Prophylaxis against deep-vein thrombosis following trauma: a prospective, randomized comparison of mechanical and pharmacologic prophylaxis

Bilateral pterygoid abscesses in a patient with Lemierre's syndrome

Patients with Lemierre's syndrome may have complications such as lung lesions, large joint arthritis and central nervous system involvement. However, complications involving a pterygoid abscess have scarcely been reported. Here, we report a case of bilateral Lemierre's syndrome accompanied with an intracranial epidural abscess and bilateral pterygoid abscesses. A woman in her 70s presented to the emergency room with a decreased level of consciousness. Infection was suspected, and Slackia exigua and species of Fusobacterium were identified in blood cultures, which suggested that the origin of infection was odontogenic, particularly as the patient had poor oral hygiene. Head and neck CT with contrast enhancement revealed bilateral internal jugular vein thrombophlebitis, septic pulmonary embolism, frontal epidural abscess and bilateral pterygoid abscesses. After antibiotic treatment and drainage, her condition improved. Pterygoid abscesses should be recognised as a rare complication of Lemierre's syndrome, especially when the infection origin is odontogenic.

Saudi Critical Care Society clinical practice guidelines on the prevention of venous thromboembolism in adults with trauma: reviewed for evidence-based integrity and endorsed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

BACKGROUND

To develop evidence-based clinical practice guidelines on venous thromboembolism (VTE) prevention in adults with trauma in inpatient settings.

METHODS

The Saudi Critical Care Society (SCCS) sponsored guidelines development and included 22 multidisciplinary panel members who completed conflict-of-interest forms. The panel developed and answered structured guidelines questions. For each question, the literature was searched for relevant studies. To summarize treatment effects, meta-analyses were conducted or updated. Quality of evidence was assessed using the Grading Recommendations, Assessment, Development, and Evaluation (GRADE) approach, then the evidence-to-decision (EtD) framework was used to generate recommendations. Recommendations covered the following prioritized domains: timing of pharmacologic VTE prophylaxis initiation in non-operative blunt solid organ injuries; isolated blunt traumatic brain injury (TBI); isolated blunt spine trauma or fracture and/or spinal cord injury (SCI); type and dose of pharmacologic VTE prophylaxis; mechanical VTE prophylaxis; routine duplex ultrasonography (US) surveillance; and inferior vena cava filters (IVCFs).

RESULTS

The panel issued 12 clinical practice recommendations-one, a strong recommendation, 10 weak, and one with no recommendation due to insufficient evidence. The panel suggests starting early pharmacologic VTE prophylaxis for non-operative blunt solid organ injuries, isolated blunt TBIs, and SCIs. The panel suggests using low molecular weight heparin (LMWH) over unfractionated heparin (UFH) and suggests either intermediate-high dose LMWH or conventional dosing LMWH. For adults with trauma who are not pharmacologic candidates, the panel strongly recommends using mechanical VTE prophylaxis with intermittent pneumatic compression (IPC). The panel suggests using either combined VTE prophylaxis with mechanical and pharmacologic methods or pharmacologic VTE prophylaxis alone. Additionally, the panel suggests routine bilateral lower extremity US in adults with trauma with elevated risk of VTE who are ineligible for pharmacologic VTE prophylaxis and suggests against the routine placement of prophylactic IVCFs. Because of insufficient evidence, the panel did not issue any recommendation on the use of early pharmacologic VTE prophylaxis in adults with isolated blunt TBI requiring neurosurgical intervention.

CONCLUSION

The SCCS guidelines for VTE prevention in adults with trauma were based on the best available evidence and identified areas for further research. The framework may facilitate adaptation of recommendations by national/international guideline policymakers.

High Altitude as a Risk Factor for Venous Thromboembolism in Tibial Plateau Fractures

Background: Tibial plateau fractures are often significant injuries that can require complex surgical interventions with prolonged perioperative immobilization, thereby increasing the risk of developing venous thromboembolic (VTE) events, specifically, deep vein thrombosis (DVT) and pulmonary embolism (PE). Risk stratification is paramount for guiding VTE prophylaxis. Although high altitude has been suggested to create a prothrombotic state, virtually no studies have explored its clinical effects in lower extremity trauma. The purpose of this study was to compare surgical fixation of tibial plateau fractures at high and low altitudes and its effects on post-operative VTE development.

Methods: The Truven MarketScan claims database was used to retrospectively identify patients who underwent surgical fixation of isolated and closed tibial plateau fractures using Current Procedural Terminology (CPT) codes over a 10-year period. Extraneous injuries were excluded using the International Classification of Diseases, 10^th edition (ICD-10), and CPT codes. Patient demographics, comorbidities, and DVT chemoprophylaxis prescriptions were obtained. Patients were partitioned into high altitude (>4000 feet) or low altitude (<100 feet) cohorts based on the zip codes of their surgery locations. One-to-one matching and univariate analysis were used to assess and control any baseline discrepancies between cohorts; multivariate regression was then performed between cohorts to determine the odds ratios (OR) for developing VTEs post-operatively.

Results: There were 7,832 patients included for analysis. There was no statistical difference between high and low altitude cohorts in developing VTEs within 30 days post-operatively. Higher altitudes were associated with increased odds of developing DVT (OR 1.21, p = 0.043) and PE (OR 1.27, p = 0.037) within 90 days post-operatively.

