Contemporary thromboprophylaxis of trauma patients

Thromboprophylaxis in critically ill patients: balancing on a tightrope

Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is a common and potentially fatal complication in the intensive care unit (ICU). Critically ill patients have some special characteristics that increase the risk for VTE and complicate risk stratification and diagnosis. Given the positive effect of thromboprophylaxis on main outcomes, its use is mandatory in these patients, which is documented by various studies and recommended by all published guidelines. However, anticoagulation management is not an easy issue in clinical practice, as the critical patient may be at high risk for thrombosis or, conversely, at increased risk of bleeding or may balance between thrombotic and bleeding risk. Thrombotic and bleeding risk scoring should be evaluated daily in order to select the appropriate form of thromboprophylaxis. The selection depends on the degree of bleeding risk and the subgroup of ICU patients involved, such as patients with sepsis, acute brain injury, major trauma or coronavirus disease-2019. If there is no bleeding risk or other contraindication, the patient should receive pharmacologic thromboprophylaxis with unfractionated heparin or low molecular weight heparins, weighing the advantages of each agent. If the patient is at high risk of bleeding or there is a contraindication to pharmacologic prophylaxis, he should receive mechanical thromboprophylaxis mainly with intermittent pneumatic compression or graduated compression stockings. Thromboprophylaxis compliance with the guidelines is a prerequisite for moving from theory to practice. Direct oral anticoagulants have been studied in ICU patients and have no place at present in VTE prophylaxis requiring further research.

NONSPECIFIC DYSPLASIA OF THE CONNECTIVE TISSUE – A FACTOR OF VENOUS THROMBOEMBOLIC COMPLICATIONS IN ENDOPROSTHETICS OF HIP JOINTS

Background. Important part of orthopedic surgery is endoprosthetics of hip joints, which eliminates pain syndrome, restores the amplitude of movement and the support ability of lower limbs. But some complications usually take place; venous thromboembolism is leading among them. Objective. The aim of the study was to investigate endothelial dysfunction and activity of the hemocoagulation system at different levels of VTEC risks and thus to work out the strategy of thromboprophylaxis in patients with osteoarthrosis of the hip joint and femoral neck fracture combined with non-specific dysplasia of the connective tissue. Methods. 219 patients of a mean age of 64.7±3.8 years old underwent surgery. In 137 (62.1%) cases, a total cement hip replacement was performed for osteoarthritis. 82 (37.4%) patients underwent total and unipolar cement hip replacement for cervical femoral neck fractures. Results. Clinical manifestations of non-specific connective tissue dysplasia were detected in 83 (37.9%) patients that was confirmed by the laboratory determination of the level of general, bound and free oxyproline. In the postoperative period, the thrombotic process in the venous system of the inferior vena cava was diagnosed in 23 (10.5%) cases. The level of indicators of endothelium status dysfunction was much more significant in the patients in cases of nonspecific dysplasia of connective tissue. Operative intervention on the hip joint in the patients with nonspecific dysplasia of connective tissue in 11 (13.3%) cases was complicated by development of venous thrombosis. In the patients without non-specific connective tissue dysplasia, postoperative thrombosis in the system of the inferior vena cava was diagnosed in 12 (8.8%) cases. Conclusions. Patients with osteoarthrosis of the hip joint and the femoral neck fracture accompanied by the non-specific dysplasia of the connective tissue are characterized by high levels of endothelial dysfunction and increased activity of the blood-coagulation system.

Early Thromboprophylaxis in Operative Spinal Trauma Does Not Increase Risk of Bleeding Complications

BACKGROUND

Thromboprophylaxis in patients with spinal trauma is often delayed due to the risk of bleeding and expansion of the intraspinal hematoma (ISH). Our study aimed to assess the safety of early initiation of thromboprophylaxis in patients with operative spinal trauma (OST).

METHODS

We performed a 2014-2017 retrospective analysis of our level I trauma registry and included all adult patients with isolated OST who received low-molecular-weight heparin (LMWH). Patients were stratified into early (≤48 h) and late (>48 h) initiation of LMWH groups. Outcomes were a decline in hemoglobin level, packed red blood cell transfusion, and progression of ISH. We performed multivariable logistic regression.

RESULTS

We identified a total of 526 patients (early: 332, late: 194). Mean age was 46 ± 22y, and the median spine abbreviated injury scale was 3 [2-4]. After thromboprophylaxis, 1.5% (8) of the patients had progression of ISH and 1% (5) underwent surgical decompression of the spinal canal. There was no difference between the two groups regarding the rate of postprophylaxis ISH progression (1.5% versus 1.6%, P = 0.11) or surgical decompression (0.9% versus 1.1%, P = 0.19). Patients who received LMWH within 48 hrs had a lower incidence of clinically significant deep vein thrombosis (2.4% versus 6.8%, P = 0.02), but no difference in pulmonary embolism (0.6% versus 1.6%, P = 0.33) or mortality (1.2% versus 1.5%, P = 0.41). On regression analysis, there was no difference regarding decline in hemoglobin levels (β = 0.079, [-0.253 to 1.025]; P = 0.23) or number of packed red blood cell units transfused (β = -0.011, [-0.298 to 0.471]; P = 0.35).

CONCLUSIONS

Thromboprophylaxis with LMWH within the first 48 h in patients with OST is safe and efficacious. Prospective studies are needed to further validate their risk-benefit ratio.

LEVEL OF EVIDENCE

Level III therapeutic.

It's sooner than you think: Blunt solid organ injury patients are already hypercoagulable upon hospital admission - Results of a bi-institutional, prospective study

INTRODUCTION

The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis in blunt solid organ injury (BSOI) patients is debated. We hypothesize that 1) BSOI patients are hypercoagulable within 12 h of injury and 2) hypercoagulability dominates in patients who develop clot complications (CC).

MATERIAL AND METHODS

This is a prospective study of BSOI patients admitted to two Level-1 Trauma Centers' trauma intensive care units (ICU). Serial kaolin thrombelastography (TEG) and tissue plasminogen activator (tPA)-challenge TEGs were performed. CC included VTE and cerebrovascular accidents.

RESULTS

On ICU admission, all patients (n = 95) were hypercoagulable, 58% were in fibrinolysis shutdown, and 50% of patients were tPA-resistant. Twelve patients (13%) developed CC. Compared to those without CC, they demonstrated decreased fibrinolysis at 12 h and higher clot strength at 48 h CONCLUSIONS: BSOI patients are universally hypercoagulable upon ICU admission. VTE chemoprophylaxis should be started immediately in BSOI patients with hypercoagulability on TEG.