A 20-year retrospective analysis of deep venous thrombosis and pulmonary embolism among combat casualties requiring damage-control laparotomy at US military Role 2 surgical units

BACKGROUND

Combat casualties receiving damage-control laparotomy at forward deployed, resource-constrained US military Role 2 (R2) surgical units require multiple evacuations, but the added risk of venous thromboembolism (VTE) in this population has not been defined. To fill this gap, we retrospectively analyzed 20 years of Department of Defense Trauma Registry data to define the VTE rate in this population.

METHODS

Department of Defense Trauma Registry from 2002 to 2023 was queried for US military combat casualties requiring damage-control laparotomy at R2. All deaths were excluded in subsequent analysis. Rates of VTE were assessed, and subgroup analysis was performed on patients requiring massive transfusion.

RESULTS

Department of Defense Trauma Registry (n = 288) patients were young (mean age, 25 years) and predominantly male (98%) with severe (mean Injury Severity Score, 26), mostly penetrating injury (76%) and high mortality. Venous thromboembolism rate was high: 15.8% (DVT, 10.3%; pulmonary embolism, 7.1%). In the massively transfused population, the VTE rate was even higher (26.7% vs. 10.2%, p < 0.001).

CONCLUSION

This is the first report that combat casualties requiring damage-control laparotomy at R2 have such high VTE rates. Therefore, for military casualties, we propose screening ultrasound upon arrival to each subsequent capable echelon of care and low threshold for initiating thromboprophylaxis.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Prevalence and risk factors for proximal deep vein thrombosis at admission in patients with traumatic fractures: a multicenter retrospective study

Objective

This study aimed to determine the associated risk factors for proximal deep vein thrombosis (DVT) in patients with lower extremity and pelvic-acetabular fractures.

Methods

The medical records of 4,056 patients with lower extremity and pelvic-acetabular fractures were retrospectively reviewed. The patients were classified into proximal or non-proximal DVT groups. Logistic regression models were used to determine the independent risk variables for proximal DVT. The predictive value of the related risk factors was further analyzed using receiver operating characteristic curves.

Results

The prevalence of proximal DVT was 3.16%. Sex, body mass index (BMI), fracture site, injury mechanism, diabetes, coronary heart disease (CHD), injury-to-admission interval, hematocrit, platelet counts, and D-dimer levels differed significantly between the two groups. BMI ≥ 24.0 kg/m2, femoral shaft fractures, high-energy injury, diabetes, injury-to-admission interval >24 h were independent risk factors for proximal DVT. CHD decreased the risk of proximal DVT. The platelet and D-dimer had high negative predictive value for predicting proximal DVT formation, with cut-off values of 174 × 109/L and 2.18 mg/L, respectively.

Conclusion

BMI ≥ 24.0 kg/m2, femoral shaft fractures, high-energy injury, diabetes, injury-to-admission interval >24 h were independent risk factors for proximal DVT in patients with lower extremity and pelvic-acetabular fractures. Platelet count and D-dimer level were effective indicators for excluding proximal DVT occurrence. CHD decreased the risk of proximal DVT.

Incidence and risk factors of clinically important venous thromboembolism in tibial plateau fractures

While there are multiple reports on venous thromboembolism (VTE) associated with several orthopedic procedures, the knowledge regarding incidence and risk factors of VTE in tibial plateau fractures is limited. This study aimed to investigate the incidence and risk factors of clinically important venous thromboembolism (CIVTE) in patients with tibial plateau fractures. All adult patients who underwent surgical treatment of tibia plateau fractures between 2003 and 2018 in our level 1 trauma center were included in the study. All patients suspected CIVTE were assessed by the ultrasonography and/or CT scan. Univariate and multivariate analysis were used to evaluate the association between potential risk factors and CIVTE Variables. Thirty-nine of 462 patients (8.4%) developed clinically important venous thromboembolism, in which pulmonary embolism (PE) and deep vein thrombosis (DVT) were observed in 18 (3.9%) and 21 (4.54%) patients, respectively. Male gender (OR 9.75; 95% CI 2.34-40.66), spine injury (OR 9.51; 95% CI 3.39-26.64), other extremity injury (OR 3.7; 95% CI 1.58-8.66), length of stay in ICU (OR 1.14; 95% CI 1.09-1.2) were all risk factors for CIVTE. The incidence of CIVTE in tibial plateau fracture was relatively high (8.4%); The male gender, spine injury, other extremity injury, length of stay in ICU were the independent risk factors.