Conclusions: Surgical fixation of tibial plateau fractures is associated with an increased risk of developing VTEs at high altitudes within 90 days post-operatively. Understanding such risk factors in specific orthopaedic patient populations is essential for optimizing DVT prophylaxis protocols. Further studies should investigate this relationship and the role of DVT prophylaxis regimens in this population. 

Relationship Between the Incidence of Deep Vein Thrombosis During Hospitalization and the Energy of Injury in Tibial Plateau Fractures

This study aimed to investigate the relationship between the incidence of deep vein thrombosis (DVT) during hospitalization and the energy of injury in tibial plateau fractures (TPFs). One hundred and forty patients were enrolled between September 1, 2014, and October 1, 2017. According to Schatzker's classification, they were classified into the low-energy (type I-III) and high-energy (type IV-VI) groups. For DVT evaluation, duplex ultrasonography was performed in the lower extremities preoperatively and postoperatively. The location and changes of DVT were recorded. All patients underwent mechanical and chemical thromboprophylaxis. The incidence of DVT in TPFs was 36.43% and 46.43% preoperatively and postoperatively, respectively. The DVT incidence was 31.75% (20/63) in the low-energy group and 40.26% (31/77) in the high-energy group preoperatively, and 44.44% (28/63) in the low-energy group and 48.05% (37/77) in the high-energy group postoperatively. There was no significant difference between the 2 groups preoperatively (P = .298) and postoperatively (P = .785). The days between operation and discharge (P = .016), blood loss during surgery (P = .016), and preoperative d-dimer level (P = .02) showed differences between the 2 groups. Additionally, 29 new thrombi (14 [48.28%] in the high-energy group and 15 [51.72%] in the low-energy group) appeared and 16 preoperative thrombi disappeared postoperatively. Despite mechanical and chemical thromboprophylaxis, the DVT risk in patients with TPFs remains high. Although the DVT incidence is not significantly different between high-energy and low-energy injuries, the occurrence of DVT should be carefully monitored.

Guidelines for the prevention of venous thromboembolism in hospitalized patients with pelvi-acetabular trauma

BACKGROUND

Venous thromboembolism is a dreaded complication leading to increased morbidity and mortality in patients having pelvi-acetabular fractures.

OBJECTIVES

These evidence based guidelines aim to provide the decision making ability in the prevention of venous thromboembolism in patients with pelvi-acetabular trauma planned for operative or non operative treatment.

METHODS

The patients were subclassified into 5 categories. The PICO framework was used to devise research questions in each category. The systematic reviews were performed for each research question. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess outcomes of critical interest. The guideline panel consisting of expert members of different subspecialties, analyzed the evidence and made recommendations.

RESULTS

The guideline panel proposed 21 recommendations. There are five recommendations in category 1 to 3, two recommendations in category 4 and four recommendations in category 5.

CONCLUSION

In pelvi-acetabular fractures there is strong evidence to suggest that thromboprophylaxis should be given. It should be initiated as early as possible after control of hemorrhage. The chemical prophylaxis is the preferred mode and LMWH is the preferred agent of choice. The mechanical methods can be used as an adjunct. The routine prophylactic use of IVC filters is not recommended. However, the use of retrievable IVC filters in high risk patients with established VTE in preoperative period can be considered. The use of newer directly acting oral anticoagulants is gaining importance.

Perioperative symptomatic venous thromboembolism after immediate chemoprophylaxis in patients with pelvic and lower-extremity fractures

The purpose of this study was to investigate the incidence of symptomatic venous thromboembolism (VTE) after chemoprophylaxis in patients with pelvic and lower-extremity fractures, and to identify risk factors for VTEs in this subgroup of patients. To detect VTE, multi-detector computed tomography (CT) angiography was performed. Of 363 patients assessed, the incidence of symptomatic VTE was 12.4% (45 patients), and the incidence of symptomatic PE was 5.2% (19 patients). For the risk-factor analysis, a higher Charlson comorbidity index (p = 0.037), and a history of external fixator application (p = 0.007) were associated with increased VTE risk. Among patients who had VTE, male sex (p = 0.017), and above-the-knee fractures (p = 0.035) were associated with increased pulmonary embolism (PE) risk. In conclusions, the incidence of VTE in post-traumatic patients is not low after chemoprophylaxis. Risk factors for VTE and PE are different among patients with pelvic and lower-extremity fractures.

Incidence and Risk Factors of Deep Vein Thrombosis in Patients With Pelvic and Acetabular Fractures

This study aimed to investigate the incidence and risk factors for deep vein thrombosis (DVT) in patients with pelvic and acetabular fractures. Patients with pelvic or acetabular fractures were included. Demographic data, fracture classification, time to surgery, and d-dimer levels at admission and one day after surgical intervention were recorded. Duplex ultrasonography was performed in the lower extremities for DVT evaluation. All patients received mechanical and chemical thromboprophylaxis. One hundred ten patients with a mean age of 44.2 ± 13.8 years were included. There were 48 patients with pelvic fractures and 62 patients with acetabular fractures. Thirty-two (29.09%) patients sustained DVT; 21 (19.09%) patients exhibited proximal thrombosis, and 3 patients suffered pulmonary embolism. The incidence of DVT in patients with acetabular fractures was significantly higher than that of patients with pelvic fractures (χ² = 4.42, P = .04). The incidence of proximal DVT was significantly higher in patients with complex acetabular fractures than in patients with simple acetabular fractures (χ² = 6.65, P = .01). Multivariate analysis showed that age older than 60 years, associated injuries, and the time to surgery longer than 2 weeks were independent risk factors (P < .05). Despite mechanical and chemical thromboprophylaxis, the risk of DVT in patients with pelvic and acetabular fractures is still very high, and most of the thromboses were localized proximally. The risk of DVT is higher in patients older than 60 years, in those with associated injuries, and when the time from injury to operation is more than 2 weeks.

