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Wilson JM, Shelvin KB, Lawhon SE, Crabill GA, Hayden EA, Velander AJ. Safety and timing of early therapeutic anticoagulation therapy after craniotomy. Surg Neurol Int 2024; 15:31. [PMID: 38468647 PMCID: PMC10927226 DOI: 10.25259/sni_887_2023] [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: 11/01/2023] [Accepted: 12/19/2023] [Indexed: 03/13/2024] Open
Abstract
Background To date, there are few guidelines and studies to guide the timing of initiation of therapeutic anticoagulation (AC) after craniotomy. The goal of this study was to assess the timing, safety, and outcomes of patients following the administration of therapeutic AC after craniotomy. Methods A retrospective case-control study was performed evaluating all craniotomy patients from August 2017 to July 2021. Cases were selected if they received therapeutic AC within ten days of craniotomy. Nineteen out of 1013 craniotomy patients met the inclusion criteria. Indications for therapeutic AC were diverse, including deep venous thrombosis, pulmonary embolism, dural venous sinus thrombosis, mechanical heart valve, and left ventricular thrombus. Results The mean and median time to therapeutic AC were 5.35 and 5 days, respectively. Three patients developed intracerebral hemorrhage (ICH) that was stable on repeat imaging and did not require any surgical intervention or result in new neurologic deficits. There was no significant association between therapeutic AC and postoperative ICH (P = 0.067). Conclusion This study demonstrated that the initiation of therapeutic AC in postoperative craniotomy patients from postoperative days 2 to 10 did not result in any major complications. A prospective study is warranted to clarify the indications and safety of therapeutic AC after craniotomy.
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Affiliation(s)
| | - Kierany B. Shelvin
- Department of Neurosurgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana, United States
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Labuz DF, Tobias J, Selesner L, Han X, Cunningham A, Marenco CW, Escobar MA, Hazeltine MD, Cleary MA, Kotagal M, Falcone RA, Vogel AM, MacArthur T, Klinkner DB, Shah A, Chernoguz A, Orioles A, Zagel A, Gosain A, Knaus M, Hamilton NA, Jafri MA. Impact of institutional prophylaxis guidelines on rates of pediatric venous thromboembolism following trauma-A multicenter study from the pediatric trauma society research committee. J Trauma Acute Care Surg 2023; 95:341-346. [PMID: 36872513 DOI: 10.1097/ta.0000000000003918] [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: 03/07/2023]
Abstract
BACKGROUND A paucity of data exists with regard to the incidence, management, and outcomes of venous thromboembolism (VTE) in injured children. We sought to determine the impact of institutional chemoprophylaxis guidelines on VTE rates in a pediatric trauma population. METHODS A retrospective review of injured children (≤15 years) admitted between 2009 and 2018 at 10 pediatric trauma centers was performed. Data were gathered from institutional trauma registries and dedicated chart review. The institutions were surveyed as to whether they had chemoprophylaxis guidelines in place for high-risk pediatric trauma patients, and outcomes were compared based on the presence of guidelines using χ 2 analysis ( p < 0.05). RESULTS There were 45,202 patients evaluated during the study period. Three institutions (28,359 patients, 63%) had established chemoprophylaxis policies during the study period ("Guidelines"); the other seven centers (16,843 patients, 37%) had no such guidelines ("Standard"). There were significantly lower rates of VTE in the Guidelines group, but these patients also had significantly fewer risk factors. Among critically injured children with similar clinical presentations, there was no difference in VTE rate. Specifically within the Guidelines group, 30 children developed VTE. The majority (17/30) were actually not indicated for chemoprophylaxis based on institutional guidelines. Still, despite protocols only one VTE patient in the guidelines group who was indicated for intervention ended up receiving chemoprophylaxis prior to diagnosis. No consistent ultrasound screening protocol was in place at any institution during the study. CONCLUSION The presence of an institutional policy to guide chemoprophylaxis for injured children is associated with a decreased overall frequency of VTE, but this disappears when controlling for patient factors. However, the overall efficacy is impacted by a combination of deficits in guideline compliance and structure. Further prospective data are needed to help determine the ideal role for chemoprophylaxis and protocols in pediatric trauma. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Daniel F Labuz
- From the Division of Pediatric Surgery, Department of Surgery (D.F.L., J.T., L.S., X.Y.H., A.C., N.A.H., M.A.J.), Oregon Health & Science University, Portland, Oregon; Department of Surgery (C.W.M.), Madigan Army Medical Center, Tacoma, Washington; Department of Pediatric Surgery (M.A.E.Jr.), Mary Bridge Children's Hospital, Tacoma, Washington; Division of Pediatric Surgery, Department of Surgery (M.D.H., M.A.C.), University of Massachusetts Medical School, Worcester, Massachusetts; Division of Pediatric General and Thoracic Surgery (M.K., R.A.F.Jr.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Pediatric Surgery (A.M.V.), Texas Children's Hospital, Houston, Texas; Division of Pediatric Surgery, Department of Surgery (T.M.A., D.B.K.), Mayo Clinic, Rochester, Minnesota; Division of Pediatric Surgery (A.S., A.C.), Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts; Division of Critical Care (A.O., A.Z.), Children's Hospital and Clinics of Minnesota, Minneapolis, Minnesota; Division of Pediatric Surgery, Department of Surgery (A.G., M.K.), University of Tennessee Health Sciences Center, Memphis, Tennessee; and Division of Pediatric Surgery (M.A.J.), Randall Children's Hospital at Legacy Emanuel, Portland, Oregon
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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.
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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
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Lara-Reyna J, Alali L, Wedderburn R, Margetis K. Compliance with venous thromboembolism chemoprophylaxis guidelines in non-operative traumatic brain injury. Clin Neurol Neurosurg 2022; 215:107212. [DOI: 10.1016/j.clineuro.2022.107212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 11/03/2022]
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Labuz DF, Cunningham A, Tobias J, Dixon A, Dewey E, Marenco CW, Escobar MA, Hazeltine MD, Cleary MA, Kotagal M, Falcone RA, Fallon SC, Naik-Mathuria B, MacArthur T, Klinkner DB, Shah A, Chernoguz A, Orioles A, Zagel A, Gosain A, Knaus M, Hamilton NA, Jafri MA. Venous thromboembolic risk stratification in pediatric trauma: A Pediatric Trauma Society Research Committee multicenter analysis. J Trauma Acute Care Surg 2021; 91:605-611. [PMID: 34039921 DOI: 10.1097/ta.0000000000003290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) in injured children is rare, but its consequences are significant. Several risk stratification algorithms for VTE in pediatric trauma exist with little consensus, and all are hindered in development by relying on registry data with known inaccuracies. We performed a multicenter review to evaluate trauma registry fidelity and confirm the effectiveness of one established algorithm across diverse centers. METHODS Local trauma registries at 10 institutions were queried for all patients younger than 18 years admitted between 2009 and 2018. Additional chart review was performed on all "VTE" cases and random non-VTE controls to assess registry errors. Corrected data were then applied to our prediction algorithm using 10 real-time variables (Glasgow Coma Scale, age, sex, intensive care unit admission, transfusion, central line placement, lower extremity/pelvic fracture, major surgery) to calculate VTE risk scores. Contingency table classifiers and the area under a receiver operator characteristic curve were calculated. RESULTS Registries identified 52,524 pediatric trauma patients with 99 episodes of VTE; however, chart review found that 13 cases were misclassified for a corrected total of 86 cases (0.16%). After correction, the algorithm still displayed strong performance in discriminating VTE-fated encounters (sensitivity, 69%; area under the receiver operating characteristic curve, 0.96). Furthermore, despite wide institutional variability in VTE rates (0.04-1.7%), the algorithm maintained a specificity of >91% and a negative predictive value of >99.7% across centers. Chart review also revealed that 54% (n = 45) of VTEs were directly associated with a central line, usually femoral (n = 34, p < 0.001 compared with upper extremity), and that prophylaxis rates were underreported in the registries by about 50%; still, only 19% of the VTE cases had been on prophylaxis before diagnosis. CONCLUSION The VTE prediction algorithm performed well when applied retrospectively across 10 diverse pediatric centers using corrected registry data. These findings can advance initiatives for VTE screening/prophylaxis guidance following pediatric trauma and warrant prospective study. LEVEL OF EVIDENCE Clinical decision rule evaluated in a single population, level III.
