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Baranich AI, Sychev AA, Savin IA, Danilov GV, Strunina YV. Thromboelastometry-Based Prophylaxis for Venous Thromboembolism in the Acute Period Following Isolated Severe Traumatic Brain Injury. Korean J Neurotrauma 2024; 20:45-51. [PMID: 38576501 PMCID: PMC10990693 DOI: 10.13004/kjnt.2024.20.e10] [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: 12/21/2023] [Revised: 01/22/2024] [Accepted: 03/06/2024] [Indexed: 04/06/2024] Open
Abstract
Objective Traumatic brain injury (TBI) is an independent risk factor for venous thromboembolism (VTE). This study aimed to determine the optimal timing for initiating pharmacological thromboprophylaxis for VTE in patients with isolated severe TBI using rotational thromboelastometry (ROTEM). Methods This single-center observational study enrolled 115 patients aged 18-59 years with isolated severe TBI within the first 48 hours after injury. Results Using ROTEM data, we identified hypercoagulation due to an increase in clot density (MCF EXTEM >72), which was attributed to fibrinogen (MCF FIBTEM >25). From day 4, hypercoagulation occurred in 14.8% of the patients. By day 7, these changes were observed in 85.2% of patients. According to brain computed tomography findings, patients who received early VTE chemoprophylaxis on days 3-4 after severe TBI did not experience progression of hemorrhagic foci. Conclusion Our results emphasize the clinical significance of thromboelastometry in patients with isolated severe traumatic TBI. Anticoagulant prophylaxis started on 3-4 days after severe TBI was relatively safe, and most patients did not experience hemorrhagic foci progression. The data acquired in this study may enable the optimization of VTE chemoprophylactic approaches, thereby reducing the associated risks to patients.
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Affiliation(s)
- Anastasia I. Baranich
- Neurocritical Care Department, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Aleksandr A. Sychev
- Neurocritical Care Department, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Ivan A. Savin
- Neurocritical Care Department, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Gleb V. Danilov
- Laboratory of Biomedical Informatics and Artificial Intelligence, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Yulia V. Strunina
- Laboratory of Biomedical Informatics and Artificial Intelligence, N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
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Prognostic Significance of Plasma Insulin Level for Deep Venous Thrombosis in Patients with Severe Traumatic Brain Injury in Critical Care. Neurocrit Care 2022; 38:263-278. [PMID: 36114315 DOI: 10.1007/s12028-022-01588-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 08/10/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Whether insulin resistance underlies deep venous thrombosis (DVT) development in patients with severe traumatic brain injury (TBI) is unclear. In this study, the association between plasma insulin levels and DVT was analyzed in patients with severe TBI. METHODS A prospective observational study of 73 patients measured insulin, glucose, glucagon-like peptide 1 (GLP-1), inflammatory factors, and hematological profiles within four preset times during the first 14 days after TBI. Ultrasonic surveillance of DVT was tracked. Two-way analysis of variance was used to determine the factors that discriminated between patients with and without DVT or with and without insulin therapy. Partial correlations of insulin level with all the variables were conducted separately in patients with DVT or patients without DVT. Factors associated with DVT were analyzed by multivariable logistic regression. Neurological outcomes 6 months after TBI were assessed. RESULTS Among patients with a mean (± standard deviation) age of 53 (± 16 years), DVT developed in 20 patients (27%) on median 10.4 days (range 4-22), with higher Acute Physiology and Chronic Health Evaluation II scores but similar Sequential Organ Failure Assessment scores and TBI severity. Patients with DVT were more likely to receive insulin therapy than patients without DVT (60% vs. 28%; P = 0.012); hence, they had higher 14-day insulin levels. However, insulin levels were comparable between patients with DVT and patients without DVT in the subgroups of patients with insulin therapy (n = 27) and patients without insulin therapy (n = 46). The platelet profile significantly discriminated between patients with and without DVT. Surprisingly, none of the coagulation profiles, blood cell counts, or inflammatory mediators differed between the two groups. Patients with insulin therapy had significantly higher insulin (P = 0.006), glucose (P < 0.001), and GLP-1 (P = 0.01) levels and were more likely to develop DVT (60% vs. 15%; P < 0.001) along with concomitant platelet depletion. Insulin levels correlated with glucose, GLP-1 levels, and platelet count exclusively in patients without DVT. Conversely, in patients with DVT, insulin correlated negatively with GLP-1 levels (P = 0.016). Age (P = 0.01) and elevated insulin levels at days 4-7 (P = 0.04) were independently associated with DVT. Patients with insulin therapy also showed worse Glasgow Outcome Scale scores (P = 0.001). CONCLUSIONS Elevated insulin levels in the first 14 days after TBI may indicate insulin resistance, which is associated with platelet hyperactivity, and thus increasing the risk of DVT.