Patient preferences for venous thromboembolism prophylaxis after injury: a discrete choice experiment

OBJECTIVE

Limited evidence for the optimal venous thromboembolism (VTE) prophylaxis regimen in orthopaedic trauma leads to variability in regimens. We sought to delineate patient preferences towards cost, complication profile, and administration route (oral tablet vs. subcutaneous injection).

DESIGN

Discrete choice experiment (DCE).

SETTING

Level 1 trauma center in Baltimore, USA.

PARTICIPANTS

232 adult trauma patients (mean age 47.9 years) with pelvic or acetabular fractures or operative extremity fractures.

PRIMARY AND SECONDARY OUTCOME MEASURES

Relative preferences and trade-off estimates for a 1% reduction in complications were estimated using multinomial logit modelling. Interaction terms were added to the model to assess heterogeneity in preferences.

RESULTS

Patients preferred oral tablets over subcutaneous injections (marginal utility, 0.16; 95% CI: 0.11 - 0.21, P<0.0001). Preferences changed in favor of subcutaneous injections with an absolute risk reduction of 6.98% in bleeding, 4.53% in wound complications requiring reoperation, 1.27% in VTE, and 0.07% in death from pulmonary embolism (PE). Patient characteristics (sex, race, type of injury, time since injury) affected patient preferences (P<0.01).

CONCLUSIONS

Patients preferred oral prophylaxis and were most concerned about risk of death from PE. Furthermore, the findings estimated the trade-offs acceptable to patients and heterogeneity in preferences for VTE prophylaxis.

Intermittent pneumatic compression devices combined with anticoagulants for prevention of symptomatic deep vein thrombosis after total knee arthroplasty: a pilot study

OBJECTIVES

To investigate the effectiveness of intermittent pneumatic compression (IPC) devices combined with anticoagulants for the prevention of deep vein thrombosis (DVT) after total knee arthroplasty (TKA).

PATIENTS AND METHODS

In total 120 patients were involved in this pilot study. Patients in the control group received 10 mg of rivaroxaban per day after surgery. In addition to the prescription of rivaroxaban, IPC devices were used in the experimental group. The diagnosis of DVT was made by compression duplex ultrasound on postoperative day 9.

RESULTS

The incidence rates of overall, proximal, distal, and intermuscular DVT were 8.3%, 0%, 1.67%, and 6.67% in the experimental group; and 18.3%, 0%, 5%, and 13.33% in the control group, respectively. The incidence rates of total, distal, and intermuscular DVT in TKA patients was significantly lower in the experimental group than in the control group. For patients with DVT, enoxaparin was used instead of rivaroxaban, and DVT was found to have disappeared 10-14 days postoperatively.

CONCLUSION

Compared with the use of rivaroxaban alone, IPC devices combined with anticoagulants can significantly reduce the incidence rate of distal DVT and intermuscular DVT in the early postoperative period after TKA.

F11 rs2289252T and rs2036914C Polymorphisms Increase the Activity of Factor XI in Post-trauma Patients with Fractures Despite Thromboprophylaxis

OBJECTIVE

To evaluate the association between F11 rs2289252, rs2036914 polymorphisms and the activity of clotting factor XI in post-trauma patients with fractures receiving routine anticoagulation therapy for deep venous thrombosis (DVT).

METHODS

A case-control study involving 110 consecutive post-trauma patients with fractures and DVT in our hospital was conducted from April 2014 to October 2015; these patients comprised a DVT group. Another 40 sex- and age-matched patients with fractures but without DVT served as controls. Additionally, 40 sex- and age-matched healthy people were chosen as a normal group. Venous blood samples (2 mL) were drawn from all participants and genomic DNA extracted from the leukocytes of the patients with fracture-related DVT, whose genotype and allele frequency distribution of F11 gene rs2089252 and rs2036914 single nucleotide polymorphism were then assessed by a sequencing method. The activity of factor XI was measured by a solidification method in all participants, including those in control and normal groups.

RESULTS

The activity of factor XI in patients with fracture-related DVT and F11 rs2089252 CT was 1.16 times that of those with CC genotypes (P < 0.0001), whereas in patients with fracture-related DVT and F11 rs2089252 TT genotypes it was 1.32 times that of those with CC genotypes (P < 0.0001), in patients with fracture-related DVT and F11 rs2089252 T allele it was 1.24 times that of those with C allele (P < 0.05), in patients with fracture-related DVT and F11 rs2036914 CC it was 1.35 times that of those with TT genotypes, in patients with fracture-related DVT and F11 rs2036914 CT genotypes it was 1.12 times that of those with TT genotypes (P < 0.05), and in patients with fracture-related DVT F11 and rs2036914 C allele it was 1.22 times that of those with T allele (P < 0.05). The activity of factor XI was significantly higher in the control than in the normal group (P < 0.05).

CONCLUSIONS

High activity of factor XI indicates a risk of occurrence of DVT in post-trauma patients with fractures. F11 rs2089252 and rs2036914 (single nucleotide polymorphisms) are associated with activity of factors XI in such patients despite prophylaxis.

Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism

BACKGROUND

It is generally assumed by practitioners and guideline authors that combined modalities (methods of treatment) are more effective than single modalities in preventing venous thromboembolism (VTE), defined as deep vein thrombosis (DVT) or pulmonary embolism (PE), or both. This is an update of the review first published in 2008.

OBJECTIVES

The aim of this review was to assess the efficacy of combined intermittent pneumatic leg compression (IPC) and pharmacological prophylaxis versus single modalities in preventing venous thromboembolism.

SEARCH METHODS

For this update the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (May 2016). In addition the CIS searched the Cochrane Register of Studies (CENTRAL (2016, Issue 4)). Clinical trials databases were searched for details of ongoing or unpublished studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) or controlled clinical trials (CCTs) of combined IPC and pharmacological interventions used to prevent VTE.

DATA COLLECTION AND ANALYSIS

We independently selected trials and extracted data. Disagreements were resolved by discussion. We performed fixed-effect model meta-analyses with odds ratios (ORs) and 95% confidence intervals (CIs). We used a random-effects model when there was heterogeneity.

MAIN RESULTS

We included a total of 22 trials (9137 participants) of which 15 were randomized trials (7762 participants). The overall risk of bias was mostly unclear or high due to selection and performance bias. We used GRADE to assess the quality of the evidence and this was downgraded from high to moderate or very low due to the risk of bias, imprecision or indirectness.The rate of PE in the studies comparing IPC alone with combined IPC and pharmacological prophylaxis was low, underpowering the analyses. The incidence of symptomatic PE was 0.79% with IPC, but ranged between 0.1 to 1% with combined IPC and pharmacological prophylaxis (OR 0.49, 95% CI 0.18 to 1.34; 12 studies, 3017 participants, moderate quality evidence). The incidence of DVT was 4.10% in the IPC group and 2.19% in the combined group showing a reduced incidence of DVT in favour of the combined group (OR 0.52, 95% CI 0.33 to 0.82; 11 studies, 2934 participants, moderate quality evidence). The addition of an anticoagulant to IPC, however, increased the risk of any bleeding compared to IPC alone; 0.66% (7/1053) in the IPC group and 4.0% (44/1102) in the combined group (OR 5.04, 95% CI 2.36 to 10.77; 7 studies, 2155 participants, moderate quality evidence). Major bleeding followed a similar pattern; 0.1% (1/1053) in the IPC group to 1.5% (17/1102) in the combined group (OR 6.81, 95% CI 1.99 to 23.28; 7 studies, 2155 participants, moderate quality evidence).We detected no difference between the type of surgery subgroups such as orthopedic and non-orthopedic participants for DVT incidence (P = 0.16). Tests for differences between type of surgery subgroups were not possible for PE incidence.Compared with pharmacological prophylaxis alone, the use of combined IPC and pharmacological prophylaxis modalities reduced the incidence of symptomatic PE from 2.92% to 1.20% (OR 0.39, 95% CI 0.23 to 0.64; 10 studies, 3544 participants, moderate quality evidence). The incidence of DVT was 6.2% in the pharmacological prophylaxis group and 2.9% in the combined group showing no difference between the combined and pharmacological prophylaxis groups (OR 0.42, 95% CI 0.18 to 1.03; 11 studies, 2866 participants, moderate quality evidence). Increased bleeding side effects were not observed for IPC when it was added to anticoagulation (bleeding: OR 0.80, 95% CI 0.30 to 2.14, very low quality evidence; major bleeding: OR 1.21, 95% CI 0.35 to 4.18, very low quality evidence, 3 studies, 244 participants).No difference was detected between the type of surgery subgroups for PE incidence (P = 0.68) or for DVT incidence (P = 0.10).

AUTHORS' CONCLUSIONS

Moderate quality evidence suggests that combining IPC and pharmacological prophylaxis, compared with IPC or pharmacological prophylaxis alone, decreases the incidence of DVT when compared to compression, and incidence of PE when compared to anticoagulation. Moderate quality evidence suggests that there is no difference between combined and single modalities in the incidence of PE when compared with compression alone and DVT when compared with anticoagulation alone. The quality of evidence for PE or DVT was downgraded to moderate due to imprecision or risk of bias in study methodology, highlighting the need for further research. Moderate quality evidence suggests the addition of pharmacological prophylaxis to IPC, increased the risk of bleeding compared to IPC alone, a side effect not observed for IPC when added to pharmacological prophylaxis (very low quality evidence), as expected for a physical method of thromboprophylaxis. The quality of evidence for bleeding was downgraded to moderate due to indirectness or very low due to risk of bias in study methodology, indirectness and imprecision highlighting the need for further research. Nevertheless, the results of the current review agree with current guideline recommendations, which support the use of combined modalities in hospitalised patients (limited to those with trauma or undergoing surgery) at risk of developing VTE. More studies on the role of combined modalities in VTE prevention are needed.

Thromboembolic Disease After Orthopedic Trauma

Orthopedic trauma results in systemic physiologic changes that predispose patients to venous thromboembolism (VTE). In the absence of prophylaxis, VTE incidence may be as high as 60%. Mechanical and pharmacologic thromboprophylaxis are effective in decreasing rates of VTE. Combined mechanical and pharmacologic thromboprophylaxis is more efficacious for decreasing VTE incidence than either regimen independently. If pharmacologic thromboprophylaxis is contraindicated, mechanical prophylaxis should be used. Patients with isolated lower extremity fractures who are ambulatory, or those with isolated upper extremity trauma, do not require pharmacologic prophylaxis in the absence of other VTE risk factors.