Viscoelastic Hemostatic Assays for Orthopedic Trauma and Elective Procedures

The application of viscoelastic hemostatic assays (VHAs) (e.g., thromboelastography (TEG) and rotational thromboelastometry (ROTEM)) in orthopedics is in its relative infancy when compared with other surgical fields. Fortunately, several recent studies describe the emerging use of VHAs to quickly and reliably analyze the real-time coagulation and fibrinolytic status in both orthopedic trauma and elective orthopedic surgery. Trauma-induced coagulopathy—a spectrum of abnormal coagulation phenotypes including clotting factor depletion, inadequate thrombin generation, platelet dysfunction, and dysregulated fibrinolysis—remains a potentially fatal complication in severely injured and/or hemorrhaging patients whose timely diagnosis and management are aided by the use of VHAs. Furthermore, VHAs are an invaluable compliment to common coagulation tests by facilitating the detection of hypercoagulable states commonly associated with orthopedic injury and postoperative status. The use of VHAs to identify hypercoagulability allows for an accurate venous thromboembolism (VTE) risk assessment and monitoring of VTE prophylaxis. Until now, the data have been insufficient to permit an individualized approach with regard to dosing and duration for VTE thromboprophylaxis. By incorporating VHAs into routine practice, orthopedic surgeons will be better equipped to diagnose and treat the complete spectrum of coagulation abnormalities faced by orthopedic patients. This work serves as an educational primer and up-to-date review of the current literature on the use of VHAs in orthopedic surgery.

THE EFFICACY OF WEIGHT-BASED ENOXAPARIN DOSING FOR VTE-PROPHYLAXIS IN TRAUMA PATIENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

Trauma patients are at high risk of developing venous thromboembolism (VTE), and standard dosing enoxaparin regimens may be inadequate for prophylaxis. This meta-analysis was performed to clarify the efficacy of alternative dosing regimens for VTE prophylaxis in this high-risk group. The objective of this systematic review was to review the evidence regarding weight-based dosing of enoxaparin for VTE prophylaxis in trauma patients.

METHODS

A systematic database search was undertaken for studies comparing standard vs weight-based dosing of enoxaparin for VTE prophylaxis in adult trauma patients, aged ≥18 years. The primary outcome was the achievement of Anti-Factor Xa (AFXa) levels within the prophylactic range. Secondary outcomes included: sub-prophylactic AFXa levels, supra-prophylactic AFXa levels, VTE incidence and bleeding events. Meta-analysis was conducted using both fixed- and random-effects models, and presented as odds ratios (OR), risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI).

RESULTS

Four cohort studies were eligible for inclusion. Compared to standard dosing, weight-based enoxaparin prophylaxis dosing was associated with increased odds of prophylactic AFXa levels (OR = 5.85., 95%CI: 3.02-11.30, p < 0.00001) and reduced risk of sub-prophylactic AFXa levels (RR = 3.97, 95%CI: 3.02-5.22, p < 0.00001). Standard dosing was associated with a reduced risk of supra-therapeutic AFXa levels (RR = 0.23, 95%CI: 0.11-0.50, P = 0.0002), but this was not associated with a difference in risk of bleeding events (RD = -0.00, 95%CI: -0.02-0.01, P = 0.55). There was no statistical difference in incidence VTE between the two groups (RD = 0.01, 95%CI: -0.02-0.03, P = 0.64).

CONCLUSIONS

Compared with standard dosing, weight-based enoxaparin dosing regimens are associated with increased odds of prophylactic range AFXa levels. Further investigation is required to determine if this translates into improved VTE prophylaxis and reduced VTE incidence.

LEVEL OF EVIDENCE

Systematic Review, level III.

Vena Cava Filters: A Synopsis of Complications and Related Topics

Deep venous thrombosis and pulmonary embolism constitute common preventable causes of morbidity and mortality. The incidence of venous thromboembolism (VTE) continues to increase. Standard anticoagulation therapy may reduce the risk of fatal PE by 75% and that of recurrent VTE by over 90%. For patients who are not candidates for anticoagulation, a vena cava filter (VCF) may be beneficial. Despite a good overall safety record, significant complications related to VCF are occasionally seen. This review discusses both procedural and non-procedural complications associated with VCF placement and use. We will also discuss VCF use in the settings of pregnancy, malignancy, and the clinical need for more than one filter.