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Bahloul M, Dlela M, Bouchaala K, Kallel H, Ben Hamida C, Chelly H, Bouaziz M. Post-traumatic pulmonary embolism: incidence, physiopathology, risk factors of early occurrence, and impact outcome. A narrative review. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2020; 10:432-443. [PMID: 33224594 PMCID: PMC7675152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/16/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a well-established complication of trauma. So far, the factors that are related to early post-traumatic pulmonary embolism (PE) occurrence have been given little attention. AIMS We have conducted this literature review in order to analyze the incidence and the physiopathology of post-traumatic PE among intensive care unit (ICU) trauma patients, analyze the incidence of early post-traumatic PE, and elucidate risk factors associated with post-traumatic PE. Moreover, we aim to study the impact/outcome of post-traumatic PE in the ICU. METHODS We used the PubMed and EMBASE databases and entered the following key words in MeSH research: Deep vein thrombosis (DVT), Post-traumatic Pulmonary embolism, Early pulmonary-embolism, risk factors, and Prognosis. RESULTS The incidence of PE among trauma patients varies considerably, ranging from 0.35% to 24%. The incidence of early post-traumatic PE varies widely from 10 to 42%. After a traumatic injury, many factors have been found to be responsible for the formation of DVT and PE. In addition to the risk factors of hypercoagulability described by Virchow in his original triad, inflammation acting via endothelial damage may be considered as a fourth factor. The literature review showed that lower limb fractures and age are the most frequent factors associated with PE (particularly in early PE). The heterogeneity among studies limits reliable conclusions regarding the true risk factors for the timing of the occurrence of post-traumatic PE. Fatality from pulmonary embolism (PE) is close to 50% in some series. Moreover, high mortality rates, a high rate of nosocomial infections, and a prolonged stay in an ICU and/or in a hospital were found to be associated with the development of PE. CONCLUSION Post-traumatic PE is frequent in ICUs. Inflammation acting via endothelial damage may be considered as a fourth factor in addition to the Virchow's triad of risk factors for venous thrombosis. Fractures of the lower extremities, obesity, and age happen to be the most frequent factors associated with PE (in particular early PE). PE development was associated with high rates of mortality, nosocomial infections, and a prolonged stay in an ICU and/or in a hospital. Therefore, prevention is warranted.
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Affiliation(s)
- Mabrouk Bahloul
- Department of Intensive Care, Habib Bourguiba University Hospital, Faculté de Medicine de Sfax, Sfax University Sfax, Tunisia
| | - Mariem Dlela
- Department of Intensive Care, Habib Bourguiba University Hospital, Faculté de Medicine de Sfax, Sfax University Sfax, Tunisia
| | - Karama Bouchaala
- Department of Intensive Care, Habib Bourguiba University Hospital, Faculté de Medicine de Sfax, Sfax University Sfax, Tunisia
| | - Hela Kallel
- Department of Intensive Care, Habib Bourguiba University Hospital, Faculté de Medicine de Sfax, Sfax University Sfax, Tunisia
| | - Chokri Ben Hamida
- Department of Intensive Care, Habib Bourguiba University Hospital, Faculté de Medicine de Sfax, Sfax University Sfax, Tunisia
| | - Hedi Chelly
- Department of Intensive Care, Habib Bourguiba University Hospital, Faculté de Medicine de Sfax, Sfax University Sfax, Tunisia
| | - Mounir Bouaziz
- Department of Intensive Care, Habib Bourguiba University Hospital, Faculté de Medicine de Sfax, Sfax University Sfax, Tunisia
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Hachem LD, Mansouri A, Scales DC, Geerts W, Pirouzmand F. Anticoagulant prophylaxis against venous thromboembolism following severe traumatic brain injury: A prospective observational study and systematic review of the literature. Clin Neurol Neurosurg 2018; 175:68-73. [PMID: 30384119 DOI: 10.1016/j.clineuro.2018.09.032] [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: 08/12/2018] [Revised: 09/16/2018] [Accepted: 09/23/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Venous thromboembolism (VTE) is a serious complication following severe traumatic brain injury (TBI), however, anticoagulant prophylaxis remains controversial due to concerns of intracranial hemorrhage (ICH) progression. We examined anticoagulant prophylaxis practice patterns at a major trauma centre and determined risk estimates for VTE and ICH progression classified by timing of anticoagulant initiation. PATIENTS AND METHODS A 1-year prospective analysis of consecutive patients with severe TBI admitted to a Level-I trauma centre was conducted. In addition, we systematically reviewed the literature to identify studies on VTE and anticoagulant prophylaxis after severe TBI. RESULTS 64 severe TBI patients were included. 83% of patients received anticoagulant prophylaxis, initiated ≥3d post-TBI in 67%. The in-hospital VTE incidence was 16% and there was no significant difference between patients who received early (<3d) versus late (≥3d) prophylaxis (10% vs. 16%). Rates of ICH progression (0% vs. 7%) were similar between groups. Our systematic review identified 5 studies with VTE rates ranging from 5 to 10% with prophylaxis, to 11-30% without prophylaxis. The effect of timing of anticoagulant prophylaxis initiation on ICH progression was not reported in any study. CONCLUSION VTE is a common complication after severe TBI. Anticoagulant prophylaxis is often started late (≥3d) post-injury. Randomized trials are justifiable and necessary to provide practice guidance with regards to optimal timing of anticoagulant prophylaxis.