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Affiliation(s)
- Daniel F Labuz
- From the Division of Pediatric Surgery, Department of Surgery (D.F.L., A.C., J.T., A.D., E.D., N.A.H., M.A.J.), Oregon Health and Science University, Portland, Oregon; Department of Surgery (C.W.M.), Madigan Army Medical Center; Department of Pediatric Surgery (M.A.E.), Mary Bridge Children's Hospital, Tacoma, Washington; Division of Pediatric Surgery, Department of Surgery (M.D.H., M.A.C.), University of Massachusetts Medical School, Worcester, Massachusetts; Division of Pediatric General and Thoracic Surgery (M.K., R.A.F.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Pediatric Surgery (S.C.F., B.N.-M.), Texas Children's Hospital, Houston, Texas; Division of Pediatric Surgery, Department of Surgery (T.M., D.B.K.), Mayo Clinic, Rochester, Minnesota; Division of Pediatric Surgery (A.S., A.C.), Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts; Division of Critical Care (A.O., A.Z.), Children's Hospital and Clinics of Minnesota, Minneapolis, Minnesota; Division of Pediatric Surgery, Department of Surgery (A.G., M.K.), University of Tennessee Health Sciences Center, Memphis, Tennessee; and Division of Pediatric Surgery (M.A.J.), Randall Children's Hospital at Legacy Emanuel, Portland, Oregon
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Jakob DA, Benjamin ER, Recinos G, Cremonini C, Lewis M, Demetriades D. Venous thromboembolic pharmacological prophylaxis in severe traumatic acute subdural hematomas: Early prophylaxis is effective and safe. Am J Surg 2021; 223:1004-1009. [PMID: 34364655 DOI: 10.1016/j.amjsurg.2021.07.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the optimal timing and type of pharmacological venous thromboembolism prophylaxis (VTEp) in patients with severe blunt head trauma with acute subdural hematomas (ASDH). METHODS Matched cohort study using ACS-TQIP database (2013-2016) including patients with isolated ASDH. Outcomes of matched patients receiving early prophylaxis (EP, ≤48 h) and late prophylaxis (LP, >48 h) were compared with univariable and multivariable regression analysis. RESULTS In 1,660 matched cases VTE complications (3.1% vs 0.5%, p < 0.001) were more common in the LP compared to the EP group. Multivariable regression analysis identified EP as an independent protective factor for VTE complications (OR 0.169, p < 0.001) but not mortality (p = 0.260). The adjusted risk for delayed craniectomy was not associated with EP compared to LP (p = 0.095). LMWH was independently associated with a lower mortality (OR 0.480, p = 0.008) compared to UH. CONCLUSIONS Early VTEp (≤48 h) does not increase the risk for craniectomies and is independently associated with fewer VTE complications in patients with isolated ASDH. LMWH was independently associated with a lower mortality compared to UH.
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Affiliation(s)
- Dominik A Jakob
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Elizabeth R Benjamin
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Gustavo Recinos
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Camilla Cremonini
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Meghan Lewis
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
| | - Demetrios Demetriades
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA.
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Dhillon NK, Hashim YM, Berezin N, Yong F, Conde G, Mason R, Ley EJ. Characterizing the delays in adequate thromboprophylaxis after TBI. Trauma Surg Acute Care Open 2021; 6:e000686. [PMID: 34041364 PMCID: PMC8112398 DOI: 10.1136/tsaco-2021-000686] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/07/2021] [Accepted: 04/18/2021] [Indexed: 11/18/2022] Open
Abstract
Background We sought to compare enoxaparin dosing for venous thromboembolism (VTE) prophylaxis in trauma patients with and without traumatic brain injury (TBI) to better understand the time and dose required to reach target anti-Xa levels. Our hypothesis was that patients with TBI have significant delays in the initiation of adequate pharmacological prophylaxis and require a higher enoxaparin dose than currently recommended. Methods The medical records of trauma patients who received enoxaparin dosing based on anti-Xa trough levels between August 2014 and October 2016 were reviewed. Patients were included if their anti-Xa trough level reached the target range (0.1 IU/mL to 0.2 IU/mL). Results A total of 163 patients had anti-Xa levels within the target range of which 41 (25.2%) had TBI. Patients with TBI had longer delays before initiating enoxaparin (7.5 days vs. 1.5 days after admission, p<0.01) and were more likely to receive unfractionated heparin prior to enoxaparin (46.3% vs. 11.5%, p<0.01). Anti-Xa levels reached the target range later in patients with TBI (11 days vs. 5 days after admission, p<0.01). Enoxaparin 40 mg two times per day was the median dose required to reach the target anti-Xa levels for both cohorts. VTE rates were higher among patients with TBI (22.0% vs. 9.0%, p=0.03). Four patients (9.8%) had progression of their intracranial hemorrhage prior to receiving enoxaparin, although none progressed during enoxaparin administration. Conclusion Among patients with TBI who reached target anti-Xa levels, 11 days after admission were required to reach a median enoxaparin dose of 40 mg two times per day. Unfractionated heparin was used as pharmacological prophylaxis in about half of these patients. The delay in reaching the target anti-Xa levels and the use of unfractionated heparin likely contribute to the higher VTE rate in patients with TBI. Level of evidence Level III, therapeutic.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yassar M Hashim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Naomi Berezin
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Felix Yong
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Geena Conde
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Russell Mason
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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8
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Rivas L, Vella M, Ju T, Fernandez-Moure JS, Sparks A, Seamon MJ, Sarani B. Early Chemoprophylaxis Against Venous Thromboembolism in Patients With Traumatic Brain Injury. Am Surg 2021; 88:187-193. [PMID: 33502231 DOI: 10.1177/0003134820983171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Timing to start of chemoprophylaxis for venous thromboembolism (VTE) in patients with traumatic brain injury (TBI) remains controversial. We hypothesize that early administration is not associated with increased intracranial hemorrhage. METHODS A retrospective study of adult patients with TBI following blunt injury was performed. Patients with penetrating brain injury, any moderate/severe organ injury other than the brain, need for craniotomy/craniectomy, death within 24 hours of admission, or progression of bleed on 6 hour follow-up head computed tomography scan were excluded. Patients were divided into early (≤24 hours) and late (>24 hours) cohorts based on time to initiation of chemoprophylaxis. Progression of bleed was the primary outcome. RESULTS 264 patients were enrolled, 40% of whom were in the early cohort. The average time to VTE prophylaxis initiation was 17 hours and 47 hours in the early and late groups, respectively (P < .0001). There was no difference in progression of bleed (5.6% vs. 7%, P = .67), craniectomy/-craniotomy rate (1.9% vs. 2.5%, P = .81), or VTE rate (0% vs. 2.5%, P = .1). CONCLUSION Early chemoprophylaxis is not associated with progression of hemorrhage or need for neurosurgical intervention in patients with TBI and a stable head CT 7 hours following injury.
