Diego School of Medicine, San Diego, California, USA
| | - Jon D Simmons
- Surgery, University of South Alabama, Mobile, Alabama, USA
| |
Collapse
|
41
|
One size does not fit all: Sex bias in pharmacologic venous thromboembolism prophylaxis. J Trauma Acute Care Surg 2023; 94:78-85. [PMID: 35787601 DOI: 10.1097/ta.0000000000003738] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal enoxaparin dosing strategy to achieve venous thromboembolism (VTE) prophylaxis in trauma patients remains unclear. Current dosing guidelines often include weight, age, and renal function but still fail to achieve appropriate prophylactic anti-Xa levels in many patients. We hypothesized that additional patient factors influence anti-Xa response to enoxaparin in trauma patients. METHODS This is a retrospective review of patients admitted to a Level 1 trauma center for ≥4 days from July 2015 to September 2020, who received enoxaparin VTE prophylaxis per protocol (50-59 kg, 30 mg/dose; 60-99 kg, 40 mg/dose; ≥100 kg, 50 mg/dose; all doses every 12 hours) and had an appropriately timed peak anti-Xa level. Multivariate regression was performed to identify independent predictors of prophylactic anti-Xa levels (0.2-0.4 IU/mL) upon first measurement. RESULTS The cohort (N = 1,435) was 76.4% male, with a mean ± SD age of 49.9 ± 20.0 years and a mean ± SD weight of 82.5 ± 20.2 kg (males, 85.2 kg; females, 73.7 kg; p <0.001). Overall, 68.6% of patients (n = 984) had a prophylactic anti-Xa level on first assessment (69.6% of males, 65.1% of females). Males were more likely to have a subprophylactic level than females (22.1% vs. 8.0%, p <0.001), whereas females were more likely to have supraprophylactic levels than males (26.9% vs. 8.3%, p < 0.001). When controlling for creatinine clearance, anti-Xa level was independently associated with dose-to-weight ratio (odds ratio, 0.191 for 0.5 mg/kg; p < 0.001; confidence interval, 0.151-0.230) and female sex (odds ratio, 0.060; p < 0.001; confidence interval, 0.047-0.072). Weight and age were not significant when controlling for the other factors. CONCLUSION Male patients have a decreased anti-Xa response to enoxaparin when compared with female patients, leading to a greater incidence of subprophylactic anti-Xa levels in male patients at all dose-to-weight ratios. To improve the accuracy of VTE chemoprophylaxis, sex should be considered as a variable in enoxaparin dosing models. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
Collapse
|
42
|
Marturano MN, Khan AR, DeBlieux P, Wang H, Ross SW, Cunningham KW, Sing RF, Thomas BW. Timing of venous thromboembolism chemoprophylaxis using objective hemoglobin criteria in blunt solid organ injury. Injury 2022; 54:1356-1361. [PMID: 36581480 DOI: 10.1016/j.injury.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/19/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the safety and efficacy of early venous thromboembolism (VTE) chemoprophylaxis following blunt solid organ injury. METHODS A retrospective review of patients was performed for patients with blunt solid organ injury between 2009-2019. Enoxaparin was initiated when patients had <1g/dl Hemoglobin decline over a 24 h period. These patients were then categorized by initiation: ≤48 h and >48 h. RESULTS There were 653 patients: 328 (50.2%) <48 h and 325 (49.8%) ≥48 h. Twenty-nine (4.4%) developed VTE. Patients in ≥48 h group suffered more frequent VTE events (6.5% vs 2.4%, p = 0.021). Non-operative failure occurred in 6 patients (1.9%) in ≥48 h group, and 5 patients (1.5%) < 48 h group. Blood transfusion following chemophrophylaxis initiation was required in 69 (21.3%) in ≥48 h group, and 46 (14.0%) in < 48 h group, occurring similarly between groups (p=0.021). CONCLUSION Stable hemoglobin in the first 24 h is an efficacious, objective measure that allows early initiation of VTE chemoprophylaxis in solid organ injury. This practice is associated with earlier initiation of and fewer VTE events.