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Affiliation(s)
- Laureen D Hachem
- Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Alireza Mansouri
- Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - William Geerts
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Farhad Pirouzmand
- Division of Neurosurgery, University of Toronto, Toronto, Canada; Division of Neurosurgery, Sunnybrook Health Science Centre, Toronto, Canada.
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Henry JA, Lama T, Borrego R, Galindez N, Genuit T, Lottenberg L. Cardiac Migration of a Prophylactic Inferior Vena Cava Filter: A Rare but Potentially Lethal Complication that Must be Avoided. Am Surg 2018. [DOI: 10.1177/000313481808400806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jaymie A. Henry
- Department of Surgery Charles E. Schmidt College of Medicine Florida Atlantic University Boca Raton, Florida
| | - Teofilo Lama
- Department of Surgery Charles E. Schmidt College of Medicine Florida Atlantic University Boca Raton, Florida St. Mary's Medical Center West Palm Beach, Florida
| | - Robert Borrego
- Department of Surgery Charles E. Schmidt College of Medicine Florida Atlantic University Boca Raton, Florida St. Mary's Medical Center West Palm Beach, Florida
| | | | - Thomas Genuit
- Department of Surgery Charles E. Schmidt College of Medicine Florida Atlantic University Boca Raton, Florida
| | - Lawrence Lottenberg
- Department of Surgery Charles E. Schmidt College of Medicine Florida Atlantic University Boca Raton, Florida St. Mary's Medical Center West Palm Beach, Florida
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Micallef K. Timely Anticoagulant Thromboprophylaxis is Safe and Effective in the Care of Patients Suffering Traumatic Brain Injury. AUSTRALASIAN JOURNAL OF NEUROSCIENCE 2018. [DOI: 10.21307/ajon-2017-118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Ho KM, Rao S, Honeybul S, Zellweger R, Wibrow B, Lipman J, Holley A, Kop A, Geelhoed E, Corcoran T. Detailed assessment of benefits and risks of retrievable inferior vena cava filters on patients with complicated injuries: the da Vinci multicentre randomised controlled trial study protocol. BMJ Open 2017; 7:e016747. [PMID: 28706106 PMCID: PMC5541499 DOI: 10.1136/bmjopen-2017-016747] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/16/2017] [Accepted: 05/22/2017] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Retrievable inferior vena cava (IVC) filters have been increasingly used in patients with major trauma who have contraindications to anticoagulant prophylaxis as a primary prophylactic measure against venous thromboembolism (VTE). The benefits, risks and cost-effectiveness of such strategy are uncertain. METHODS AND ANALYSIS Patients with major trauma, defined by an estimated Injury Severity Score >15, who have contraindications to anticoagulant VTE prophylaxis within 72 hours of hospitalisation to the study centre will be eligible for this randomised multicentre controlled trial. After obtaining consent from patients, or the persons responsible for the patients, study patients are randomly allocated to either control or IVC filter, within 72 hours of trauma admission, in a 1:1 ratio by permuted blocks stratified by study centre. The primary outcomes are (1) the composite endpoint of (A) pulmonary embolism (PE) as demonstrated by CT pulmonary angiography, high probability ventilation/perfusion scan, transoesophageal echocardiography (by showing clots within pulmonary arterial trunk), pulmonary angiography or postmortem examination during the same hospitalisation or 90-day after trauma whichever is earlier and (B) hospital mortality; and (2) the total cost of treatment including the costs of an IVC filter, total number of CT and ultrasound scans required, length of intensive care unit and hospital stay, procedures and drugs required to treat PE or complications related to the IVC filters. The study started in June 2015 and the final enrolment target is 240 patients. No interim analysis is planned; incidence of fatal PE is used as safety stopping rule for the trial. ETHICS AND DISSEMINATION Ethics approval was obtained in all four participating centres in Australia. Results of the main trial and each of the secondary endpoints will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ACTRN12614000963628; Pre-results.