Correction of multiple complex lower limb deformities by intramedullary nailing

A female patient presented to our institution suffering from long bone post-traumatic multiple deformities. Her walking was limited, painful and teetering. It had worsened over the past months. The right leg was shortened by 6 cm compared to the contralateral. The right femur was 18° varus, the right tibia was 16° valgus, the left tibia was 12° varus. Both knee joints showed marked radiographic signs of osteosclerosis. After a thorough study with simulations using paper models, we carried out three osteotomies, two open wedge and one cuneiform, stabilizing them with intramedullary nails. We conducted the operation in two stages, in order to avoid an excessive surgical stress that could give rise to complications such as DVT, fat embolism, and respiratory insufficiency. This allowed a rapid recovery of her weight bearing and walking capacity, reducing significantly also the leg length discrepancy. She progressed uneventfully to healing of the osteotomy sites and she returned to her previous occupation.

Bilateral femoral shaft fractures complicated by fat and pulmonary embolism: a case report

A 25-year-old man was admitted to our hospital because of pulmonary embolism and suspected fat embolism after sustaining bilateral femoral shaft fracture. A left arm weakness, tachycardia and sudden hemoglobin drop delayed his definitive fixation with intramedullary nailing. His clinical course was further complicated by bleeding from the pin sites of the external fixators which had initially been used to temporarily stabilize his femoral fractures (clotting disturbances). A lower leg Doppler ultrasound and a new pelvic-chest CT angiography excluded any remaining thrombus, meanwhile the embolus had broken in smaller pieces, more distally. His unfractionated heparin was revised to a Low Molecular Weight Heparin at prophylactic dose. After a 10 day period and when his condition had been improved bilateral reamed nailing was performed. Although bilateral closed femoral shaft fractures should be stabilized early, fat embolism syndrome (FES) and thromboembolic events (TEV) should always be kept in mind in these patients.

Post-traumatic thrombo-embolic complications in polytrauma patients

INTRODUCTION

Thrombo-embolic events after trauma are considered to be life-threatening complications. Our aim was to determine the incidence of arterial and venous thrombo-embolic events (TE) in severely-injured trauma patients, and its associated risk factors by using a large trauma registry.

METHODS

Patients' data from the TraumaRegister DGU® (TR-DGU) were screened for TE (DVT [symptomatic deep vein thrombosis], PE [symptomatic pulmonary embolism], MI [myocardial infarction], and stroke) through the clinical course of severely injured adult trauma patients from January 2005 to December 2012. Univariate analysis was used to compare the clinical outcomes (endpoints: mortality, ICU and hospital length of stay, ventilator days), and a multivariate regression analysis was used to assess the independent risk factors associated with each TE event.

RESULTS

From a cohort of 40,846 trauma patients, 1122 (2.8%) patients developed a TE during their post-traumatic clinical course (313, 0.8% DVT; 425, 1.0% PE; 160, 0.4% MI and 231, 0.6% stroke). ICU length of stay [LOS], total LOS, days on mechanical ventilation, and incidence of multiple organ failure (MOF) and sepsis were significantly increased in patients with TE complications. Injury severity, major pelvic injury, and one or more operations were found to be independent risk factors for the development of DVT. Age ≥ 60 years, male gender, and more than one operation were risk factors for PE development. For MI age was the only significant risk factor. The occurrence of a stroke is increased in patients with an age ≥ 60 years, major head injury (AIS head ≥ 3), and more than one operation. Finally, mortality rates were significantly higher in the TE group when compared to the non-TE cohort (21.8% vs. 12.7%; p < 0.001).

CONCLUSION

TE complications were associated with longer ICU and hospital stay as well as a higher mortality. Overall, age and repeated operations were the most important risk factors for the development of TE events.

Venous thromboembolism during combat operations: a 10-y review

BACKGROUND

This article examines the incidence of venous thromboembolism (VTE) in combat wounded, identifies risk factors for pulmonary embolism (PE), and compares the rate of PE in combat with previously reported civilian data.

METHODS

A retrospective review was performed of all U.S. military combat casualties in Operation Enduring Freedom and Operation Iraqi Freedom with a VTE recorded in the Department of Defense Trauma Registry from September 2001 to July 2011. The Military Amputation Database of all U.S. military amputations during the same 10-y period was also reviewed. Demographic data, injury characteristics, and outcomes were evaluated.

