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Heim C, Bruder N, Davenport R, Duranteau J, Gaarder C. European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 11: Trauma. Eur J Anaesthesiol 2024; 41:612-617. [PMID: 38957029 DOI: 10.1097/eja.0000000000002017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Catherine Heim
- From the Department of Anesthesiology, CHUV - University Hospital Lausanne, Switzerland (CH), Aix-Marseille University, APHM, Marseille, France (NB), Centre for Trauma Sciences, Blizard Insitute, Queen Mary University of London, UK (RD), Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France (JD) and Department of Traumatology, Oslo University Hospital, Oslo, Norway (CG)
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Witte AB, Van Arendonk K, Bergner C, Bantchev M, Falcone RA, Moody S, Hartman HA, Evans E, Thakkar R, Patterson KN, Minneci PC, Mak GZ, Slidell MB, Johnson M, Landman MP, Markel TA, Leys CM, Cherney Stafford L, Draper J, Foley DS, Downard C, Skaggs TM, Lal DR, Gourlay D, Ehrlich PF. Venous Thromboembolism Prophylaxis in High-Risk Pediatric Trauma Patients. JAMA Surg 2024:2821820. [PMID: 39083300 PMCID: PMC11292570 DOI: 10.1001/jamasurg.2024.2487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/11/2024] [Indexed: 08/03/2024]
Abstract
Importance The indications, safety, and efficacy of chemical venous thromboembolism prophylaxis (cVTE) in pediatric trauma patients remain unclear. A set of high-risk criteria to guide cVTE use was recently recommended; however, these criteria have not been evaluated prospectively. Objective To examine high-risk criteria and cVTE use in a prospective multi-institutional study of pediatric trauma patients. Design, Setting, and Participants This cohort study was completed between October 2019 and October 2022 in 8 free-standing pediatric hospitals designated as American College of Surgeons level I pediatric trauma centers. Participants were pediatric trauma patients younger than 18 years who met defined high-risk criteria on admission. It was hypothesized that cVTE would be safe and reduce the incidence of VTE. Exposures Receipt and timing of chemical VTE prophylaxis. Main Outcomes and Measures The primary outcome was overall VTE rate stratified by receipt and timing of cVTE. The secondary outcome was safety of cVTE as measured by bleeding or other complications from anticoagulation. Results Among 460 high-risk pediatric trauma patients, the median (IQR) age was 14.5 years (10.4-16.2 years); 313 patients (68%) were male and 147 female (32%). The median (IQR) Injury Severity Score (ISS) was 23 (16-30), and median (IQR) number of high-risk factors was 3 (2-4). A total of 251 (54.5%) patients received cVTE; 62 (13.5%) received cVTE within 24 hours of admission. Patients who received cVTE after 24 hours had more high-risk factors and higher ISS. The most common reason for delayed cVTE was central nervous system bleed (120 patients; 30.2%). There were 28 VTE events among 25 patients (5.4%). VTE occurred in 1 of 62 patients (1.6%) receiving cVTE within 24 hours, 13 of 189 patients (6.9%) receiving cVTE after 24 hours, and 11 of 209 (5.3%) who had no cVTE (P = .31). Increasing time between admission and cVTE initiation was significantly associated with VTE (odds ratio, 1.01; 95% CI, 1.00-1.01; P = .01). No bleeding complications were observed while patients received cVTE. Conclusions and Relevance In this prospective study, use of cVTE based on a set of high-risk criteria was safe and did not lead to bleeding complications. Delay to initiation of cVTE was significantly associated with development of VTE. Quality improvement in pediatric VTE prevention may center on timing of prophylaxis and barriers to implementation.