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Affiliation(s)
- Lisbi Rivas
- Center for Trauma and Critical Care, Department of Surgery, 50430George Washington University, Washington, DC, USA
| | - Michael Vella
- Department of Surgery, Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Department of Surgery at the University of Rochester Medical Center, Rochester, NY, USA
| | - Tammy Ju
- Center for Trauma and Critical Care, Department of Surgery, 50430George Washington University, Washington, DC, USA
| | - Joseph S Fernandez-Moure
- Department of Surgery, Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Department of Surgery at Duke Medical Center, 14640University of Pennsylvania Perelman School of Medicine, Durham, NC, USA
| | - Andrew Sparks
- Center for Trauma and Critical Care, Department of Surgery, 50430George Washington University, Washington, DC, USA
| | - Mark J Seamon
- Department of Surgery, Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Babak Sarani
- Center for Trauma and Critical Care, Department of Surgery, 50430George Washington University, Washington, DC, USA
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9
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Therapeutic anticoagulation in patients with traumatic brain injuries and pulmonary emboli. J Trauma Acute Care Surg 2020; 89:529-535. [PMID: 32467467 DOI: 10.1097/ta.0000000000002805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with traumatic intracranial hemorrhage (ICH) and concomitant pulmonary embolus (PE) have competing care needs and demand a careful balance of anticoagulation (AC) versus potential worsening of their ICH. The goal of this study is to determine the safety of therapeutic AC for PE in patients with ICH. METHODS This is a retrospective single-center study of patients older than 16 years with concomitant ICH and PE occurring between June 2013 and December 2017. Early AC was defined as within 7 days of injury or less; late was defined as after 7 days. Primary outcomes included death, interventions for worsening ICH following AC, and pulmonary complications. Multivariate logistic regression was used to evaluate for clinical and demographic factors associated with worsening traumatic brain injury (TBI), and recursive partitioning was used to differentiate risk in groups. RESULTS Fifty patients met criteria. Four did not receive any AC and were excluded. Nineteen (41.3%) received AC early (median, 4.1; interquartile range, 3.1-6) and 27 (58.7%) received AC late (median, 14; interquartile range, 9.7-19.5). There were four deaths in the early group, and none in the late cohort (21.1% vs. 0%, p = 0.01). Two deaths were due to PE and the others were from multi-system organ failure or unrecoverable underlying TBI. Three patients in the early group, and two in the late, had increased ICH on computed tomography (17.6% vs. 7.4%, p = 0.3). None required intervention. CONCLUSION This retrospective study failed to find instances of clinically significant progression of TBI in 46 patients with computed tomography-proven ICH after undergoing AC for PE. Therapeutic AC is not associated with worse outcomes in patients with TBI, even if initiated early. However, two patients died from PE despite AC, underlining the severity of the disease. Intracranial hemorrhage should not preclude AC treatment for PE, even early after injury. LEVEL OF EVIDENCE Care management, Level IV.
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Yeates EO, Grigorian A, Schubl SD, Kuza CM, Joe V, Lekawa M, Borazjani B, Nahmias J. Chemoprophylaxis and Venous Thromboembolism in Traumatic Brain Injury at Different Trauma Centers. Am Surg 2020. [DOI: 10.1177/000313482008600433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Patients with severe traumatic brain injury (TBI) are at an increased risk of venous thromboembolism (VTE). Because of concerns of worsening intracranial hemorrhage, clinicians are hesitant to start VTE chemoprophylaxis in this population. We hypothesized that ACS Level I trauma centers would be more aggressive with VTE chemoprophylaxis in adults with severe TBI than Level II centers. We also predicted that Level I centers would have a lower risk of VTE. We queried the Trauma Quality Improvement Program (2010–2016) database for patients with Abbreviated Injury Scale scores of 4 and 5 of the head and compared them based on treating the hospital trauma level. Of 204,895 patients with severe TBI, 143,818 (70.2%) were treated at Level I centers and 61,077 (29.8%) at Level II centers. The Level I cohort had a higher rate of VTE chemoprophylaxis use (43.2% vs 23.3%, P < 0.001) and a shorter median time to chemoprophylaxis (61.9 vs 85.9 hours, P < 0.001). Although Level I trauma centers started VTE chemoprophylaxis more often and earlier than Level II centers, there was no difference in the risk of VTE ( P = 0.414) after controlling for covariates. Future prospective studies are warranted to evaluate the timing, safety, and efficacy of early VTE chemoprophylaxis in severe TBI patients.
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Affiliation(s)
- Eric O. Yeates
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Areg Grigorian
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Sebastian D. Schubl
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Catherine M. Kuza
- Department of Anesthesiology, University of Southern California Medical Center, Los Angeles, California
| | - Victor Joe
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Michael Lekawa
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Boris Borazjani
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Jeffry Nahmias
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
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Tignanelli CJ, Gipson J, Nguyen A, Martinez R, Yang S, Reicks PL, Sybrant C, Roach R, Thorson M, West MA. Implementation of a Prophylactic Anticoagulation Guideline for Patients with Traumatic Brain Injury. Jt Comm J Qual Patient Saf 2020; 46:185-191. [PMID: 31899154 DOI: 10.1016/j.jcjq.2019.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients with traumatic brain injury (TBI) are at an increased risk of developing complications from venous thromboembolisms (VTEs [blood clots]). Benchmarking by the American College of Surgeons Trauma Quality Improvement Program identified suboptimal use of prophylactic anticoagulation in patients with TBI. We hypothesized that institutional implementation of an anticoagulation protocol would improve clinical outcomes in such patients. METHODS A new prophylactic anticoagulation protocol that incorporated education, weekly audits, and real-time adherence feedback was implemented in July 2015. The trauma registry identified patients with TBI before (PRE) and after (POST) implementation. Multivariable regression analysis with risk adjustment was used to compare use of prophylactic anticoagulation, VTE events, and mortality. RESULTS A total of 681 patients with TBI (368 PRE, 313 POST) were identified. After implementation of the VTE protocol, more patients received anticoagulation (PRE: 39.4%, POST: 80.5%, p < 0.001), time to initiation was shorter (PRE: 140 hours, POST: 59 hours, p < 0.001), and there were fewer VTE events (PRE: 19 [5.2%], POST: 7 [2.2%], p = 0.047). Multivariable analysis showed that POST patients were more likely to receive anticoagulation (odds ratio [OR] = 10.8, 95% confidence interval [CI] = 6.9-16.7, p < 0.001) and less likely to develop VTE (OR = 0.33, 95% CI = 0.1-1.0, p = 0.05). CONCLUSION Benchmarking can assist institutions to identity potential clinically relevant areas for quality improvement in real time. Combining education and multifaceted protocol implementation can help organizations to better focus limited quality resources and counteract barriers that have hindered adoption of best practices.
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Dynamic coagulability after injury: Is delaying venous thromboembolism chemoprophylaxis worth the wait? J Trauma Acute Care Surg 2019; 85:907-914. [PMID: 30124623 DOI: 10.1097/ta.0000000000002048] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Severely injured patients often progress from early hypocoagulable to normal and eventually hypercoagulable states, developing increased risk for venous thromboembolism (VTE). Prophylactic anticoagulation can decrease this risk, but its initiation is frequently delayed for extended periods due to concerns for bleeding. To facilitate timely introduction of VTE chemoprophylaxis, we characterized the transition from hypo- to hypercoagulability and hypothesized that trauma-induced coagulopathy resolves within 24 hours after injury. METHODS Serial blood samples were collected prospectively from critically injured patients for 120 hours after arrival at an urban Level I trauma center. Extrinsic thromboelastometry maximum clot firmness was used to classify patients as hypocoagulable (HYPO, <49 mm), normocoagulable (NORM, 49-71 mm), or hypercoagulable (HYPER, >71 mm) at each time point. Changes in coagulability over hospital course, VTE occurrence, and timing of prophylaxis initiation were analyzed. RESULTS 898 patients (median Injury Severity Score, 13; mortality, 12%; VTE, 8%) were enrolled. Upon arrival, 3% were HYPO (90% NORM, 7% HYPER), which increased to 9% at 6 hours before down-trending. Ninety-seven percent were NORM by 24 hours, and 53% were HYPER at 120 hours. Median maximum clot firmness began in the NORM range, up-trended gradually, and entered the HYPER range at 120 hours. Patients with traumatic brain injury (TBI) followed a similar course and were not more HYPO at any time point than those without TBI. Failure to initiate prophylaxis by 72 hours was predicted by TBI and associated with VTE development (27% vs 16%, p < 0.05). CONCLUSIONS Regardless of injury pattern, trauma-induced coagulopathy largely resolves within 24 hours, after which hypercoagulability becomes increasingly more prevalent. Deferring initiation of chemoprophylaxis, which is often biased toward patients with intracranial injuries, is associated with VTE development. LEVEL OF EVIDENCE Prognostic study, level III; Therapeutic, level IV.