Risk Factors for Deep Venous Thrombosis Following Orthopaedic Trauma Surgery: An Analysis of 56,000 patients

Background:

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are recognized as major causes of morbidity and mortality in orthopaedic trauma patients. Despite the high incidence of these complications following orthopaedic trauma, there is a paucity of literature investigating the clinical risk factors for DVT in this specific population. As our healthcare system increasingly emphasizes quality measures, it is critical for orthopaedic surgeons to understand the clinical factors that increase the risk of DVT following orthopaedic trauma.

Objectives:

Utilizing the ACS-NSQIP database, we sought to determine the incidence and identify independent risk factors for DVT following orthopaedic trauma.

Patients and Methods:

Using current procedural terminology (CPT) codes for orthopaedic trauma procedures, we identified a prospective cohort of patients from the 2006 to 2013 ACS-NSQIP database. Using Wilcoxon-Mann-Whitney and chi-square tests where appropriate, patient demographics, comorbidities, and operative factors were compared between patients who developed a DVT within 30 days of surgery and those who did not. A multivariate logistic regression analysis was conducted to calculate odds ratios (ORs) and identify independent risk factors for DVT. Significance was set at P < 0.05.

Results:

56,299 orthopaedic trauma patients were included in the analysis, of which 473 (0.84%) developed a DVT within 30 days. In univariate analysis, twenty-five variables were significantly associated with the development of a DVT, including age (P < 0.0001), BMI (P = 0.037), diabetes (P = 0.01), ASA score (P < 0.0001) and anatomic region injured (P < 0.0001). Multivariate analysis identified several independent risk factors for development of a DVT including use of a ventilator (OR = 43.67, P = 0.039), ascites (OR = 41.61, P = 0.0038), steroid use (OR = 4.00, P < 0.001), and alcohol use (OR = 2.98, P = 0.0370). Compared to patients with upper extremity trauma, those with lower extremity injuries had significantly increased odds of developing a DVT (OR = 7.55, P = 0.006). The trend toward increased odds of DVT among patients with injuries to the hip/pelvis did not reach statistical significance (OR = 4.51, P = 0.22). Smoking was not found to be an independent risk factor for developing a DVT (P = 0.1217).

Conclusions:

This is the largest study to date using the NSQIP database to identify risk factors for DVT in orthopaedic trauma patients. Although the incidence of DVT was low in our cohort, the presence of certain risk factors significantly increased the odds of developing a DVT following orthopaedic trauma. These findings will enable orthopaedic surgeons to target at-risk patients and implement post-operative care protocols aimed at reducing the morbidity and mortality associated with DVT in orthopaedic trauma patients.

Methods and Guidelines for Venous Thromboembolism Prevention in Polytrauma Patients with Pelvic and Acetabular Fractures

Sequential compression devices and chemical prophylaxis are the standard venous thromboembolism (VTE) prevention for trauma patients with acetabular and pelvic fractures. Current chemical pharmacological contemplates the use of heparins or fondaparinux. Other anticoagulants include coumarins and aspirin, however these oral agents can be challenging to administer and may need monitoring. When contraindications to anticoagulation in high-risk patients are present, prophylactic inferior vena cava filters can be an option to prevent pulmonary emboli. Unfortunately strong evidence about the most effective method, and the timing of their commencement, in patients with pelvic and acetabular fractures remains controversial.

Venous thromboembolism associated with lower limb fractures after trauma: dilemma and management

BACKGROUND

Trauma patients have the highest risk of developing venous thromboembolism (VTE) among hospitalised patients, with a reported 13-fold greater risk of developing VTE over non-trauma patients. This study examines the incidence of VTE and associated complications in trauma patients with lower limb fractures or injuries.

METHODS

We retrospectively analysed 6,227 trauma patients and classified them according to injury severity score (ISS). The minor trauma group (ISS ≤15) contained 5,637 patients and the major trauma group (ISS >15) contained 590 patients.

RESULTS

In the minor trauma group, VTE incidence was 1.17 %: 0.67 % were diagnosed with deep vein thrombosis (DVT) and 0.5 % with pulmonary embolism (PE). The readmission rate in the following 3-month period was 11 %, of which 2.8 % were subsequently rediagnosed with VTE. The 30-day mortality rate was 2.2 %. Seven patients died from PE following their initial admission and treatment, and another patient died from PE within three months after discharge. In the major trauma group, the VTE incidence was 6.8 %: 5.1 % with diagnosed with DVT and 1.7 % with PE. The readmission rate during the following three-month period was 6.6 %, of which 5 % were readmitted because of VTE and two cases were readmitted because of DVT. The overall 30-day mortality rate was 9.7 %, but no patients were formally diagnosed with a fatal case of PE.

CONCLUSION

This study found that major trauma patients have an approximate six-fold increased risk of developing VTE during admission compared with minor trauma patients (relative risk: 5.79; 95 % confidence interval: 3.94-8.49). Our findings support the use of extended prophylaxis to treat minor trauma patients.