RESULTS

Among 26,634 subjects, 587 (2.2%) had a VTE. This number included 270 subjects (1.0%) with deep venous thrombosis (DVT), 223 (0.8%) with PE, and 94 (0.4%) with both DVT and PE. Lower extremity amputation was independently associated with PE (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.07-2.69). A total of 1003 subjects suffered a lower extremity amputation, with 174 (17%) having a VTE. Of these, 75 subjects (7.5%) were having DVT, 70 (7.0%) were having PE, and 29 (2.9%) were found to have both a DVT and a PE. Risk factors found to be independently associated with VTE in amputees were multiple amputations (OR, 2; 95% CI, 1.35-3.42) and above the knee amputation (OR, 2.11; 95% CI, 1.3-3.32).

CONCLUSIONS

Combat wounded are at a high risk for thromboembolic complications with the highest risk associated with multiple or above the knee amputations.

Hypercoagulability following blunt solid abdominal organ injury: when to initiate anticoagulation

BACKGROUND

The optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown.

METHODS

Postinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours.

RESULTS

Forty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance).

CONCLUSIONS

Patients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.

Implante profilático e temporário de filtro de veia cava inferior no trauma

O tromboembolismo pulmonar (TEP) é importante causa de óbito no trauma e esse, na maioria das vezes, contraindica a principal farmacoterapia na prevenção e no tratamento do TEP: a anticoagulação. Relatamos um caso de paciente politraumatizado, com risco elevado de embolia pulmonar, submetido ao implante preventivo e temporário de filtro de veia cava inferior (FVC).

Incidence of venous thromboembolism in fractures around and below the knee with physical prophylaxis

Fractures occurring at the distal part of the lower extremities are recognized to have a relatively lower risk of venous thromboembolism (VTE); however, few detailed reports exist on the subject. The purpose of this study was to investigate the incidence of VTE in fractures around and below the knee. Overall, 109 consecutive patients with fractures around and below the knee who were surgically treated at the authors' hospital were analyzed retrospectively. Physical prophylaxis was performed in all patients. Until April 2009, VTE screening was performed by contrast-enhanced computed tomography or ultrasonography when the D-dimer value did not decline predictably, exceeded 20 μg/mL 5 days after trauma and surgery, or increased above 20 μg/mL after a period of decline. After April 2009, ultrasonography was routinely performed pre- and postoperatively irrespective of the D-dimer value. The patients were divided into 2 groups based on the absence or presence of accompanying injuries, including head, chest, abdominal, or spinal injury and other fractures of the pelvis and lower extremities. Overall, VTE and pulmonary thromboembolism were detected in 28 (25.7%) patients and 5 (4.6%) patients, respectively. All cases were asymptomatic. The VTE incidence rates were 8.6% (former screening) and 40% (newer screening) in patients with isolated fractures and 25% (former screening) and 41.7% (newer screening) in patients with accompanying injuries. The pulmonary thromboembolism incidence rates were 2.9% (former screening) and 0% (newer screening) in patients with isolated fractures and 3.2% (former screening) and 25.0% (newer screening) in patients with accompanying injuries. Surgeons should be vigilant for symptoms of VTE in patients with fractures occurring at the distal part of the lower extremities.

Venous thromboembolism in Japanese patients with fractures of the pelvis and/or lower extremities using physical prophylaxis alone

PURPOSE

To investigate the rate of venous thromboembolism (VTE) in Japanese patients with fractures of the pelvis and/or lower extremities using physical prophylaxis alone.

METHODS

Records of 66 men and 60 women aged 15 to 95 (mean, 57) years with fractures of the pelvis and/ or lower extremities were retrospectively reviewed. They were screened for VTE based on D-dimer values. Contrast-enhanced computed tomography and/or ultrasonography were performed when the D-dimer value did not decline predictably or exceeded 20 μg/ml even 5 days after injury or surgery. Physical prophylaxis for VTE in terms of graduated compression stockings and intermittent pneumatic compression were applied for all patients.

RESULTS

Of the 126 patients, 24 were detected to have VTE (10 of 29 with multiple fractures and 14 of 97 with single fractures). Six patients were detected to have asymptomatic pulmonary thromboembolism (PTE), whereas 20 patients were detected to have deep vein thrombosis (bilaterally in 7). The rates of VTE were high in patients with multiple fractures (35%), pelvic fractures (18%), and femoral shaft fractures (50%). The rate of PTE was high in patients with pelvic fractures (12%).

CONCLUSION

The rate of VTE in the Japanese patients was similar to that in western populations. Our screening method was useful for preventing fatal PTEs. Surgeons should be vigilant for VTE during the first 2 weeks after injury, especially in patients with multiple and pelvic fractures.