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Mandalaywala MD, Crawford KM, Pinto SM. Management of Traumatic Brain Injury: Special Considerations for Older Adults. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00239-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Shenoy R, Cunningham KW, Ross SW, Christmas AB, Thomas BW, Avery MJ, Lessne ML, Prasad T, Sing RF. “Death Knell” for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline. Am Surg 2019. [DOI: 10.1177/000313481908500829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group ( P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.
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Affiliation(s)
- Rathna Shenoy
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Kyle W. Cunningham
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Samuel Wade Ross
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - A. Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Bradley W. Thomas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Michael J. Avery
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Mark L. Lessne
- Vascular and Interventional Specialists of Charlotte Radiology, Charlotte, North Carolina
| | - Tanushree Prasad
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Ronald F. Sing
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
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15
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Management of Head Trauma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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16
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Early Chemical Thromboprophylaxis Does not Increase the Risk of Intracranial Hematoma Progression in Patients with Isolated Severe Traumatic Brain Injury. World J Surg 2019; 43:2804-2811. [DOI: 10.1007/s00268-019-05072-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Baharvahdat H, Ganjeifar B, Etemadrezaie H, Farajirad M, Zabihyan S, Mowla A. Enoxaparin in the treatment of severe traumatic brain injury: A randomized clinical trial. Surg Neurol Int 2019; 10:10. [PMID: 30783541 PMCID: PMC6367949 DOI: 10.4103/sni.sni_112_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 12/12/2018] [Indexed: 11/04/2022] Open
Abstract
Background: Enoxaparin was shown to have a neuroprotective effect in animal models as well as a human study following traumatic brain injury. This study was conducted to assess the effect of enoxaparin on the clinical outcome of severe traumatic brain injury (TBI) and its safety. Methods: This study is a randomized double-blinded placebo-controlled trial. The inclusion criteria were age 16–70, a closed head injury, a postresuscitation Glasgow Coma Scale (GCS) between 5 and 8, and a latency time between the injury and entering the study of less than 5 h. The patients were randomized into enoxaparin and placebo groups. In the enoxaparin group, 0.5 mg/kg enoxaparin was injected subcutaneously every 6 h in six total doses. The two groups were compared for the occurrence of intracranial hematoma (ICH) and for clinical neurological outcome, assessed by the Glasgow Outcome Scale. Results: Twenty-seven patients were assigned to the placebo group and 26 to the enoxaparin group. The two groups were similar regarding baseline characteristics, including age, sex, postresuscitation GCS, and best motor response. The occurrence of new ICH or an ICH size increase was insignificantly more frequent in the enoxaparin group than the placebo group (26.9% vs. 7.4%, P = 0.076). The favorable outcome rate in the enoxaparin group was significantly higher than in the placebo group (57.7% vs. 25.9%, P = 0.019). Conclusions: This study showed that the early administration of enoxaparin could lead to favorable outcomes in severe TBI patients without significantly increasing cerebral hemorrhagic complications.
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Affiliation(s)
- Humain Baharvahdat
- Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad 99199-91766, Iran
| | - Babak Ganjeifar
- Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad 99199-91766, Iran
| | - Hamid Etemadrezaie
- Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad 99199-91766, Iran
| | - Mohammad Farajirad
- Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad 99199-91766, Iran
| | - Samira Zabihyan
- Department of Neurosurgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad 99199-91766, Iran
| | - Ashkan Mowla
- Division of Interventional Neuroradiology, Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA
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Seifi A, Dengler B, Martinez P, Godoy DA. Pulmonary embolism in severe traumatic brain injury. J Clin Neurosci 2018; 57:46-50. [DOI: 10.1016/j.jocn.2018.08.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 08/13/2018] [Indexed: 11/28/2022]
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Clinical outcomes following early versus late pharmacologic thromboprophylaxis in patients with traumatic intracranial hemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2018; 43:861-872. [DOI: 10.1007/s10143-018-1045-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/26/2018] [Accepted: 10/23/2018] [Indexed: 12/23/2022]
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20
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Frisoli FA, Shinseki M, Nwabuobi L, Zeng XL, Adrados M, Kanter C, Frangos SG, Huang PP. Early Venous Thromboembolism Chemoprophylaxis After Traumatic Intracranial Hemorrhage. Neurosurgery 2018; 81:1016-1020. [PMID: 28973510 DOI: 10.1093/neuros/nyx164] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 05/23/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Venous thromboembolism is a common complication of traumatic brain injury with an estimated incidence of 25% when chemoprophylaxis is delayed. The timing of initiating prophylaxis is controversial given the concern for hemorrhage expansion. OBJECTIVE To determine the safety of initiating venous thromboembolic event (VTE) chemoprophylaxis within 24 h of presentation. METHODS We performed a retrospective analysis of patients with traumatic intracranial hemorrhage presenting to a level I trauma center. Patients receiving early chemoprophylaxis (<24 h) were compared to the matched cohort of patients who received heparin in a delayed fashion (>48 h). The primary outcome of the study was radiographic expansion of the intracranial hemorrhage. Secondary outcomes included VTE, use of intracranial pressure (ICP) monitoring, delayed decompressive surgery, and all-cause mortality. RESULTS Of 282 patients, 94 (33%) received chemoprophylaxis within 24 h of admission. The cohorts were evenly matched across all variables. The primary outcome occurred in 18% of patients in the early cohort compared to 17% in the delayed cohort (P = .83). Fifteen patients (16%) in the early cohort underwent an invasive procedure in a delayed fashion; this compares to 35 patients (19%) in the delayed cohort (P = .38). Five patients (1.7%) in our study had a VTE during their hospitalization; 2 of these patients received early chemoprophylaxis (P = .75). The rate of mortality from all causes was similar in both groups. CONCLUSION Early (<24 h) initiation of VTE chemoprophylaxis in patients with traumatic intracranial hemorrhage appears to be safe. Further prospective studies are needed to validate this finding.
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Affiliation(s)
- Fabio A Frisoli
- Department of Neurosurgery, New York University School of Medicine, New York, New York
| | - Matthew Shinseki
- Department of Neurosurgery, New York University School of Medicine, New York, New York
| | - Lynda Nwabuobi
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Xiaopei L Zeng
- Department of Surgery, Division of Trauma and Acute Care Surgery, Bellevue Hospital Center, New York, New York
| | - Murillo Adrados
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Carolyn Kanter
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Spiros G Frangos
- Department of Surgery, Division of Trauma and Acute Care Surgery, Bellevue Hospital Center, New York, New York
| | - Paul P Huang
- Department of Neurosurgery, Bellevue Hospital Center, New York, New York
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A Systematic Review of the Risks and Benefits of Venous Thromboembolism Prophylaxis in Traumatic Brain Injury. Can J Neurol Sci 2018; 45:432-444. [PMID: 29895339 DOI: 10.1017/cjn.2017.275] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients suffering from traumatic brain injury (TBI) are at increased risk of venous thromboembolism (VTE). However, initiation of pharmacological venous thromboprophylaxis (VTEp) may cause further intracranial hemorrhage. We reviewed the literature to determine the postinjury time interval at which VTEp can be administered without risk of TBI evolution and hematoma expansion. METHODS MEDLINE and EMBASE databases were searched. Inclusion criteria were studies investigating timing and safety of VTEp in TBI patients not previously on oral anticoagulation. Two investigators extracted data and graded the papers' levels of evidence. Randomized controlled trials were assessed for bias according to the Cochrane Collaboration Tool and Cohort studies were evaluated for bias using the Newcastle-Ottawa Scale. We performed univariate meta-regression analysis in an attempt to identify a relationship between VTEp timing and hemorrhagic progression and assess study heterogeneity using an I 2 statistic. RESULTS Twenty-one studies were included in the systematic review. Eighteen total studies demonstrated that VTEp postinjury in patients with stable head computed tomography scan does not lead to TBI progression. Fourteen studies demonstrated that VTEp administration 24 to 72 hours postinjury is safe in patients with stable injury. Four studies suggested that administering VTEp within 24 hours of injury in patients with stable TBI does not lead to progressive intracranial hemorrhage. Overall, meta-regression analysis demonstrated that there was no relationship between rate of hemorrhagic progression and VTEp timing. CONCLUSIONS Literature suggests that administering VTEp 24 to 48 hours postinjury may be safe for patients with low-hemorrhagic-risk TBIs and stable injury on repeat imaging.