Venous thromboembolism in orthopaedic trauma

Patients who sustain orthopaedic trauma are at risk for developing deep venous thrombosis and symptomatic pulmonary emboli. The prevention of venous thromboembolism has moved to the forefront of patient safety initiatives, resulting in the formation of various guidelines to assist the practitioner. Recommendations for venous thromboembolism prophylaxis in the orthopaedic trauma patient exist, but there is insufficient evidence in the literature to make strong recommendations regarding type and duration of prophylaxis. The associated morbidity of chemical anticoagulants used in the orthopaedic trauma patient must also be taken into consideration, specifically the increased risk of bleeding. Mechanical prophylaxis is used in place of, or in addition to, these medications in certain situations. New, potentially superior anticoagulants have been developed but are still understudied. Larger studies are needed to further define the type and duration of deep venous thrombosis prophylaxis in the orthopaedic trauma patient.

The incidence and the risk factors of venous thromboembolism in Korean patients with pelvic or acetabular fractures

BACKGROUND

Pelvic ring and acetabular fractures are the results of high energy trauma, but there is a paucity of information available regarding the incidence and risk factors of venous thromboembolism (VTE) after these injuries in Asians. This study was undertaken to evaluate the incidence of VTE after a pelvic or an acetabular fracture and to identify predictive factors.

METHODS

A prospective evaluation was performed by indirect computed tomography (CT) venography in patients with pelvic or acetabular fractures. Ninety-five patients were examined by indirect CT venography. Fifty-five patients suffered from a pelvic ring injury (anteroposterior compression 5, lateral compression 25, vertical shear 25), and the remaining 40 from acetabular fractures (simple 18, complex 22). Indirect CT venography was performed within 1-2 weeks of initial trauma. Relationships between VTE and sex, age, fracture pattern, body mass index, injury severity score, period of immobilization, and need for surgical treatment were analyzed. Deep vein thrombosis (DVT) in a more proximal to popliteal vein and the existence of PE were considered clinically significant.

RESULTS

Thirty-two patients (33.7 %) were found to have VTE at an average of 11 days after initial injury. Clinically significant DVT was found 20 cases (21.1 %). No statistical difference was found between pelvic ring injuries and acetabular fractures with respect to the development of VTE. For those with pelvic ring injury, the incidence of VTE in those with a vertical shear injury (52 %) was significantly greater than in others with a pelvic ring injury (p = 0.014). Patients with an age >50 were found to be at greater risk of VTE (p = 0.032).

CONCLUSION

Our findings demonstrate that Korean patients with pelvic or acetabular fractures have a higher risk of VTE than is generally believed, and caution should be taken to prevent and treat VTE, especially in high energy pelvic ring injury and elderly patients.

A retrospective analysis of the effectiveness of low molecular weight heparin for venous thromboembolism prophylaxis in trauma patients

BACKGROUND

In trauma patients, Enoxaparin (a low molecular weight heparin, LMWH) prophylaxis for venous thromboembolism (VTE) risk reduction is unproven.

METHODS

Cohort analysis conducted consisting of all trauma patients age >13 admitted to Level-I trauma center and hospitalized >48 hours. VTE risk determined by the Risk Assessment Profile. High risk patients received LMWH unless contraindicated, while low and moderate risk patients received LMWH at attending surgeon's discretion. Odds ratio for VTE by logistic regression. VTE incidence, relative risk (RR), and number needed to treat (NNT) to prevent deep vein thrombosis (DVT) or pulmonary embolism determined by risk category.

RESULTS

Cohort consisted of 2,281 patients (1,211 low, 979 moderate, 91 high risks). VTE occured in 254 patients (11.1%). High-risk patients had significantly higher VTE incidence, odds ratio = 31.8 (P < .001). VTE was significantly reduced in high-risk patients receiving LMWH versus those who did not (.26 vs .53, P = .02). Among moderate and high risk, prophylactic LMWH reduced the incidence of pulmonary embolism (RR = .19, NNT = 40.4, P = .01), and trended toward reduced DVT incidence (RR = .81, NNT = 27.3, P = .15). LMWH lowered DVT incidence (RR = .52, NNT = 4.1, P = .03) in high risk patients.

CONCLUSION

Prophylactic LMWH is associated with reduction of VTE in trauma patients.

Surgical management of acetabular fractures: a case series

INTRODUCTION

For decades, acetabular fractures were treated conservatively. Judet et al. in 1960s established the operative treatment of these fractures by continuous improvement of pre-operative evaluation and classification of fractures. Several studies demonstrated that accurate fracture reduction decreases the incidence of post-traumatic arthritis and improves functional outcome.

CASE SERIES

We report 67 consecutive patients who underwent surgical treatment for acetabular fracture; 44 patients were available for follow-up. In 35 (79.5%) cases, congruent reductions were achieved. The final mean Harris hip score was 81.8 (53-95). Functional outcomes according to Harris score were excellent and good in 31 patients (70.5%).

CONCLUSIONS

The results of internal fixation of displaced acetabular fractures in our series were satisfactory.

Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

BACKGROUND

VTE is a common cause of preventable death in surgical patients.

METHODS

We developed recommendations for thromboprophylaxis in nonorthopedic surgical patients by using systematic methods as described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.