Collapse
Affiliation(s)
- Matthew N Marturano
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | | | - Paige DeBlieux
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Huaping Wang
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | - Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | - Kyle W Cunningham
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | - Ronald F Sing
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA
| | - Bradley W Thomas
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA.
| |
Collapse
|
43
|
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
|
44
|
Crush J, Seah M, Chou D, Rawal J, Hull P, Carrothers A. Sequential low molecular weight heparin and rivaroxaban for venous thromboprophylaxis in pelvic and acetabular trauma. Arch Orthop Trauma Surg 2022; 142:3271-3277. [PMID: 34495362 DOI: 10.1007/s00402-021-04152-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patients with pelvic trauma are at high risk of thromboembolic complications, but effective methods of prophylaxis are still to be accepted widely. The incidence of venous thromboembolism (VTE) has been reported to be as high as 61%, which represents the commonest cause of morbidity and mortality in this cohort. New oral anticoagulants are now available and may be used instead of LMWH injections for extended prophylaxis. Rivaroxaban has not been comprehensively considered in the previous pelvic and acetabular trauma literature, but its known benefits include increased patient compliance, especially in the minority of patients who are unable to self-administer injections, and that it does not require monitoring. MATERIALS AND METHODS All patients referred to our pelvic trauma service between 2015 and 2020 were considered for this study, exclusion criteria involved those patients who had contraindications to rivaroxaban, those who were referred to our service but were never managed at our centre and those managed by other teams (e.g. neurosurgery). Operative patients were initially managed with LMWH until 24 h post-operatively when they started rivaroxaban. Conservatively managed patients started Rivaroxaban straight away. Data were collected on demographics, injury mechanism, fracture classification and clinically relevant VTE and bleeding events up until 3 months post discharge. RESULTS The overall incidence of VTE was 2%. These represented 3 DVTs and 3 PEs, and occurred in patients who were managed operatively. No major bleeding events were observed. There were two minor bleeding events, both occurring in patients who were managed conservatively with rivaroxaban alone, and they did not require further intervention. 90% of patients surveyed expressed preference for oral prophylaxis. Reported compliance with rivaroxaban was 100%. CONCLUSION Our data show that this VTE regimen protocol is safe and effective in this group of injured patients and is at least non-inferior to the standard prophylaxis of LMWH alone.
Collapse
Affiliation(s)
- Jos Crush
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.
| | - Matthew Seah
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Daud Chou
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Jaikirty Rawal
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Peter Hull
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Andrew Carrothers
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| |
Collapse
|
45
|
Nimmons S, Rizkalla J, Solis J, Dawkins J, Syed I. Design and Retrospective Application of a Spine Trauma DVT Prophylaxis Protocol on Level 1 Trauma Center Patient Database. Global Spine J 2022; 12:1321-1329. [PMID: 33877927 PMCID: PMC9393969 DOI: 10.1177/2192568220979139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Systematic literature review. OBJECTIVES The impact of thromboembolic disease on the morbidity and mortality of patients with acute spinal cord injury is well documented, with rates as high as 67%-100% among untreated patients. The efficacy of mechanical prophylaxis as a stand-alone measure has been questioned, so we sought to determine a safe perioperative window for chemical anticoagulation use after spine surgery. Many surgeons have concerns anticoagulants may cause post-operative hematoma. METHODS A systematic literature review was performed, ultimately yielding 13 articles. Based on the existing literature and input from our multidisciplinary institutional trauma committee, a Spine Trauma DVT Prophylaxis Protocol was developed. RESULTS Effort was placed to identify cases within our institution in which patients suffered vertebral column fractures and/or spinal cord injuries. Of these 466 vertebral column fractures and/or spinal cord injuries, 4 patients were identified and diagnosed with DVTs while admitted. CONCLUSIONS Of these patients, there is a clear dilemma with regard to safety of chemoprophylaxis use versus risk of developing a DVT. Though none of the patients developed a PE, utilizing the protocol would have led to earlier IVC filter placement or initiation of a VTE surveillance protocol in 2 of the patients. Initiation of enoxaparin before surgery in one patient (despite delay of surgical timing) may have avoided his subsequent LUE DVT. Though not appropriate for all clinical scenarios, we are confident that our treatment algorithm will prove beneficial for patient care in avoiding DVTs and helping trauma surgeons with evidence-based clinical decision making.