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Abstract
PURPOSE OF REVIEW The traumatically injured patient is at high risk for developing venous thromboembolism. Clinical practice guidelines developed by the American College of Chest Physicians and the Eastern Association for the Surgery of Trauma recognize the importance of initiating thromboprophylaxis, but the guidelines lack specific recommendations regarding the timing and dose of pharmacologic thromboprophylaxis. We review the literature regarding initiation of thromboprophylaxis in different injuries, the use of inferior vena cava filters, laboratory monitoring, dosing regimens, and the use of antiplatelet therapy. RECENT FINDINGS Use of pharmacologic thromboprophylaxis with invasive intracranial monitors is not associated with increased bleeding complications. The initiation of low-molecular-weight heparin (LMWH) prophylaxis 48 h postinjury in blunt solid organ injury is not associated with an increase in the rate of failed nonoperative management. Antiplatelet therapy in conjunction with LMWH may help to prevent venous thromboembolism. SUMMARY In the setting of blunt traumatic brain and solid organ injury, initiation of pharmacologic thromboprophylaxis 48 h after injury is not associated with increased bleeding complications. There is no consensus or clear data showing which dosing regimen of LMWH is most effective or whether routine laboratory measurements are beneficial for determining effective thromboprophylaxis.
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Evaluation of Appropriate Venous Thromboembolism Prophylaxis in Patients With Orthopaedic Trauma With Symptom-Driven Vascular and Radiographic Studies. J Orthop Trauma 2017; 31:611-616. [PMID: 28742789 DOI: 10.1097/bot.0000000000000991] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate venous thromboembolism (VTE) prophylaxis adherence and effectiveness in orthopaedic trauma patients who had vascular or radiographic studies showing deep vein thromboses or pulmonary emboli. DESIGN Retrospective review. SETTING A level I trauma center that independently services a 5-state region. PATIENTS Four hundred seventy-six patients with orthopaedic trauma who underwent operative treatments for orthopaedic injuries and had symptom-driven diagnostic VTE studies. INTERVENTION The medical records of patients treated surgically between July 2010 and March 2013 were interrogated using a technical tool that electronically captures thrombotic event data from vascular and radiologic imaging studies by natural language processing. MAIN OUTCOME MEASUREMENTS Patients were evaluated for hospital guideline-directed VTE prophylaxis adherence with mechanical or chemical prophylaxis. Patient demographics, associated injuries, mechanism of injury, and symptoms that led to imaging for a VTE were also assessed. RESULTS Of the 476 orthopaedic patients who met inclusion criteria, 100 (mean age 52.3 median 52, SD 18.3, 70% men) had positive VTE studies. Three hundred seventy-six (age 47.3, SD 17.3, 69% men) had negative VTE studies. Of the 100 patients with VTE, 63 deep vein thromboses, and 49 pulmonary emboli were found. Eight-five percent of all patients met hospital guideline-VTE prophylaxis standards. CONCLUSION The study population had better than previously reported VTE prophylaxis adherence, however, patients still developed VTEs. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Lassiter RL, Ashley DW, Medeiros RS, Adam BL, Nesmith EG, Johns TJ, Atkins EV, Dente CJ, Ferdinand CH. Descriptive Analysis of Venous Thromboembolism in Georgia Trauma Centers Compared with National Trauma Centers Participating in the Trauma Quality Improvement Program. Am Surg 2017. [DOI: 10.1177/000313481708301132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study was designed to compare the incidence of venous thromboembolism (VTE) in Georgia trauma centers with other national trauma centers participating in the Trauma Quality Improvement Program (TQIP). The use of chemoprophylaxis and characteristics of patients who developed VTE were also examined. We conducted a retrospective observational study of 325,703 trauma admissions to 245 trauma centers from 2013 to 2014. Patient demographics, rate of VTE, as well as the use, type, and timing of chemoprophylaxis were compared between patients admitted to Georgia and non-Georgia trauma centers. The rate of VTE in Georgia trauma centers was 1.9 per cent compared with 2.1 per cent in other national trauma centers. Overall, 49.6 per cent of Georgia patients and 45.5 per cent of patients in other trauma centers had documented chemoprophylaxis. Low molecular weight heparin was the most commonly used medication. Most patients who developed VTE did so despite receiving prophylaxis. The rate of VTE despite prophylaxis was 3.2 per cent in Georgia and 3.1 per cent in non-Georgia trauma centers. Mortality associated with VTE was higher in Georgia trauma centers compared with national TQIP benchmarks. The incidence of VTE and use of chemoprophylaxis within Georgia trauma centers were similar to national TQIP data. Interestingly, most patients who developed VTE in both populations received VTE prophylaxis. Further research is needed to develop best-practice guidelines for prevention, early detection, and treatment in high-risk populations.
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Affiliation(s)
| | | | | | - Bao-ling Adam
- Department of Surgery, Augusta University, Augusta, Georgia
| | | | - Tracy J. Johns
- Department of Surgery, Augusta University, Augusta, Georgia
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How long should we fear? Long-term risk of venous thromboembolism in patients with traumatic brain injury. J Trauma Acute Care Surg 2017; 81:71-8. [PMID: 27015575 DOI: 10.1097/ta.0000000000001046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although patients with traumatic brain injury (TBI) are known to be at high risk for venous thromboembolism (VTE), it is not clear how long this risk persists after injury. We aimed to determine the risk of VTE in patients with TBI during one year after injury and to identify associated factors. METHODS Patients 18 years and older with International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses of isolated TBI (head Abbreviated Injury Scale [AIS] ≥3 and AIS <3 for all other body regions) were identified in the California State Inpatient Database (2007-2011). Patient and admission (injury severity score, length of stay, and discharge disposition) characteristics were assessed. Hospital factors (teaching status, trauma center verification, and bed size) were extracted from the American Hospital Association database. Patients who developed VTE during the index admission and at different time points after discharge were determined. Multivariate logistic regression models were used to assess the associated risk factors for VTE after discharge. RESULTS There were 38,984 patients with isolated TBI identified. The incidence of VTE was 1.31% during the index admission and the cumulative incidence of VTE involving hospitalization within one year of injury was 2.83%. The major risk factors for VTE one year after injury (not including the index admission) were discharge to extended care facilities versus home [adjusted odds ratio, 2.69 (95% confidence interval, 2.14-3.37)], age older than 64 years versus 18 to 44 years [2.62 (1.80-3.81)], having an operation during the index admission [1.65 (1.36-2.01)], and hospital length of stay of more than 7 days versus 3 days or less [1.64 (1.27-2.11)]. CONCLUSION The risk of VTE persists long after discharge in a significant proportion of patients with TBI. Demographic and admission characteristics of patients play significant roles in the risk of VTE after discharge. These results highlight the need for sustained surveillance and preventive measures among patients with TBI at increased risk for long-term VTE. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Dunham CM, Huang GS. Lethal Trauma Pulmonary Embolism is a Black Swan Event in Patients at Risk for Deep Vein Thrombosis: An Evidence-Based Review. Am Surg 2017. [DOI: 10.1177/000313481708300431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We delineated the incidence of trauma patient pulmonary embolism (PE) and risk conditions by performing a systematic literature review of those at risk for deep vein thrombosis (DVT). The PE proportion was 1.4 per cent (95% confidence interval = 1.2–1.6) in at-risk patients. Of 10 conditions, PE was only associated with increased age (P < 0.01) or leg injury (P < 0.01; risk ratio = 1.6). As lower extremity DVT (LEDVT) proportions increased, mortality proportions (P = 0.02) and hospital stay (P = 0.0002) increased, but PE proportions did not (P = 0.13). LEDVT was lower with chemoprophylaxis (CP) (4.9%) than without CP (19.1%; P < 0.01). PEwas lower withCP (1.0%) than without CP (2.2%; P = 0.0004). Mortality was lower with CP (6.6%) than without CP (11.6%; P = 0.002). PE was similar with (1.2%) and without (1.9%; P = 0.19) mechanical prophylaxis (MP). LEDVT was lower with MP (8.5%) than without MP (12.2%; P = 0.0005). PE proportions were similar with (1.3%) and without (1.5%; P = 0.24) LEDVTsurveillance. Mortality was higher with LEDVTsurveillance (7.9%) than without (4.8%; P < 0.01). A PE mortality of 19.7 per cent (95% confidence interval = 18–22) 3 a 1.4 per cent PE proportion yielded a 0.28 per cent lethal PE proportion. As PE proportions increased, mortality (P = 0.52) and hospital stay (P = 0.13) did not. Of 176 patients with PE, 76 per cent had no LEDVT. In trauma patients at risk for DVT, PE is infrequent, has a minimal impact on outcomes, and death is a black swan event. LEDVTsurveillance did not improve outcomes. Because PE was not associated with LEDVT and most patients with PE had no LEDVT, preventing, diagnosing, and treating LEDVT may be ineffective PE prophylaxis.