RESULTS

We describe several alternatives for stratifying the risk of VTE in general and abdominal-pelvic surgical patients. When the risk for VTE is very low (< 0.5%), we recommend that no specific pharmacologic (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation. For patients at low risk for VTE (∼1.5%), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC), over no prophylaxis (Grade 2C). For patients at moderate risk for VTE (∼3%) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated heparin (Grade 2B), or mechanical prophylaxis with IPC (Grade 2C) over no prophylaxis. For patients at high risk for VTE (∼6%) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or low-dose unfractionated heparin (Grade 1B) over no prophylaxis. In these patients, we suggest adding mechanical prophylaxis with elastic stockings or IPC to pharmacologic prophylaxis (Grade 2C). For patients at high risk for VTE undergoing abdominal or pelvic surgery for cancer, we recommend extended-duration, postoperative, pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B). For patients at moderate to high risk for VTE who are at high risk for major bleeding complications or those in whom the consequences of bleeding are believed to be particularly severe, we suggest use of mechanical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Grade 2C). For patients in all risk groups, we suggest that an inferior vena cava filter not be used for primary VTE prevention (Grade 2C) and that surveillance with venous compression ultrasonography should not be performed (Grade 2C). We developed similar recommendations for other nonorthopedic surgical populations.

CONCLUSIONS

Optimal thromboprophylaxis in nonorthopedic surgical patients will consider the risks of VTE and bleeding complications as well as the values and preferences of individual patients.

Deep vein thrombosis prophylaxis in trauma patients

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are known collectively as venous thromboembolism (VTE). Venous thromboembolic events are common and potentially life-threatening complications following trauma with an incidence of 5 to 63%. DVT prophylaxis is essential in the management of trauma patients. Currently, the optimal VTE prophylaxis strategy for trauma patients is unknown. Traditionally, pelvic and lower extremity fractures, head injury, and prolonged immobilization have been considered risk factors for VTE; however it is unclear which combination of risk factors defines a high-risk group. Modalities available for trauma patient thromboprophylaxis are classified into pharmacologic anticoagulation, mechanical prophylaxis, and inferior vena cava (IVC) filters. The available pharmacologic agents include low-dose heparin (LDH), low molecular weight heparin (LMWH), and factor Xa inhibitors. Mechanical prophylaxis methods include graduated compression stockings (GCSs), pneumatic compression devices (PCDs), and A-V foot pumps. IVCs are traditionally used in high risk patients in whom pharmacological prophylaxis is contraindicated. Both EAST and ACCP guidelines recommend primary use of LMWHs in trauma patients; however there are still controversies regarding the definitive VTE prophylaxis in trauma patients. Large randomized prospective clinical studies would be required to provide level I evidence to define the optimal VTE prophylaxis in trauma patients.

Thromboprophylaxis following major skeletal trauma: a systematic review

PURPOSE

Venous thromboembolic disease following skeletal polytrauma is a major issue for trauma surgeons, but there is no consensus of opinion regarding the optimal form of prophylaxis. The purpose of this paper was to compare the incidence of venous thromboembolic events (VTE) after major skeletal trauma managed with different prophylactic methods and their combinations.

METHODS

A search of AMED, CINAHL, Cochrane Library, EMBASE and MEDLINE databases was performed from their inception to July 2010. A search of unpublished literature databases was undertaken. All randomised controlled trials assessing the incidence of VTE events between two or more forms of thromboprophylaxis for patient following major skeletal trauma were included. Two reviewers independently identified all eligible articles, extracted the data, and critically appraised all included publications using the Critical Appraisal Skills Programme tool.

RESULTS

A total of 11 papers were identified. The findings of this study suggest that low molecular weight heparin (LMWH) may be superior to low dose heparin (LDH), and that LMWH should be used in addition to mechanical prophylaxis measures in patients following major skeletal trauma. There is limited evidence for the use of electrostimulation. There appeared to be no significant difference between the use of LDH compared to calf compression devices. However, the evidence-base was insufficient in both size and methodological quality.

CONCLUSIONS

There is currently insufficient research to be able to inform trauma surgeons as to the optimal method of thromboprophylaxis for patients following major skeletal trauma.

Nonadherence in outpatient thrombosis prophylaxis with low molecular weight heparins after major orthopaedic surgery

BACKGROUND

According to some current guidelines, extended thromboprophylaxis after hip and knee arthroplasties is recommended. Outpatient prophylaxis with low molecular weight heparins (LMWH) is an important part of this prophylaxis, although the rates of adherence to these regimens is not known.

QUESTIONS/PURPOSES

We determined (1) the degree of nonadherence (NA) of patients with LMWH outpatient prophylaxis, and (2) whether specific independent factors explain NA.

METHODS

NA was determined by syringe count and by indirect and direct questions to patients. We defined six different NA indicators. To identify factors explaining LMWH NA, we used three different logistic regression models.

RESULTS

NA rates ranged between 13% and 21% depending on the indicator used for measurement. Patients who were nonadherent missed between 38% and 53% of their outpatient LMWH injections. If patients attended an outpatient rehabilitation program, the probability for their NA increased substantially. Moreover, the NA probability increased with each additional day between acute hospitalization and start of rehabilitation (linking days). NA was lower for patients who feared thrombosis or who believed antithrombotic drugs to be the most important measure in thromboprophylaxis.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Adverse drug events associated with disorders of coagulation

Disorders of coagulation are common adverse drug events encountered in critically ill patients and present a serious concern for intensive care unit (ICU) clinicians. Dosing strategies for medications used in the ICU are typically developed for use in noncritically ill patients and, therefore, do not account for the altered pharmacokinetic and pharmacodynamic properties encountered in the critically ill as well as the increased potential for drug-drug interactions, given the far greater number of medications ordered. This substantially increases the risk for coagulation-related adverse reactions, such as a bleeding or prothrombotic events. Although many medications used in the ICU have the potential to cause coagulation disorders, the exact incidence will vary based on the specific medication, dose, concomitant drug therapy, ICU setting, and patient-specific comorbidities. Clinicians must strongly consider these factors when evaluating the risk/benefit ratio for a particular therapy. This review surveys recent literature documenting the risk for adverse drug reactions specific to bleeding and/or clotting with commonly used medications in the ICU.