Incidence and risk factors for deep venous thrombosis after moderate and severe brain injury

BACKGROUND

Patients with traumatic injuries possess a high risk of developing deep venous thrombosis (DVT), thus the need for appropriate prophylaxis. Patients with head injuries pose a unique challenge due to contraindication to the use of anticoagulation. We sought to determine the incidence of DVT and identify specific risk factors for its development in patients with head injuries.

METHODS

All head injury admissions between January 1, 2000, and July 31, 2006, with a length of stay >or=7 days were identified. Patient data including age, sex, injuries, Glasgow Coma Scale, Injury Severity Score (ISS), and venous duplex scan results were collected. Mechanical methods were routinely used for prophylaxis; heparin was not used in this population. Weekly duplex screening was commenced at 7 days to 10 days after admission.

RESULTS

There were 939 patients who met criteria for review, however, duplex scans were performed in only 677, which was the population studied. Overall, DVT was present in 31.6%. There were fewer DVTs in patients with isolated head injuries (25.8%) compared with patients with those with head and extracranial injuries (34.3%)--p = 0.026. Independent predictors for DVT identified included male gender (p = 0.04), age >or=55 (p < 0.001), ISS >or=15 (p = 0.014), subarachnoid hemorrhage (p = 0.006), and lower extremity injury (p = 0.001).

CONCLUSIONS

DVT occurs in one third of moderately to severely brain injured patients. Isolated head injuries have a lower incidence. Older age, male gender, higher ISS, and the presence of a lower extremity injury are strong predictors for developing DVT. Regular screening and the use of prophylactic inferior vena cava filters in patients with risk factors should be strongly considered.

Venous thromboembolism after severe trauma: incidence, risk factors and outcome

BACKGROUND

Venous thromboembolic events (VTEs) are common life-threatening complications after trauma, but epidemiology and reported risk factors still vary. The purpose of this investigation was to determine the incidence of VTEs among hospitalised trauma patients, to identify potential risk factors and to assess whether their presence was associated with: (a) the magnitude and pattern of injury, (b) therapeutic interventions and (c) outcome, all by using a large population-based registry.

PATIENTS AND METHODS

Patient data from the Trauma Registry of the German Society for Trauma Surgery (TR-DGU) including datasets from more than 35,000 trauma patients were screened for all clinically relevant VTEs, i.e. deep vein thrombosis (DVT) and pulmonary embolism (PE). A total of 7937 patients were identified for further investigation and multivariate logistic regression analyses were performed to assess potential risk factors for VTEs and to evaluate the effect of VTEs on outcome.

RESULTS

One hundred forty-six of 7937 patients developed clinically relevant VTEs during post-traumatic hospitalisation corresponding to an overall incidence rate of 1.8%. Two-thirds (97/146) of all VTEs occurred during the first 3 weeks after admission. At the time point of the event 118/146 (80.8%) patients were under either mechanical or chemical prophylaxis. Multivariate analysis with VTE as dependent variable identified injury severity score, the number of operative procedures, pelvic injury (abbreviated injury scale > or = 2) and concomitant diseases (i.e. diabetes, renal failure, malignancies and congenital or acquired coagulation disorders) as independent risk factors. The presence of VTEs was associated with higher frequencies of sepsis (25% vs. 9.1%), single (63.6% vs. 41.3%) and multiple organ failure (49% vs. 25%) and prolonged in-hospital length of stay (52+/-34 days vs. 29+/-30 days; all p<0.001). The mortality in the VTE group totaled 13.7% vs. 7.4% in the non-VTE group (p=0.004). The presence of PE was associated with a mortality rate of 25.7%. The adjusted odds ratio of post-traumatic VTEs for hospital mortality was 2.08 (CI95 1.15-3.78; p=0.016).

CONCLUSION

The occurrence of clinically apparent VTEs during post-traumatic hospitalisation is low but associated with increased morbidity and mortality. Conclusions about the effectiveness of different thromboprophylactic measures could not be drawn, since detailed information was not recorded. However, 80.8% of VTE patients had received thromboprophylaxis at the time point of the event.

Serial compression B-scan and Doppler sonography for the screening of deep venous thrombosis in patients with spinal cord injuries

PURPOSE

To evaluate the usefulness of serial compression B-scan and Doppler sonography (US) in screening for deep venous thrombosis (DVT) of the lower extremities in patients with spinal cord injuries.