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Affiliation(s)
- C. Michael Dunham
- General Surgery/Trauma Services/Surgical Critical Care, St. Elizabeth Youngstown Hospital, Youngstown, Ohio
| | - Gregory S. Huang
- General Surgery/Trauma Services/Surgical Critical Care, St. Elizabeth Youngstown Hospital, Youngstown, Ohio
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The effectiveness and safety of pharmacological prophylaxis against venous thromboembolism in patients with moderate to severe traumatic brain injury. J Trauma Acute Care Surg 2016; 81:567-74. [DOI: 10.1097/ta.0000000000001134] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Murphy PB, Sothilingam N, Charyk Stewart T, Batey B, Moffat B, Gray DK, Parry NG, Vogt KN. Very early initiation of chemical venous thromboembolism prophylaxis after blunt solid organ injury is safe. Can J Surg 2016; 59:118-22. [PMID: 26820318 DOI: 10.1503/cjs.010815] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The optimal timing of initiating low-molecular weight heparin (LMWH) in patients who have undergone nonoperative management (NOM) of blunt solid organ injuries (SOIs) remains controversial. We describe the safety of early initiation of chemical venous thromboembolism (VTE) prophylaxis among patients undergoing NOM of blunt SOIs. METHODS We retrospectively studied severely injured adults who sustained blunt SOI without significant intracranial hemorrhage and underwent an initial NOM at a Canadian lead trauma hospital between 2010 and 2014. Safety was assessed based on failure of NOM, defined as the need for operative intervention, in patients who received early (< 48 h) or late LMWH (≥ 48 h, or early discharge [< 72 h] without LMWH). RESULTS We included 162 patients in our analysis. Most were men (69%), and the average age was 42 ± 18 years. The median injury severity score was 17, and splenic injuries were most common (97 [60%], median grade 2), followed by liver (57 [35%], median grade 2) and kidney injuries (31 [19%], median grade 1). Combined injuries were present in 14% of patients. A total of 78 (48%) patients received early LMWH, while 84 (52%) received late LMWH. The groups differed only in percent of high-grade splenic injury (14% v. 32%). Overall 2% of patients failed NOM, none after receiving LMWH. Semielective angiography was performed in 23 (14%) patients. The overall rate of confirmed VTE on imaging was 1.9%. CONCLUSION Early initiation of medical thromboembolic prophylaxis appears safe in select patients with isolated SOI following blunt trauma. A prospective multicentre study is warranted.
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Affiliation(s)
- Patrick B Murphy
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Sothilingam, Moffat, Gray, Parry, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Sothilingam, Stewart, Batey, Gray, Parry, Vogt); and the Centre for Critical Illness Research, London, Ont. (Parry)
| | - Niroshan Sothilingam
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Sothilingam, Moffat, Gray, Parry, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Sothilingam, Stewart, Batey, Gray, Parry, Vogt); and the Centre for Critical Illness Research, London, Ont. (Parry)
| | - Tanya Charyk Stewart
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Sothilingam, Moffat, Gray, Parry, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Sothilingam, Stewart, Batey, Gray, Parry, Vogt); and the Centre for Critical Illness Research, London, Ont. (Parry)
| | - Brandon Batey
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Sothilingam, Moffat, Gray, Parry, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Sothilingam, Stewart, Batey, Gray, Parry, Vogt); and the Centre for Critical Illness Research, London, Ont. (Parry)
| | - Brad Moffat
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Sothilingam, Moffat, Gray, Parry, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Sothilingam, Stewart, Batey, Gray, Parry, Vogt); and the Centre for Critical Illness Research, London, Ont. (Parry)
| | - Daryl K Gray
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Sothilingam, Moffat, Gray, Parry, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Sothilingam, Stewart, Batey, Gray, Parry, Vogt); and the Centre for Critical Illness Research, London, Ont. (Parry)
| | - Neil G Parry
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Sothilingam, Moffat, Gray, Parry, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Sothilingam, Stewart, Batey, Gray, Parry, Vogt); and the Centre for Critical Illness Research, London, Ont. (Parry)
| | - Kelly N Vogt
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Murphy, Sothilingam, Moffat, Gray, Parry, Vogt); the Trauma Program, London Health Sciences Centre, London, Ont. (Sothilingam, Stewart, Batey, Gray, Parry, Vogt); and the Centre for Critical Illness Research, London, Ont. (Parry)
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Byrne JP, Mason SA, Gomez D, Hoeft C, Subacius H, Xiong W, Neal M, Pirouzmand F, Nathens AB. Timing of Pharmacologic Venous Thromboembolism Prophylaxis in Severe Traumatic Brain Injury: A Propensity-Matched Cohort Study. J Am Coll Surg 2016; 223:621-631.e5. [PMID: 27453296 DOI: 10.1016/j.jamcollsurg.2016.06.382] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 06/27/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patients with severe traumatic brain injury (sTBI) are at high risk for developing venous thromboembolism (VTE). Nonetheless, pharmacologic VTE prophylaxis is often delayed out of concern for precipitating extension of intracranial hemorrhage (ICH). The purpose of this study was to compare the effectiveness of early vs late VTE prophylaxis in patients with sTBI, and to characterize the risk of subsequent ICH-related complication. STUDY DESIGN Adults with isolated sTBI (head Abbreviated Injury Scale score ≥3 and total Glasgow Coma Scale score ≤8) who received VTE prophylaxis with low-molecular-weight or unfractionated heparin were derived from the American College of Surgeons Trauma Quality Improvement Program (2012 to 2014). Patients were divided into EP (<72 hours) or LP (≥72 hours) groups. Propensity score matching was used to minimize selection bias. The primary end point was VTE (pulmonary embolism or deep vein thrombosis). Secondary outcomes were defined as late neurosurgical intervention (≥72 hours) or death. RESULTS We identified 3,634 patients with sTBI. Early prophylaxis was given in 43% of patients. Higher head injury severity, presence of ICH, and early neurosurgery were associated with late prophylaxis. Propensity score matching yielded a well-balanced cohort of 2,468 patients. Early prophylaxis was associated with lower rates of both pulmonary embolism (odds ratio = 0.48; 95% CI, 0.25-0.91) and deep vein thrombosis (odds ratio = 0.51; 95% CI, 0.36-0.72), but no increase in risk of late neurosurgical intervention or death. CONCLUSIONS In this observational study of patients with sTBI, early initiation of VTE prophylaxis was associated with decreased risk of pulmonary embolism and deep vein thrombosis, but no increase in risk of late neurosurgical intervention or death. Early prophylaxis may be safe and should be the goal for each patient in the context of appropriate risk stratification.