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Affiliation(s)
- Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- School of Population Health, University of Western Australia, Perth, Western Australia, Australia
- School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia
| | - Sudhakar Rao
- State Trauma Unit, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Stephen Honeybul
- Department of Neurosurgery, Royal Perth Hospital and Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rene Zellweger
- State Trauma Unit, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Bradley Wibrow
- Department of Intensive Care Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jeffrey Lipman
- Critical Care Services, Royal Brisbane and Women’s Hospital and University of Queensland, Herston, Queensland, Australia
| | - Anthony Holley
- Critical Care Services, Royal Brisbane and Women’s Hospital and University of Queensland, Herston, Queensland, Australia
| | - Alan Kop
- Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Elizabeth Geelhoed
- School of Population Health, University of Western Australia, Perth, Western Australia, Australia
| | - Tomas Corcoran
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
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Lu J, Wang X, Chen Q, Chen M, Cheng L, Jiang H, Sun Z. D-dimer Is a Predictor of 28-Day Mortality in Critically Ill Patients Receiving Continuous Renal Replacement Therapy. Arch Med Res 2017; 47:356-364. [PMID: 27751369 DOI: 10.1016/j.arcmed.2016.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 08/08/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS Continuous renal replacement therapy (CRRT) is an important treatment in the intensive care unit (ICU). Nevertheless, the outcome of CRRT remains unclear. It is important to find a useful and easy indicator to predict the prognosis in patients on CRRT treatment. We undertook this study to observe the association between serum D-dimer level and mortality of ICU patients in the treatment of CRRT. METHODS A total of 149 patients who received CRRT were enrolled in our study. We observed the correlation of D-dimer with the information of biochemical parameters, acute physiology and chronic health evaluation II (APACHE II) score. We analyzed the association between serum D-dimer level before CRRT and 28-d mortality retrospectively. Furthermore, we used Cox regression analysis to assess whether D-dimer could be the independent risk factor for mortality. RESULTS There were significant correlations between D-dimer and C-reaction protein (r2 = 0.033, p = 0.026), creatinine (r2 = 0.066, p = 0.002) and APACHE II (r2 = 0.036, p = 0.021). The difference in 28-d mortality risk between elevated D-dimer group and normal D-dimer group was significant (HR 2.872, 95% CI 1.563-5.278, p = 0.001), and the elevated D-dimer level was an independent risk factor for 28-d mortality (HR 2.067, 95% CI 1.104-3.872, p = 0.023). The difference in 28-d mortality was significant between groups (p <0.001). ROC curves showed that the area under the curve (AUC) of D-dimer was 0.763. CONCLUSION The present study demonstrates that serum D-dimer could be a useful and easy prognostic variable of 28-d mortality in critically ill patients who received CRRT.
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Affiliation(s)
- Jun Lu
- Intensive Care Unit, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - Xing Wang
- Intensive Care Unit, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - Qiuhua Chen
- Intensive Care Unit, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - Mingqi Chen
- Intensive Care Unit, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - Lu Cheng
- Intensive Care Unit, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - Hua Jiang
- Intensive Care Unit, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - Zhiguang Sun
- The First Clinical College, Nanjing University of Traditional Chinese Medicine, Nanjing, China.
