Inadequate Venous Thromboembolism Chemoprophylaxis Is Associated With Higher Venous Thromboembolism Rates Among Trauma Patients With Epidurals

INTRODUCTION

Guidelines encourage higher doses of low molecular weight heparin (LMWH) for prophylaxis in trauma patients. The risks of LMWH must be considered for patients who require an epidural catheter. We compared adequate and inadequate prophylaxis to determine if venous thromboembolism (VTE) and complication rates differed among patients with epidural catheters.

METHODS

Trauma patients who required an epidural catheter between 2012 and 2019 were reviewed for VTE and epidural-related complications. Adequate dosing was defined as enoxaparin 30 mg or 40 mg twice daily. Inadequate dosing was defined as unfractionated heparin subcutaneously or enoxaparin once daily.

RESULTS

Over the 8-y study period, 113 trauma patients required an epidural catheter of which 64.6% were males with a mean age of 55.8 y and injury severity score of 14. Epidural catheters were associated with 11 (9.7%) patients developing an acute deep vein thrombosis (DVT) and 2 (1.8%) patients with an acute pulmonary embolism. Those patients who received adequate doses of enoxaparin were less likely to have any VTE or DVT. Complications associated with epidural catheters were not dependent on the type of pharmacological prophylaxis.

CONCLUSIONS

Given the high VTE rate observed in trauma patients who required an epidural catheter, along with the low complication rate that was observed independent of the type of pharmacological prophylaxis given, the data indicate that current efforts for higher doses of LMWH appear to be safe and associated with a lower VTE rate.

Epidural catheters are associated with an increased risk of venous thromboembolism in trauma

Little is known about the association between epidural catheters (EC) and venous thromboembolism (VTE) in trauma. We sought to study this association and hypothesized that trauma patients with EC were more likely to develop VTE. Using the Pennsylvania Trauma Outcomes Study (PTOS) registry, we identified all adult trauma patients (age ≥ 18) admitted for at least 2 days between 1/2013 and 12/2017. Baseline characteristics and outcome variables were compared between patients who underwent EC placement and those who did not. The primary outcome was development of VTE. 147,721 patients met inclusion criteria; 2247 (1.5%) developed a VTE. Patients were mostly white (85%), male (56%), with blunt trauma (94%). 776 (0.5%) had an EC placed. Patients who underwent EC placement were more likely to develop a VTE (2.8% vs. 1.5%, p = 0.003). After adjusting for covariates, patients with EC were 1.6 times more likely to develop VTE (95% CI 1.1-2.5). The overall rate of VTE was low and associated with the use of EC. Future work should focus on determining the underlying mechanisms.

Incidence of venous thromboembolism and bleeding after pulmonary lobectomy: evaluating the timing for thromboprophylaxis

Venous thromboembolism (VTE) is an important postoperative complication after major lung cancer resective surgery, such as lobectomy. It is recommended to start chemical thromboprophylaxis within the first 12 h following the procedure. Postoperative bleeding is also a relevant complication in patients with predisposing conditions. However, the criterion for classifying a patient as "high risk of bleeding" is not standardized and is left to the expertise of the attending physician or surgeon. We aim to describe the incidence and risk factors for postoperative VTE and hemorrhage after pulmonary lobectomy; and to assess the impact of the timing of thromboprophylaxis on the incidence of postoperative thrombotic or hemorrhagic events. A retrospective observational study of 358 lobectomies performed in a single center was performed, analyzing the rates of postoperative thrombotic and hemorrhagic events and predisposing factors, including postoperative thromboprophylaxis management. Cumulative incidence of VTE was 3.07% (95% CI 1.54-5.43), and early postoperative bleeding was 10.05% (95% CI 7.14-13.64). Underlying pulmonary disease was associated with VTE (p = 0.001) and open approach was associated with hemorrhagic events (p = 0.01). The use of thromboprophylaxis and timing of its initiation were not associated with a higher incidence of events. VTE and postoperative hemorrhage are relevant complications following pulmonary lobectomy. Compliance with VTE prophylaxis guidelines is essential. Even so, a case-by-case risk evaluation of VTE and bleeding remains preferable and safe in order to decide on the most suitable timing of thromboprophylaxis.