Collapse
Affiliation(s)
- Scott Nimmons
- Baylor University Medical Center, Dallas, TX, USA,Scott Nimmons, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75228, USA.
| | | | - Jaicus Solis
- Baylor University Medical Center, Dallas, TX, USA
| | | | - Ishaq Syed
- Baylor University Medical Center, Dallas, TX, USA
| |
Collapse
|
46
|
Störmann P, Osinloye W, Verboket RD, Schindler CR, Woschek M, Marzi I, Lustenberger T. Early start of thromboprophylaxis does not increase risk of intracranial hematoma progression in multiply injured patients with traumatic brain injury. Brain Inj 2022; 36:1046-1052. [PMID: 35923095 DOI: 10.1080/02699052.2022.2105951] [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: 11/02/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) in severely injured patients with severe traumatic brain injury (TBI) is a risk during the clinical course. Data on the safety of an early initiation of pharmacological VTE prophylaxis in severely injured patients with concomitant severe TBI is sparse. METHODS Admissions to our level-1-trauma center between January 2015 and December 2018 were screened. Patients suffering from severe TBI (Abbreviated Injury Scale (AIS) of the head ≥3) and at least one further AIS ≥ 3 in any other body region were included. Demographic data, thromboembolic events, and progression of the intracranial hemorrhage were extracted from the patient's charts. According to the first application of pharmacological thromboprophylaxis (VTEp), patients were categorized either to the early, the late (later than 24 h) or the no therapy group. RESULTS In 79 patients (early: n = 35, late: n = 29, no therapy: n = 15) the Injury Severity Score (ISS) was 36.7 ± 12.7 points (AIShead 4.1 ± 0.8). No differences were found regarding the progression of the intracranial hemorrhage after initiation of the VTE prophylaxis (adj. p = 0.8). The VTE rate was low (n = 1, 1.6%). CONCLUSION In severely injured patients with severe TBI, the early administration of pharmacological thromboprophylaxis did not result in a higher rate of intracranial hematoma progression.
Collapse
Affiliation(s)
- Philipp Störmann
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| | - William Osinloye
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| | - René D Verboket
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| | - Cora R Schindler
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| | - Mathias Woschek
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| | - Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe - University Frankfurt am Main, Frankfurt/Main, Germany
| |
Collapse
|
47
|
Murphy PB, de Moya M, Karam B, Menard L, Holder E, Inaba K, Schellenberg M. Optimal timing of venous thromboembolic chemoprophylaxis initiation following blunt solid organ injury: meta-analysis and systematic review. Eur J Trauma Emerg Surg 2022; 48:2039-2046. [PMID: 34537859 DOI: 10.1007/s00068-021-01783-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The need to prevent venous thromboembolism (VTE) following blunt solid organ injury must be balanced against the concern for exacerbation of hemorrhage. The optimal timing for initiation of VTE chemoprophylaxis is not known. The objective was to determine the safety and efficacy of early (≤ 48 h) VTE chemoprophylaxis initiation following blunt solid organ injury. METHODS An electronic search was performed of medical libraries for English language studies on timing of VTE chemoprophylaxis initiation following blunt solid organ injury published from inception to April 2020. Included studies compared early (≤ 48 h) versus late (> 48 h) initiation of VTE chemoprophylaxis in adults with blunt splenic, liver, and/or kidney injury. Estimates were pooled using random-effects meta-analysis. Odds ratios were utilized to quantify differences in failure of nonoperative management, need for blood transfusion and rates of VTE. RESULTS The search identified 2,111 studies. Of these, ten studies comprising 14,675 patients were included. All studies were non-randomized and only one was prospective. The overall odds of failure of nonoperative management were no different between early and late groups, OR 1.09 (95%CI 0.92-1.29). Similarly, there was no difference in the need for blood transfusion either during overall hospital stay, OR 0.91 (95%CI 0.70-1.18), or post prophylaxis initiation, OR 1.23 (95%CI 0.55-2.73). There were significantly lower odds of VTE when patients received early VTE chemoprophylaxis, OR 0.51 (95%CI 0.33-0.81). CONCLUSIONS Patients undergoing nonoperative management for blunt solid organ injury can be safely and effectively prescribed early VTE chemoprophylaxis. This results in significantly lower VTE rates without demonstrable harm.