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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: 98] [Impact Index Per Article: 12.3] [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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Case-Control Study of Patients at Risk of Medical Complications after Elective Craniotomy. World Neurosurg 2016; 91:58-65. [DOI: 10.1016/j.wneu.2016.03.087] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 03/22/2016] [Accepted: 03/23/2016] [Indexed: 11/18/2022]
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Kimmell KT, Jahromi BS. Clinical factors associated with venous thromboembolism risk in patients undergoing craniotomy. J Neurosurg 2015; 122:1004-11. [DOI: 10.3171/2014.10.jns14632] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECT
Patients undergoing craniotomy are at risk for developing venous thromboembolism (VTE). The safety of anticoagulation in these patients is not clear. The authors sought to identify risk factors predictive of VTE in patients undergoing craniotomy.
METHODS
The authors reviewed a national surgical quality database, the American College of Surgeons National Surgical Quality Improvement Program. Craniotomy patients were identified by current procedural terminology code. Clinical factors were analyzed to identify associations with VTE.
RESULTS
Four thousand eight hundred forty-four adult patients who underwent craniotomy were identified. The rate of VTE in the cohort was 3.5%, including pulmonary embolism in 1.4% and deep venous thrombosis in 2.6%. A number of factors were found to be statistically significant in multivariate binary logistic regression analysis, including craniotomy for tumor, transfer from acute care hospital, age ≥ 60 years, dependent functional status, tumor involving the CNS, sepsis, emergency surgery, surgery time ≥ 4 hours, postoperative urinary tract infection, postoperative pneumonia, on ventilator ≥ 48 hours postoperatively, and return to the operating room. Patients were assigned a score based on how many of these factors they had (minimum score 0, maximum score 12). Increasing score was predictive of increased VTE incidence, as well as risk of mortality, and time from surgery to discharge.
CONCLUSIONS
Patients undergoing craniotomy are at low risk of developing VTE, but this risk is increased by preoperative medical comorbidities and postoperative complications. The presence of more of these clinical factors is associated with progressively increased VTE risk; patients possessing a VTE Risk Score of ≥ 5 had a greater than 20-fold increased risk of VTE compared with patients with a VTE score of 0.
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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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Jamjoom AA, Jamjoom AB. Safety and Efficacy of Early Pharmacological Thromboprophylaxis in Traumatic Brain Injury: Systematic Review and Meta-Analysis. J Neurotrauma 2013; 30:503-11. [DOI: 10.1089/neu.2012.2584] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Aimun A.B. Jamjoom
- Department of Clinical Neuroscience, Western General Hospital, Edinburgh, United Kingdom
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14
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Glassner S, Srivastava K, Cofnas P, Deegan B, DeMaria P, Denis R, Ginzburg E. Prevention of venous thrombotic events in brain injury: review of current practices. Rambam Maimonides Med J 2013; 4:e0001. [PMID: 23908851 PMCID: PMC3678914 DOI: 10.5041/rmmj.10101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Venous thromboembolic event after traumatic brain injury represents a unique clinical challenge. Physicians must balance appropriate timing of chemoprophylaxis with risk of increased cerebral hemorrhage. Despite an increase in the literature since the 1990s, there are clear disparities in treatment strategies. This review discusses the prominent studies and subsequent findings regarding the topic with an attempt to establish recommendations using the existing evidence-based literature.
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15
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Interrupted Pharmocologic Thromboprophylaxis Increases Venous Thromboembolism in Traumatic Brain Injury. ACTA ACUST UNITED AC 2011; 70:19-24; discussion 25-6. [DOI: 10.1097/ta.0b013e318207c54d] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Chan CM, Zilberberg MD. Preferences in traumatic intracranial hemorrhage: bleeding vs. clotting. Crit Care 2010; 14:153. [PMID: 20497598 PMCID: PMC2911700 DOI: 10.1186/cc8996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Patients with traumatic brain injury and resultant intracranial hemorrhage (ICH) are at high risk for developing venous thromboembolism (VTE). The use of thromboprophylaxis is effective at decreasing the rate of VTE, but at the potential expense of an increased risk of ICH progression. Physicians must carefully consider both the benefits and risks of VTE prophylaxis before prescribing chemical anticoagulants to these patients. To help clarify this difficult choice, Scales and colleagues performed a decision analysis to determine whether the benefits of thromboprophylaxis outweigh the potential risk of worsening ICH. There is increasing evidence that bleeding risks are not as prominent as previously thought. Although the results were largely inconclusive, the present study has identified areas for future research.
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Affiliation(s)
- Chee M Chan
- Division of Pulmonary and Critical Care Medicine, Washington Hospital Center, 110 Irving Street NW #2B-39, Washington, DC 20010, USA.
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