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Affiliation(s)
- James P Byrne
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Clinical Epidemiology Program, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Stephanie A Mason
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Clinical Epidemiology Program, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David Gomez
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Hoeft
- Trauma Quality Improvement Program, American College of Surgeons, Chicago, IL
| | - Haris Subacius
- Trauma Quality Improvement Program, American College of Surgeons, Chicago, IL
| | - Wei Xiong
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Trauma Quality Improvement Program, American College of Surgeons, Chicago, IL
| | - Melanie Neal
- Trauma Quality Improvement Program, American College of Surgeons, Chicago, IL
| | - Farhad Pirouzmand
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Avery B Nathens
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Clinical Epidemiology Program, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Trauma Quality Improvement Program, American College of Surgeons, Chicago, IL
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Tracy BM, Dunne JR, O'Neal CM, Clayton E. Venous thromboembolism prophylaxis in neurosurgical trauma patients. J Surg Res 2016; 205:221-7. [PMID: 27621023 DOI: 10.1016/j.jss.2016.06.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 04/22/2016] [Accepted: 06/09/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Venous thromboembolisms (VTEs) occur more frequently in patients with traumatic brain injuries (TBIs) and spinal cord injuries, yet the use of chemoprophylaxis is controversial. The purpose of this study was to investigate the relationship between the timing of chemical VTE prophylaxis initiation and the development of VTE events in these patients. METHODS Prospective data were collected and retrospectively reviewed on 1425 patients sustaining TBIs or spinal injuries from 2010 to 2014. Patients were reviewed with respect to age, gender, injury severity score, Glasgow coma score, and mechanism of injury as well as timing of initiation of chemical VTE prophylaxis and presence or absence of VTE. RESULTS Patients who developed a VTE had a significantly longer time to initiation of chemical VTE prophylaxis (6.7 ± 4.9 d versus 4.7 ± 4.9 d, P < 0.001) compared with those that did not develop a VTE. Also, for each 1 d increase in time to prophylaxis initiation, the odds of developing a VTE increased significantly (odds ratio = 1.055, P < 0.001). The combination subarachnoid hemorrhage/subdural hemorrhage group was started on VTE prophylaxis significantly later (8.3 ± 6.1 d versus 6.7 ± 3.9 d, P < 0.01) than the overall TBI group and had a higher incidence of VTE (14.4 versus 10.4%, P = NS). In contrast, patients sustaining isolated spinal injuries received chemical VTE prophylaxis significantly earlier (3.4 ± 4.2 d versus 6.7 ± 3.9 d, P < 0.001) and had a significant decrease in their VTE rate (4.4 versus 10.4%, P < 0.0001) compared with the overall TBI group. CONCLUSIONS Patients with VTEs had a significant delay in time to initiation of chemoprophylaxis compared with patients without VTEs. Patients sustaining a TBI had a 2-fold delay in initiation of chemoprophylaxis and an associated 2-fold increase in VTE events compared with patients who sustained spinal injuries. Of those patients who developed a TBI, patients who sustained a combination subarachnoid hemorrhage and/or subdural hemorrhage had a significant delay in initiation of chemoprophylaxis with a higher rate of VTE events.
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Affiliation(s)
- Brett M Tracy
- Department of Surgery, Memorial University Medical Center, Savannah, Georgia.
| | - James R Dunne
- Department of Surgery, Memorial University Medical Center, Savannah, Georgia
| | - Cindy Marie O'Neal
- Department of Surgery, Memorial University Medical Center, Savannah, Georgia
| | - Eric Clayton
- Department of Surgery, Memorial University Medical Center, Savannah, Georgia
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Matsushima K, Inaba K, Cho J, Mohammed H, Herr K, Leichtle S, Zada G, Demetriades D. Therapeutic anticoagulation in patients with traumatic brain injury. J Surg Res 2016; 205:186-91. [PMID: 27621017 DOI: 10.1016/j.jss.2016.06.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/02/2016] [Accepted: 06/14/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Therapeutic anticoagulation (TAC) is often required in trauma patients for various indications. However, it remains unknown whether TAC can be safely initiated in the postinjury period for patients with traumatic brain injury (TBI). The purpose of this study was to evaluate the safety of TAC in TBI patients. MATERIALS AND METHODS We conducted a 7-y retrospective study. All TBI patients who received TAC within 60 d postinjury were included. In addition to patient and injury characteristics, detailed information regarding TAC was collected. The primary outcome was the incidence of neurologic deterioration or progression of hemorrhagic TBI on repeat head computed tomography (CT) after initiation of TAC. Univariate and multivariate analyses were used to identify factors associated with progression of hemorrhagic TBI after TAC. RESULTS A total of 3355 TBI patients were identified. Of those, 72 patients (2.1%) received TAC. Median age, 59; 76.4% male; median Injury Severity Score, 19; median admission Glasgow Coma Scale, 14; and median Rotterdam score on the initial head CT, 3. Although atrial fibrillation was the most common preinjury indication for TAC, venous thromboembolism was the most common postinjury indication. The median postinjury time of initiation of TAC was 9 d. Intravenous heparin infusion was the most commonly used agent for TAC (70.8%). None of our study patients developed any signs of neurologic deterioration due to TAC. Progression of hemorrhagic TBI on repeat head CT was observed in six patients. In a multiple logistic regression model, aged ≥65 y was significantly associated with progression of hemorrhagic TBI after TAC (odds ratio, 15.2; 95% confidence interval, 1.1-212.7; P = 0.04). CONCLUSIONS This study shows preliminary data regarding TAC initiated in patients with TBI. Further prospective study is warranted to determine the risks and benefits of TAC in this specific group of patients.
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Affiliation(s)
- Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California.
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Jayun Cho
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Hussan Mohammed
- Department of Radiology, University of Southern California, Los Angeles, California
| | - Keith Herr
- Department of Radiology, University of Southern California, Los Angeles, California
| | - Stefan Leichtle
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Demetrios Demetriades
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
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Prophylactic Inferior Vena Cava Filter Placement Does Not Result in a Survival Benefit for Trauma Patients. Ann Surg 2015; 262:577-85. [DOI: 10.1097/sla.0000000000001434] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Machado-Aranda DA, Jakubus JL, Wahl WL, Cherry-Bukowiec JR, To KB, Park PK, Raghavendran K, Napolitano LM, Hemmila MR. Reduction in Venous Thromboembolism Events: Trauma Performance Improvement and Loop Closure Through Participation in a State-Wide Quality Collaborative. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.05.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abdel-Aziz H, Dunham CM, Malik RJ, Hileman BM. Timing for deep vein thrombosis chemoprophylaxis in traumatic brain injury: an evidence-based review. Crit Care 2015; 19:96. [PMID: 25887600 PMCID: PMC4372323 DOI: 10.1186/s13054-015-0814-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Multiple studies have addressed deep vein thrombosis chemoprophylaxis timing in traumatic brain injuries. However, a precise time for safe and effective chemoprophylaxis is uncertain according to experts. A comprehensive literature review on brain injuries was performed to delineate temporal proportions for 1) spontaneous intracranial hemorrhage (ICH) progression, 2) post-chemoprophylaxis ICH expansion, and 3) post-chemoprophylaxis deep vein thrombosis. Twenty-three publications were found including more than 5,000 patients. Spontaneous ICH expansion at 24 hours was 14.8% in 1,437 patients from chemoprophylaxis studies and 29.9% in 1,257 patients not in chemoprophylaxis studies (P < 0.0001). With low-risk ICH (n = 136), 99% of spontaneous ICH expansion occurred within 48 hours. In moderate or high-risk ICH (n = 109), 18% of spontaneous ICH expansion occurred after day 3. If patients with pre-chemoprophylaxis ICH expansion are included, the post-chemoprophylaxis ICH expansion proportion was 5.6% in 1,258 patients with chemoprophylaxis on days 1 to 3 and was 1.5% in 401 with chemoprophylaxis after day 3 (P = 0.0116). If patients with pre-chemoprophylaxis ICH expansion were excluded, the post-chemoprophylaxis ICH expansion proportion was 3.1% in 1,570 patients with chemoprophylaxis on days 1 to 3 and was 2.8% in 582 with chemoprophylaxis after day 3 (P = 0.7769). In diffuse axonal injury (n = 188), the post-chemoprophylaxis ICH expansion proportion was 1.6% with chemoprophylaxis after day 3. The deep vein thrombosis proportions were as follows: chemoprophylaxis on days 1 to 3, 2.6% in 2,384 patients; chemoprophylaxis on days 4 or 5, 2.2% in 831; and chemoprophylaxis on day 8, 14.1% in 99 (P < 0.0001). Spontaneous ICH expansion proportions at 24 hours substantially vary between chemoprophylaxis and non-chemoprophylaxis studies. Chemoprophylaxis should not be given within 3 days of injury for moderate-risk or high-risk ICH. Chemoprophylaxis is reasonable when low-risk patients have not developed ICH expansion within 48 hours post-injury. Chemoprophylaxis is also acceptable after day 3, when low-risk patients develop ICH expansion within 48 hours post-injury. In diffuse axonal injury patients who have not developed ICH within 72 hours, chemoprophylaxis is reasonable. Deep vein thrombosis proportions significantly increase when chemoprophylaxis is withheld for greater than 7 days.