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Affiliation(s)
- Amanda B. Witte
- Children’s Wisconsin, Medical College of Wisconsin, Milwaukee
| | | | - Carisa Bergner
- Children’s Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Martin Bantchev
- Children’s Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Richard A. Falcone
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Suzanne Moody
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Emily Evans
- C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor
| | | | | | - Peter C. Minneci
- Nemours Surgical Outcomes Center, Nemours Children’s Health – Delaware Valley, Wilmington
| | - Grace Z. Mak
- Comer Children’s Hospital, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Mark B. Slidell
- Johns Hopkins Children’s Center, The Johns Hopkins University, Baltimore, Maryland
| | - MacKenton Johnson
- Comer Children’s Hospital, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | | | - Troy A. Markel
- Riley Children’s Health, Indiana University Health, Bloomington
| | - Charles M. Leys
- American Family Children’s Hospital, University of Wisconsin Health, Madison
| | | | - Jessica Draper
- American Family Children’s Hospital, University of Wisconsin Health, Madison
| | - David S. Foley
- Norton Children’s Hospital, University of Louisville, Louisville, Kentucky
| | - Cynthia Downard
- Norton Children’s Hospital, University of Louisville, Louisville, Kentucky
| | - Tracy M. Skaggs
- Norton Children’s Hospital, University of Louisville, Louisville, Kentucky
| | - Dave R. Lal
- Children’s Wisconsin, Medical College of Wisconsin, Milwaukee
| | - David Gourlay
- Children’s Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Peter F. Ehrlich
- C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor
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Lombardo S, McCrum M, Knudson MM, Moore EE, Kornblith L, Brakenridge S, Bruns B, Cipolle MD, Costantini TW, Crookes B, Haut ER, Kerwin AJ, Kiraly LN, Knowlton LM, Martin MJ, McNutt MK, Milia DJ, Mohr A, Rogers F, Scalea T, Sixta S, Spain D, Wade CE, Velmahos GC, Nirula R, Nunez J. Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry. Trauma Surg Acute Care Open 2024; 9:e001230. [PMID: 38420604 PMCID: PMC10900334 DOI: 10.1136/tsaco-2023-001230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/26/2023] [Indexed: 03/02/2024] Open
Abstract
Introduction Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD). Methods Patients from the prospective, observational CLOTT-1 registry receiving prophylactic enoxaparin (n=5539) were categorized as WB (0.45-0.55 mg/kg two times per day) or SFD (30 mg two times per day, 40 mg once a day). Multivariate logistic regression was used to generate a predicted probability of VTE for WB and SFD patients. Results Of 4360 patients analyzed, 1065 (24.4%) were WB and 3295 (75.6%) were SFD. WB patients were younger, female, more severely injured, and underwent major operation or major venous repair at a higher rate than individuals in the SFD group. Obesity was more common among the SFD group. Unadjusted VTE rates were comparable (WB 3.1% vs. SFD 3.9%; p=0.221). Early prophylaxis was associated with lower VTE rate (1.4% vs. 5.0%; p=0.001) and deep vein thrombosis (0.9% vs. 4.4%; p<0.001), but not pulmonary embolism (0.7% vs. 1.4%; p=0.259). After adjustment, VTE incidence did not differ by dosing strategy (adjusted OR (aOR) 0.75, 95% CI 0.38 to 1.48); however, early administration was associated with a significant reduction in VTE (aOR 0.47, 95% CI 0.30 to 0.74). Conclusion In young trauma patients, WB prophylaxis is not associated with reduced VTE rate when compared with SFD. The timing of the initiation of chemoprophylaxis may be more important than the dosing strategy. Further studies need to evaluate these findings across a wider age and comorbidity spectrum. Level of evidence Level IV, therapeutic/care management.
