Qualitative analysis of randomized controlled trials informing recommendations for venous thromboembolism prophylaxis after distal lower extremity injuries

Purpose:

The purpose of this study is to assess the quality of evidence to stratify recommendations for chemoprophylaxis following distal lower extremity trauma.

Methods:

Literature review identified primary studies investigating venous thromboembolism (VTE) chemoprophylaxis following traumatic injury distal to the knee. Inclusion criteria were randomized controlled trials in adult patients treated with and without operative intervention. Each primary study was assessed by the Consolidated Standards of Reporting Trials 2010 checklist and Modified Coleman methodology score.

Results:

Literature review resulted in 462 studies, of which 9 met inclusion and exclusion criteria. All studies included low molecular weight heparin as a treatment group with 2 (22%) also including a treatment group with a direct factor Xa inhibitor. Five studies (56%) used placebo as a control group. The mean Modified Coleman Methodology score was 63% (range 51%–72%), a categorical rating of Fair. The mean Consolidated Standards of Reporting Trials score was 78% (range 56%–97%). Most studies (89%) screened all asymptomatic subjects for deep venous thrombosis. Statistical significance in VTE incidence among prophylactic treatment groups was not achieved in 78%.

Conclusions:

Development of consensus for VTE prophylaxis recommendations following traumatic injury distal to the knee is complicated by heterogenous study populations, low incidence of VTE in study populations, and inconsistent definitions of clinically important VTE. Low molecular weight heparin is not consistently superior for preventing VTE. Chemoprophylaxis should be considered on an individual basis in the presence of additional risk factors, although an externally validated, evidence-based risk assessment tool does not currently exist.

Level of Evidence: IV, therapeutic

Routine Lower Extremity Screening Ultrasound Protocols in Trauma Patients Are Not Cost Effective

BACKGROUND

Despite prophylaxis, deep vein thrombosis (DVT) and pulmonary embolism remain dreaded complications following traumatic injury and are associated with significant morbidity and mortality. Screening ultrasound (US) protocols have been employed in trauma centers for early detection of lower extremity (LE) deep venous thrombosis. We hypothesized that screening lower extremity venous duplex US would not prove cost effective in our trauma population who receives early pharmacologic prophylaxis.

METHODS

Data was collected for one year on all adult trauma patients admitted to the trauma service from December 2019 to 2020. DVT screening US was obtained at 3 days after admission for patients with long bone or pelvic fracture, spinal cord injury, immobility, and/or spinal fracture requiring surgery. Screening US was obtained at 7 days for all others and repeated weekly until discharge. Data was retrospectively collected and analyzed.

RESULTS

Exactly 1365 patients met inclusion criteria with median ISS 12 (IQR, 9-17), median age 56 (IQR, 36-73 years), and with majority blunt injuries (90.7%). A total of 1369 screening US were performed finding 27 DVTs (2%). The total cost of screening for the year analyzed amounted to over $270,000 with 50.7 screening US needed to detect 1 DVT. This resulted in an average screening cost of over $10,000 for the detection of a single DVT.

DISCUSSION

In trauma patients receiving early pharmacologic prophylaxis, routine LE screening US protocols to detect LE DVT are not cost effective.

No correlation between lower extremity deep vein thrombosis and pulmonary embolism proportions in trauma: a systematic literature review

PURPOSE

To assess the effect of surveillance on deep vein thrombosis (DVT) and pulmonary embolism (PE) rates, the efficacy of chemoprophylaxis and mechanical prophylaxis, and the relationship between DVT and PE.

METHODS

A 23 year, systematic literature review was performed in PubMed. Twenty publications with > 13,000 patients were reviewed. Analyzed traits included: DVT surveillance utilization, the total number of patients included in each study, the number of patients developing DVT and/or PE, chemoprophylaxis and mechanical prophylaxis utilization. When event proportions from individual studies were combined, a weighted mean proportion was computed based on the size of each individual cohort. Combined event proportions were compared with other combined event proportions, according to differences in intervention. Inter-group event proportions were compared using Chi-Square or Fisher's exact test, as appropriate.

RESULTS

DVT rates increase with surveillance (10.7% vs. 2.5%, p < 0.001). PE rates were similar regardless of surveillance (p = 1.0). Chemoprophylaxis lowered both DVT rates (8.2% vs. 10.7%; p < 0.0001) and PE rates (1.2% vs. 1.9%; p = 0.0050). Mechanical prophylaxis did not decrease DVT rates (10.2% vs. 11.5%; p = 0.2980) or PE rates (1.7% vs. 1.6%; p = 1.0). In patients with neither chemoprophylaxis nor mechanical prophylaxis, DVT rate was 11.5%, PE was 1.6%. When chemoprophylaxis and/or mechanical prophylaxis were given, DVT rate was 8.6% (p < 0.0189) and PE was 1.3% (p = 0.4462). PE proportions were not decreased with mechanical prophylaxis or surveillance. DVT and PE rates were not associated (p = 0.7574).

CONCLUSIONS

The results suggest that PE is not associated with lower extremity DVT in adult trauma patients.

Semiautomatic intermittent pneumatic compression device applied to deep vein thrombosis in major orthopedic surgery

Objective

To investigate the effect of additional semiautomatic intermittent pneumatic compression device (IPCD) in the prevention of deep vein thrombosis (DVT) of lower extremity in these patients undergoing major orthopedic surgery, when compared with the conventional graduated compression stockings alone.

Methods

The data of 112 patients undergoing major orthopedic surgery were retrospectively analyzed. 51 patients who ever received IPCD and graduated compression stockings during major orthopedic surgery were taken as the experimental group, and 61 patients who only received the conventional graduated compression stockings during surgery were taken as the observation group. The Doppler sonography was utilized to detect the presence of DVT and pulmonary embolism pre- and postoperatively. Besides, the mean and peak velocity of blood flow in femoral vein were recorded before and after surgery. And then, the comparisons between the two groups were made, respectively.

Results

When compared with the conventional graduated compression stockings alone, the intraoperative application of IPCD and stockings contributed the significant reduction of DVT (3.92%, 2/51 versus 9.84%, 6/61, X² = 5.632, P = 0.034). In terms of the mean and peak velocity of blood flow in femoral vein, the postoperative difference was higher in the observation group than those in the control group (149.56 ± 26.35 versus 130.15 ± 22.56 mm/s, P < 0.05). With respect to perioperative blood loss, the difference between the two groups was statistically significant (800.5 ± 320.7 versus 950.1 ± 305.9 ml, P = 0.031).

Conclusions

Intraoperative application of IPCD could promote blood circulation of lower limbs, and significantly decrease the incidence of potentially fatal DVT in patients undergoing major orthopedic surgery, when compared with the conventional graduated compression stockings.