METHOD

Patients with paraplegia and tetraplegia due to spinal cord injuries were screened by a serial compression B-scan and Doppler US protocol for DVT of the bilateral lower extremities within the first 36 hours after admission, at day 7 and at day 21. In patients with DVT, a follow-up US examination was performed 3 weeks after diagnosis to assess thrombi distribution.

RESULTS

Between January 2007 and March 2008, a total of 115 patients (75 males, 40 females), aged 19 to 85 years, were included. The first US examination documented a DVT in 44 cases (38.3%). After an initial negative scan, sonography after 7 days and 21 days showed DVT in 6 patients and 2 patients, respectively. Cumulative rate of DVT after the first 3 weeks was 45.2% (n=52). Follow-up US after 3 weeks in patients with DVT documented a complete recanalization in 19 patients (36.5%), no change in 12 patients (23.1%), and residual thrombi with partial recanalization in 21 patients (40.4%).

CONCLUSION

Our study supports the use of serial compression B-scan and Doppler US as a screening tool for DVT of the lower extremities in patients with spinal cord injuries early after injury.

Rapid thrombelastography (r-TEG) identifies hypercoagulability and predicts thromboembolic events in surgical patients

BACKGROUND

Despite routine prophylaxis, thromboembolic events (TEs) in surgical patients remain a substantial problem. Furthermore, the timing and incidence of hypercoagulability, which predisposes to these events is unknown, with institutional screening programs serving primarily to establish a diagnosis after an event has occurred. Emerging evidence suggests that point of care (POC) rapid thrombelastography (r-TEG) provides a real-time analysis of comprehensive thrombostatic function, which represents an analysis of both enzymatic and platelet components of thrombus formation. We hypothesized that r-TEG can be used as a screening tool to identify hypercoagulable states in surgical patients and would predict subsequent thromboembolic events.

METHODS

Rapid thrombelastography r-TEG analyses were performed on 152 critically ill patients in the surgical intensive care unit (ICU) during 7 months. Hypercoagulability was defined as clot strength (G)>12.4 dynes/cm(2). Variables of interest for identifying hypercoagulability and thromboembolic events included sex, age, operating hospital service, specific injury patterns, injury severity score (ISS), transfusion within first 24 h, ICU duration of stay, ventilator days, hospital admission days, and thromboprophylaxis. Comparisons between the hypercoagulable and normal groups or between the groups with and without thromboembolic events were performed using Chi-square tests or the Fisher exact test for categorical variables and independent sample t tests or Wilcoxon rank sum tests for continuous variables. Multivariate logistic regression analysis (LR) was performed to identify independent predictors of thromboembolic events. A receiver operating characteristic curve was used to measure the performance of G for predicting the occurrence of a TE event. All tests were 2-sided with significance of P < .05.

RESULTS

In all, 86 patients (67%) were hypercoagulable by r-TEG. More than 85% of patients in the hypercoagulable group and 79% in the normal group received thromboprophylaxis during the study period. The differences between hypercoagulable and normal groups by bivariate analysis included high-risk injuries (52% vs 35%; P = .03), spinal cord injury (27% vs 12%; P = .03), median ICU duration of stay (13 vs 7 days; P < .001), median ventilator days (6 vs 2; P < .001), and median hospital duration of stay (20 vs 13 days; P < .001). A total of 16 patients (19%) of the hypercoagulable group suffered a thromboembolic event, and 10 hypercoagulable patients (12%) had thromboembolic events predicted by prior r-TEG hypercoagulability. No patients with normal coagulability by r-TEG had an event (P < .001). LR analysis showed that the strongest predictor of TE after controlling for the presence of thromboprophylaxis was elevated G value (odds ratio: 1.25, 95% confidence interval [CI]: 1.12-1.39). For every 1 dyne/cm(2) increase in G, the odds of a TE increased by 25%.

CONCLUSION

These results indicate that the presence of hypercoagulability identified by r-TEG is predictive of thromboembolic events in surgical patients. Subsequent study is necessary to define optimal prophylactic treatment strategies for patients with r-TEG proven hypercoagulability.

Recombinant factor VIIA in traumatic intracerebral hemorrhage: results of a dose-escalation clinical trial

OBJECTIVE

Intracerebral hemorrhages, whether spontaneous or traumatic (tICH), often expand, and an association has been described between hemorrhage expansion and worse clinical outcomes. Recombinant factor VIIa (rFVIIa) is a hemostatic agent that has been shown to limit hemorrhage expansion and which, therefore, could potentially reduce morbidity and mortality in tICH. This first prospective, randomized, placebo-controlled, dose-escalation study evaluated the safety and preliminary effectiveness of rFVIIa to limit tICH progression.