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Affiliation(s)
| | - Marta McCrum
- Surgery, University of Utah, Salt Lake City, Utah, USA
| | - M Margaret Knudson
- Surgery, University of California San Francisco, San Francisco, California, USA
| | | | - Lucy Kornblith
- Surgery, University of California San Francisco, San Francisco, California, USA
| | - Scott Brakenridge
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Brandon Bruns
- Department of Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Mark D Cipolle
- Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Todd W Costantini
- Surgery, University of California San Francisco, San Francisco, California, USA
| | - Bruce Crookes
- Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Elliott R Haut
- Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Andrew J Kerwin
- Surgery, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida, USA
| | | | | | - Matthew J Martin
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, Los Angeles, California, USA
| | - Michelle K McNutt
- Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David J Milia
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Alicia Mohr
- Surgery, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida, USA
| | | | - Thomas Scalea
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sherry Sixta
- St Anthony Hospital & Medical Campus, Lakewood, Colorado, USA
| | - David Spain
- Surgery, Stanford University, Stanford, California, USA
| | - Charles E Wade
- Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | | | - Ram Nirula
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jade Nunez
- Surgery, University of Utah, Salt Lake City, Utah, USA
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Wang J, Lv C, Song X, Hu Y, Hao W, He L, Chen Y, Gan Y, Han X, Yan S. Current situation and needs analysis of medical staff first aid ability in China: a cross-sectional study. BMC Emerg Med 2023; 23:128. [PMID: 37919639 PMCID: PMC10623825 DOI: 10.1186/s12873-023-00891-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/03/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVES We aim to understand the current situation of the first aid ability and training needs of Chinese medical personnel to provide a scientific basis for formulating the contents and methods of emergency medical rescue training and thereby improve the first aid level of Chinese medical personnel. METHODS A cross-sectional survey was conducted between June 2022 and February 2023 using a two-stage cluster sampling method with a structured questionnaire sent to medical workers in 12 provinces in China. 14,527 questionnaires were included in this study. Data were collected on demographic characteristics, first aid knowledge and skills, and training needs. Variance analysis was used to compare the difference between the first aid ability and training needs of medical staff in different hospitals, and multiple linear regression analysis was carried out to evaluate first aid ability and training needs. RESULT The study included 6041 patients (41.6%) in tertiary hospitals, 5838 patients (40.2%) in secondary hospitals, and 2648 patients (18.2%) in primary hospitals. There were significant differences in the first aid ability and training needs of medical staff in hospitals of different levels (p < 0.001). The score of first aid knowledge and skills in tertiary hospitals was the highest (209.7 ± 45.0), and the score of training needs in primary hospitals was the highest (240.6 ± 44.0). There was a significant correlation between first aid ability and training needs score (p < 0.001). Multiple linear regression analysis shows that geographic region, age, work tenure, gender, job title, department, professional title, monthly income, and hospital level are the influencing factors of training demand. CONCLUSION Medical staff in primary hospitals generally have low first aid knowledge and skills and a strong willingness to train. Therefore, it is imperative to strengthen the training of first aid ability and research training strategies. The level of the hospital is closely related to the level of first aid, so it is necessary to recognize the commonalities and differences in medical staff's demand for first aid knowledge and skills and carry out targeted education and training.
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Affiliation(s)
- Juntao Wang
- International School of Public Health and One Health, Hainan Medical University, Haikou, Hainan, China
- Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, Hainan, China
| | - Chuanzhu Lv
- Emergency Medicine Center, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
- Research Unit of Island Emergency Medicine, Chinese Academy of Medical Sciences (No. 2019RU013), Hainan Medical University, Haikou, Hainan, China
- Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, Hainan, China
| | - Xingyue Song
- Department of Emergency, Hainan Clinical Research Center for Acute and Critical Diseases, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China
| | - Yanlan Hu
- International School of Public Health and One Health, Hainan Medical University, Haikou, Hainan, China
- Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, Hainan, China
| | - Wenjie Hao
- International School of Public Health and One Health, Hainan Medical University, Haikou, Hainan, China
- Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, Hainan, China
| | - Lanfen He
- International School of Public Health and One Health, Hainan Medical University, Haikou, Hainan, China
- Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, Hainan, China
| | - Yu Chen
- International School of Public Health and One Health, Hainan Medical University, Haikou, Hainan, China
| | - Yong Gan
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaotong Han
- Department of Emergency Medicine, Hunan Provincial Key Laboratory of Emergency and Critical Care Metabolomics, Hunan Provincial Institute of Emergency Medicine, Hunan Provincial People's Hospital/The First Affiliated Hospital, Hunan Normal University, Changsha, Hunan, China.
| | - Shijiao Yan
- International School of Public Health and One Health, Hainan Medical University, Haikou, Hainan, China.
- Research Unit of Island Emergency Medicine, Chinese Academy of Medical Sciences (No. 2019RU013), Hainan Medical University, Haikou, Hainan, China.
- Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, Hainan, China.