Collapse
Affiliation(s)
- Patrick B Murphy
- Department of Surgery, Division of Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Marc de Moya
- Department of Surgery, Division of Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Basil Karam
- Department of Surgery, Division of Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Laura Menard
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erik Holder
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University Of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Morgan Schellenberg
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University Of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA.
| |
Collapse
|
48
|
THE EFFICACY OF WEIGHT-BASED ENOXAPARIN DOSING FOR VTE-PROPHYLAXIS IN TRAUMA PATIENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS. J Trauma Acute Care Surg 2022; 93:e71-e79. [PMID: 35583986 DOI: 10.1097/ta.0000000000003707] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma patients are at high risk of developing venous thromboembolism (VTE), and standard dosing enoxaparin regimens may be inadequate for prophylaxis. This meta-analysis was performed to clarify the efficacy of alternative dosing regimens for VTE prophylaxis in this high-risk group. The objective of this systematic review was to review the evidence regarding weight-based dosing of enoxaparin for VTE prophylaxis in trauma patients. METHODS A systematic database search was undertaken for studies comparing standard vs weight-based dosing of enoxaparin for VTE prophylaxis in adult trauma patients, aged ≥18 years. The primary outcome was the achievement of Anti-Factor Xa (AFXa) levels within the prophylactic range. Secondary outcomes included: sub-prophylactic AFXa levels, supra-prophylactic AFXa levels, VTE incidence and bleeding events. Meta-analysis was conducted using both fixed- and random-effects models, and presented as odds ratios (OR), risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI). RESULTS Four cohort studies were eligible for inclusion. Compared to standard dosing, weight-based enoxaparin prophylaxis dosing was associated with increased odds of prophylactic AFXa levels (OR = 5.85., 95%CI: 3.02-11.30, p < 0.00001) and reduced risk of sub-prophylactic AFXa levels (RR = 3.97, 95%CI: 3.02-5.22, p < 0.00001). Standard dosing was associated with a reduced risk of supra-therapeutic AFXa levels (RR = 0.23, 95%CI: 0.11-0.50, P = 0.0002), but this was not associated with a difference in risk of bleeding events (RD = -0.00, 95%CI: -0.02-0.01, P = 0.55). There was no statistical difference in incidence VTE between the two groups (RD = 0.01, 95%CI: -0.02-0.03, P = 0.64). CONCLUSIONS Compared with standard dosing, weight-based enoxaparin dosing regimens are associated with increased odds of prophylactic range AFXa levels. Further investigation is required to determine if this translates into improved VTE prophylaxis and reduced VTE incidence. LEVEL OF EVIDENCE Systematic Review, level III.
Collapse
|
49
|
Moore L, Bérubé M, Tardif PA, Lauzier F, Turgeon A, Cameron P, Champion H, Yanchar N, Lecky F, Kortbeek J, Evans D, Mercier É, Archambault P, Lamontagne F, Gabbe B, Paquet J, Razek T, Stelfox HT. Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care. JAMA Surg 2022; 157:507-514. [PMID: 35476055 PMCID: PMC9047751 DOI: 10.1001/jamasurg.2022.0812] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators. Objective To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care. Design, Setting, and Participants This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners. Main Outcomes and Measures Panelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability. Results Of 49 eligible experts approached, 46 (94%; 18 experts [39%] aged ≥50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery). Conclusions and Relevance In this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.
Collapse
Affiliation(s)
- Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Mélanie Bérubé
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.,Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - François Lauzier
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Alexis Turgeon
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Howard Champion
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom.,Trauma Audit and Research Network, Salford, United Kingdom
| | - John Kortbeek
- Department of Surgery, University of Calgary, Calgary, Canada
| | - David Evans
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Éric Mercier
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Transfert des Connaissances et Évaluation des Technologies et Modes d'Intervention en Santé, Centre de Recherche du CHU de Québec - Université Laval (Hôpital St François d'Assise), Université Laval, Québec City, Québec, Canada
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jérôme Paquet
- Division of Neurosurgery, Department of Surgery, Université Laval, Québec, Québec, Canada
| | - Tarek Razek
- Department of Trauma Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | | |
Collapse
|
50
|
Comorbid Conditions Increase the Incidence of Venous Thromboembolism after Colorectal Surgery. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|