METHODS

Patients were enrolled if they had tICH lesions of at least 2 ml on a baseline computed tomographic scan obtained within 6 hours of injury. rFVIIa or placebo was administered within 2.5 hours of the baseline computed tomographic scan but no later than 7 hours after injury. Computed tomographic scans were repeated at 24 and 72 hours. Five escalating dose tiers were evaluated (40, 80, 120, 160, and 200 microg/kg rFVIIa). Clinical evaluations and adverse events were recorded until Day 15.

RESULTS

No significant differences were detected in mortality rate or number and type of adverse events among treatment groups. Asymptomatic deep vein thrombosis, detected on routinely performed ultrasound at Day 3, was observed more frequently in the combined rFVIIa treatment group (placebo, 3%; rFVIIa, 8%; not significant). A nonsignificant trend for rFVIIa dose-response to limit tICH volume increase was observed (placebo, 21.0 ml; rFVIIa, 10.1 ml).

CONCLUSION

In this first prospective study of rFVIIa in tICH, there appeared to be less hematoma progression in rFVIIa-treated patients (80-200 microg/kg) compared with that seen in placebo treated patients. The potential significance of this biological effect on clinical outcomes and the significance of the somewhat higher incidence of ultrasound-detected deep vein thromboses in the rFVIIa-treated group need to be examined in a larger prospective randomized clinical trial.

Transthoracic echocardiography for suspected pulmonary embolism in the intensive care unit: unjustly underused or rightfully ignored?

Transthoracic echocardiography (TTE) is an established part of modern medical practice, and its use in documenting cardiac disorders has long been recognized. Since the introduction of 2-dimensional TTE, the right-sided heart chambers have become amenable to fairly accurate analysis, enabling the evaluation of morphologic and functional abnormalities associated with many cardiopulmonary diseases, including pulmonary embolism (PE). The availability of small, portable echocardiographic units combined with an increasing number of intensive care specialists trained in echocardiography makes TTE an attractive modality for the diagnosis of PE in the intensive care unit (ICU). In the ICU setting, prompt decision-making and appropriate triage of critically ill patients can facilitate early institution of therapy for PE while awaiting patient stabilization and further definitive testing. Although several prior reviews incorporate TTE in the overall approach and clinical decision algorithms pertaining to the diagnosis and treatment of pulmonary embolism, no dedicated review exists that focuses purely on TTE. We attempt to fill that gap by reviewing the available literature pertaining to use of TTE in the diagnosis of suspected PE, and by better defining the use of TTE in the ICU setting. Emphasis is placed on the use of TTE as a clinical triage tool for suspected PE.

Venous thromboembolism in trauma patients

Serial venous duplex scans (VDS) were done in 507 trauma patients with at least one risk factor (RF) for venous thromboembolism (VTE) during a 2-year study period. Deep vein thrombosis (DVT) was detected in 31 (6.1%) patients. This incidence was 3.1 per cent in low (1-2 RFs), 3.4 per cent in moderate (3-5 RFs), and 7.7 per cent in high (> or =6 RFs) VTE scores (P = 0.172). Incidence was statistically different (3% vs. 7.2%, P = 0.048) on reanalyzing patients in two risk categories, low-risk (1-4 RFs) and high-risk (> or =5 RFs). Only 4 of 16 RFs had statistically higher incidence of DVT in patients with or without RFs: previous VTE (27.3% vs. 5.6%, odds ratio (OR) 6.628, P = 0.024), spinal cord injury (22.6% vs. 5%, OR 5.493, P = 0.001), pelvic fractures (11.4% vs. 5.1%, OR 2.373, P = 0.042), and head injury with a greater than two Abbreviated Injury Score (10.5% vs. 4.2%, OR 2.639, P = 0.014). On reanalyzing patients with > or =5 RFs vs. <5RFs, obesity (14.3 vs. 6.1%, P = 0.007), malignancy (5.6% vs. 0.6%, P = 0.006), coagulopathy (10.8% vs. 1.8%, P = 0.000), and previous VTE (3.2% vs. 0%, P = 0.019) were significant on univariate analysis. Patients with DVT had 3.70 +/- 1.75 RFs and a 9.61 +/- 4.93 VTE score, whereas, patients without DVT had 2.66 +/- 1.50 RFs and a 6.83 +/- 3.91 VTE score (P = 0.000). DVTs had a direct positive relationship with higher VTE scores, length of stay, and number of VDS (>1 r, P < or = 0.001). Increasing age was a weak risk factor (0.03 r, P = 0.5). First two VDS diagnosed 77 per cent of DVTs. Patients with injury severity score of > or =15 and 25 had higher DVTs compared with the ones with lower injury severity score levels (P < or = 0.05). Pulmonary embolism was silent in 63 per cent and DVTs were asymptomatic in 68 per cent.