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Lineberry C, Alexis D, Mukhi A, Duh K, Tharakan M, Vosswinkel JA, Jawa RS. Venous thromboembolic disease in admitted blunt trauma patients: what matters? Thromb J 2023; 21:111. [PMID: 37891537 PMCID: PMC10604411 DOI: 10.1186/s12959-023-00555-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Venous thromboembolic events (VTE) are a significant cause of morbidity and mortality following traumatic injury. We examined demographic characteristics, chemoprophylaxis, and outcomes of VTE patients with blunt trauma requiring hospitalization. METHODS A retrospective review of adult blunt trauma hospitalizations with and without VTE between 2012 and 2019 was conducted. Deaths in the emergency department were excluded. Univariate and multivariable analyses, including machine learning classification algorithms for VTE, were performed. RESULTS Of 10,926 admitted adult blunt trauma patients, 177 had VTE events. VTE events occurred at a median of 6 [IQR 3-11] days, with 7.3% occurring within 1 day of admission. VTE patients were more often male, and more often underwent surgery. They had higher injury severity as well as longer intensive care unit and hospital lengths of stay. While VTE occurred throughout the spectrum of injury severity, 27.7% had low injury severity (ISS < = 9). In multivariable analyses, both heparin and enoxaparin had reduced adjusted odds ratios for VTE. CONCLUSION Approximately 7.3% of VTE events occurred within one day of admission. A substantial proportion of VTE events occurred in patients with low injury severity (ISS < = 9). Subcutaneous unfractionated heparin and enoxaparin chemoprophylaxis were both inversely associated with VTE. These findings underscore the need for vigilance for VTE identification in blunt trauma patients throughout their hospitalization and VTE prevention efforts.
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Affiliation(s)
- Camille Lineberry
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Dimitri Alexis
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Ambika Mukhi
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Kevin Duh
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Mathew Tharakan
- Department of Medicine, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - James A Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Randeep S Jawa
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA.
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Falksen JA, Duby JJ, Wilson MD, Fine JR, Cocanour CS. Effect of Delay and Disruption in Venous Thromboembolism Prophylaxis in Trauma Patients: Case-Control Study. J Am Coll Surg 2022; 235:34-40. [PMID: 35703960 PMCID: PMC9204836 DOI: 10.1097/xcs.0000000000000232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma patients are at high risk for venous thromboembolism (VTE) and bleeding. The purpose of this study was to characterize percentage of VTE chemoprophylaxis given to trauma patients with and without a VTE. STUDY DESIGN This retrospective case-control study evaluated trauma patients admitted to a Level I trauma center. Adult patients were included when hospitalized at least 2 days and had a head abbreviated injury score of 1 or less. Non-VTE patients were matched by decade of life and injury severity score (ISS). The primary outcome was percentage of VTE chemoprophylaxis received over the first 14 days of admission. Descriptive statistics, chi-squared test, Student's t-test, and Cox proportional hazard were used for analysis. RESULTS A total of 44 VTE patients were included with 125 matched non-VTE patients. Baseline demographics included age in years (50.7 ± 19.6 vs 49.6 ± 19.4), ISS (18.9 ± 11.3 vs 19 ± 11.6), and lower extremity fracture (54.5% vs 40%), for VTE and non-VTE groups, respectively. The primary outcome of VTE chemoprophylaxis doses given was significantly lower for VTE patients than non-VTE patients (49.3% vs 59.3%, p = 0.0069). Significant predictors of VTE were percentage of VTE chemoprophylaxis doses given (p < 0.0001) and weight (p = 0.0042) based on regression analysis. Notably, there was a 7% decrease in the hazard for VTE for every 1% increase in VTE chemoprophylaxis given. CONCLUSIONS Patients who developed VTE were more likely to have delays and disruptions in VTE chemoprophylaxis, even after controlling for age, sex, ISS, lower extremity fractures, and number of operations.
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Affiliation(s)
- Jessica A Falksen
- From the Departments of Pharmacy (Falksen, Duby), University of California, Davis Health, Sacramento, CA
| | - Jeremiah J Duby
- From the Departments of Pharmacy (Falksen, Duby), University of California, Davis Health, Sacramento, CA
| | - Machelle D Wilson
- Public Health Sciences (Wilson, Fine), University of California, Davis Health, Sacramento, CA
| | - Jeffrey R Fine
- Public Health Sciences (Wilson, Fine), University of California, Davis Health, Sacramento, CA
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