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Affiliation(s)
- Hiba Abdel-Aziz
- General Surgery/Trauma Services/Surgical Critical Care, St Elizabeth Health Center, 1044 Belmont Avenue, Youngstown, OH, 44501, USA.
| | - C Michael Dunham
- General Surgery/Trauma Services/Surgical Critical Care, St Elizabeth Health Center, 1044 Belmont Avenue, Youngstown, OH, 44501, USA.
| | - Rema J Malik
- General Surgery/Trauma Services/Surgical Critical Care, St Elizabeth Health Center, 1044 Belmont Avenue, Youngstown, OH, 44501, USA.
| | - Barbara M Hileman
- General Surgery/Trauma Services/Surgical Critical Care, St Elizabeth Health Center, 1044 Belmont Avenue, Youngstown, OH, 44501, USA.
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M. Foreman P, G. R. Schmalz P, Griessenauer CJ. Chemoprophylaxis for venous thromboembolism in traumatic brain injury: A review and evidence-based protocol. Clin Neurol Neurosurg 2014; 123:109-16. [DOI: 10.1016/j.clineuro.2014.05.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/19/2014] [Accepted: 05/18/2014] [Indexed: 10/25/2022]
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Raychaudhuri R, Litofsky NS. Which traumatic brain injury patients should be treated with anticoagulants and when? Expert Rev Neurother 2014; 14:237-9. [DOI: 10.1586/14737175.2014.888652] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Jeremitsky E, St. Germain N, Kao AH, Ong AW, Smith RS. Risk of pulmonary embolism in trauma patients: Not all created equal. Surgery 2013; 154:810-4; discussion 814-5. [DOI: 10.1016/j.surg.2013.04.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 04/19/2013] [Indexed: 10/26/2022]
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Farooqui A, Hiser B, Barnes SL, Litofsky NS. Safety and efficacy of early thromboembolism chemoprophylaxis after intracranial hemorrhage from traumatic brain injury. J Neurosurg 2013; 119:1576-82. [PMID: 24053504 DOI: 10.3171/2013.8.jns13424] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Patients with traumatic brain injury (TBI) are at risk for development of thromboembolic disease. The use of chemoprophylaxis in this patient group has not fully been characterized. The authors hypothesize that early chemoprophylaxis in patients with TBI is safe and efficacious. METHODS In May 2009, a protocol was instituted for patients with TBI where chemoprophylaxis for thromboembolic disease (either 30 mg of Lovenox twice daily or 5000 U of heparin 3 times a day) was initiated 24 hours after an intracranial hemorrhage (ICH) was demonstrated as stable on head CT image. Two cohorts were evaluated: Cohort A included patients from May 2008 through April 2009 who had no routine administration of chemoprophylaxis, and Cohort B included patients from May 2009 through May 2010 after the protocol was instituted. The groups were compared, with the major outcomes being deep venous thrombosis (DVT), pulmonary embolism, and increase in size of ICH. RESULTS Of the 312 patients with TBI who were seen during the study course, 236 patients met criteria for inclusion in the study: 107 patients in Cohort A and 129 patients in Cohort B. The DVT rate was 6 occurrences (5.61%) in Cohort A and 0 occurrences (0%) in Cohort B, which was a statistically significant difference (p = 0.0080). Pulmonary embolism was found in 4 patients (3.74%) in Cohort A and 1 patient (0.78%) in Cohort B, a difference that did not reach statistical significance (p = 0.18). Three instances (2.8%) in Cohort A and 1 instance (0.7%) in Cohort B of increased ICH occurred after starting anticoagulation for chemoprophylaxis; this was not statistically different (p = 0.33). CONCLUSIONS Use of chemoprophylaxis in TBI 24 hours after stable head CT is safe and decreases the rate of DVT formation.
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Chelladurai Y, Stevens KA, Haut ER, Brotman DJ, Sharma R, Shermock KM, Kebede S, Singh S, Segal JB. Venous thromboembolism prophylaxis in patients with traumatic brain injury: a systematic review. F1000Res 2013; 2:132. [PMID: 25309725 PMCID: PMC4184319 DOI: 10.12688/f1000research.2-132.v1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2013] [Indexed: 11/20/2022] Open
Abstract
Objective: There is considerable practice variation and clinical uncertainty about the choice of prophylaxis for preventing venous thromboembolism in patients with traumatic brain injury. We performed a systematic review to assess both the effectiveness and safety of pharmacologic and mechanical prophylaxis, and the optimal time to initiate pharmacologic prophylaxis in hospitalized patients with traumatic brain injury. Data sources and study selection: MEDLINE®, EMBASE®, SCOPUS, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library were searched in July 2012 to identify randomized controlled trials and observational studies reporting on the effectiveness or safety of venous thromboembolism prevention in traumatic brain injury patients. Data extraction: Paired reviewers extracted detailed information from included articles on standardized forms and assessed the risk of bias in each article. Data synthesis: Twelve studies (2 randomized controlled trials and 10 cohort studies) evaluated the effectiveness and safety of venous thromboembolism prophylaxis in patients with traumatic brain injury. Five of the included studies assessed the optimal timing of initiation of pharmacological prophylaxis. Low grade evidence supports the effectiveness of enoxaparin over control in reducing deep vein thrombosis. Low grade evidence also supports the safety of unfractionated heparin over control in reducing mortality in patients with traumatic brain injury. Evidence was insufficient for remaining comparisons and outcomes including the optimal timing of initiation of pharmacoprophylaxis. Conclusion: There is some evidence that pharmacoprophylaxis improves deep vein thromboses and mortality outcomes in patients hospitalized with traumatic brain injury. Additional studies are required to strengthen this evidence base.
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Affiliation(s)
| | - Kent A Stevens
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Daniel J Brotman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Ritu Sharma
- John Hopkins University Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Kenneth M Shermock
- Department of Pharmacy, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Sosena Kebede
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Sonal Singh
- John Hopkins University Bloomberg School of Public Health, Baltimore, MD, 21205, USA ; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Jodi B Segal
- John Hopkins University Bloomberg School of Public Health, Baltimore, MD, 21205, USA ; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
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Ben Hamouda N, Oddo M. Prise en charge du traumatisme crânien cérébral grave. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-012-0620-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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