Surgical critical care: from old boundaries to new frontiers

The surgical specialty of critical care has evolved into a field where the surgeon manages complex medical and surgical problems in critically ill patients. As a specialty, surgical critical care began when acutely ill surgical patients were placed in a designated area within a hospital to facilitate the delivery of medical care. As technology evolved to allow for development of increasingly intricate and sophisticated adjuncts to care, there has been recognition of the importance of physician availability and continuity of care as key factors in improving patient outcomes. Guidelines and protocols have been established to ensure quality improvement and are essential to licensing by state and national agencies. The modern ICU team provides continuous daily care to the patient in close communication with the primary operating physician. While the ultimate responsibility befalls the primary physician who performed the preoperative evaluation and operative procedure, the intensivist is expected to establish and enforce protocols, guidelines and patient care pathways for the critical care unit. It is difficult to imagine modern surgical ICU care without the surgical critical care specialist at the helm.

Incidence of clinical pulmonary embolism after laparoscopic surgery

Background

This study aimed to determine the incidence of pulmonary embolism (PE) following laparoscopic surgery and its potential risk factors.

Methods

Data concerning 44 453 patients from 114 surgical institutions were collected by the Swiss Association of Laparoscopic and Thoracoscopic Surgery. The incidence of postoperative PE despite thromboprophylaxis was evaluated and potential risk factors were assessed singly, and then in a consecutive stepwise logistic multiple regression analysis.

Results

Among 44 453 patients assessed, 55·8 per cent were female and 44·2 per cent were male. Interventions included cholecystectomy (52·8 per cent), hernia repair (17·7 per cent), appendicectomy (12·4 per cent), colonic surgery (4·6 per cent) and oesophageal surgery (5·5 per cent). Postoperative PE occurred in 86 patients (0·2 per cent), and the incidence tended to decrease during this study (P = 0·016). A total of 149 patients died (0·3 per cent) of which nine (6·0 per cent) were due to PE. Significant predictive risk factors were female sex (P &lt; 0·001), age (P &lt; 0·001), weight above 90 kg (P &lt; 0·001), emergency procedure (P &lt; 0·001) and operating time exceeding 150 min (P &lt; 0·001).

Conclusion

The low incidence of PE after laparoscopy, with a further decrease over the past decade, suggests a tendency towards improved perioperative thromboembolic risk management.

Pilot study on the comprehensive economic costs of major trauma: Consequential costs are well in excess of medical costs

BACKGROUND

Trauma care is expensive. However, reliable data on the exact lifelong costs incurred by a major trauma patient are lacking. Discussion usually focuses on direct medical costs--underestimating consequential costs resulting from absence from work and permanent disability.

METHODS

Direct medical costs and consequential costs of 63 major trauma survivors (ISS >13) at a Swiss trauma center from 1995 to 1996 were assessed 5 years posttrauma. The following cost evaluation methods were used: correction cost method (direct cost of restoring an original state), human capital method (indirect cost of lost productivity), contingent valuation method (human cost as the lost quality of life), and macroeconomic estimates.

RESULTS

Mean ISS (Injury Severity Score) was 26.8 +/- 9.5 (mean +/- SD). In all, 22 patients (35%) were disabled, causing discounted average lifelong total costs of USD 1,293,800, compared with 41 patients (65%) who recovered without any disabilities with incurred costs of USD 147,200 (average of both groups USD 547,800). Two thirds of these costs were attributable to a loss of production whereas only one third was a result of the cost of correction. Primary hospital treatment (USD 27,800 +/- 37,800) was only a minor fraction of the total cost--less than the estimated cost of police and the judiciary. Loss of quality of life led to considerable intangible human costs similar to real costs.

CONCLUSIONS

Trauma costs are commonly underestimated. Direct medical costs make up only a small part of the total costs. Consequential costs, such as lost productivity, are well in excess of the usual medical costs. Mere cost averages give a false estimate of the costs incurred by patients with/without disabilities.