Pneumatic compression with foot pumps facilitates early postoperative mobilisation in total knee arthroplasty

Deep-vein thrombosis (DVT) and pulmonary embolism (PE) represent life-threatening postoperative complications frequently responsible for in-hospital mortality following total knee arthroplasty (TKA). Mechanical prophylaxis in the form of a foot pump offers an alternative to pharmacological and physical therapy. The aim of this prospective and randomised study was to examine the clinical efficacy of the A-V Impulse (AVI) system in reduction of soft-tissue swelling of the lower limb following a TKA. A total of 80 patients undergoing cemented TKA between September 2005 and December 2006 were randomised into two groups of 40 patients (n¹ = 40, n² = 40) during the 16-month study period. All patients received a subcutaneous dose of low molecular weight heparin (LMWH) (Enoxaparin/Clexane® 40 mg) once daily beginning 24 hours prior to the operation. The mean age for the groups n¹ and n² were 68.93 and 68.15 years, respectively. The reduction of soft-tissue swelling in the n¹ group was significantly higher (p < 0.05) compared with n². Evaluation of body mass index (BMI) with regard to the average reduction of soft-tissue swelling showed no significant influence (p < 0.05). The better function of the operated knee in group AVI was a significant predictor for improved agility and mobility (p < 0.01). No complications were reported for the application of the AVI. No ultrasonographic evidence of DVT or PE was found in any of the 80 patients during the investigative time period of eight days. After three months, there was no evidence of a symptomatic DVT.

Thromboprophylaxis after multiple trauma: what treatment and for how long?

A review of current literature discussing thromboprophylaxis in the multiple-trauma patient to provide insight on the type of treatment and its duration of use. AMEDLINE search was conducted in May 2009 using keywords associated with thromboprophylactic measures in multiple-trauma patient care, including inferior vena cava (IVC) filters, mechanical-compression devices and anticoagulants. Abstracts were evaluated for relevance to this study and full-text articles were then examined individually. Fourteen full text articles were evaluated including guidelines published by the American College of Chest Physicians (ACCP) and the Eastern Association for the Surgery of Trauma (EAST) and other studies dealing with multiple-trauma patients, including those in hip-fracture surgery, lower-leg trauma and head trauma. Limited research has been performed for the multiple-trauma patient and recommendations regarding the type of treatment and its duration of use cannot be suggested beyond what has been extrapolated from existing trauma and major surgery patients. IVC filters, mechanical compression devices and anticoagulants therefore remain the standard, but their duration of use in the multiple-trauma patient is not well described. New oral anticoagulants that inhibit factor Xa or thrombin directly show promising qualities but have not been evaluated for multiple-trauma applications. Therefore, optimal thromboprophylaxis and its duration after multiple trauma is largely based on rational, clinical decision making on a case-by-case basis.

Balancing patient preferences and clinical needs: community versus hospital based care for patients with suspected DVT

OBJECTIVE

To establish patients' preferences and willingness to pay (WTP) for different service models for suspected deep vein thrombosis (DVT).

METHODS

We analysed patient responses to a discrete choice experiment (DCE) questionnaire which had been targeted at patients in Leicester, UK. The questionnaire elicited preferences/WTP for attributes of DVT provision including speed of diagnosis; access; continuity of care; and minimizing hospital visits. Additionally we evaluated trade-offs between clinical and service attributes. We analysed responses from 256 patients with suspected DVT (65% response rate).

RESULTS

Respondents are WTP pound 4.82 per extra hour of dedicated DVT service provision; pound 17.12 per hospital visit avoided; pound 115.73 per day's reduction in diagnostic wait; and pound 179.32 for 'much' not 'some' continuity, or pound 56.88 for 'some' not 'lack' of continuity in nursing.

CONCLUSIONS

Research evaluating different DVT service models usually reports on clinical efficacy in centres of excellence. Results show prompt diagnosis is valued by patients and may improve efficacy by reducing unnecessary anticoagulation. However, patients value 'process' measures such as continuity of care also. To ensure optimal provision, clinical benefit measurement ought to be augmented with information on patients' preferences.

Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients

BACKGROUND

It has been suggested that combined modalities (methods of treatment) are more effective than single modalities in preventing venous thromboembolism (defined as deep vein thrombosis and pulmonary embolism, or both) in high-risk patients.

OBJECTIVES

To assess the efficacy of intermittent pneumatic leg compression combined with pharmacological prophylaxis versus single modalities in preventing venous thromboembolism in high-risk patients.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases (PVD) Group searched their Specialized Register (last searched 17 July 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched The Cochrane Library 2008, Issue 3). We searched the reference lists of relevant articles to identify additional trials.

SELECTION CRITERIA

Randomized controlled trials (RCTs) or controlled clinical trials (CCTs) of combined intermittent pneumatic leg compression and pharmacological interventions used to prevent venous thromboembolism in high-risk patients.

DATA COLLECTION AND ANALYSIS

Data extraction was undertaken independently by two review authors using data extraction sheets.

MAIN RESULTS

Eleven studies, six of them randomized controlled trials, were identified. The trials included 7431 patients, in total. Compared with compression alone, the use of combined modalities reduced significantly the incidence of both symptomatic pulmonary embolism (PE) (from about 3% to 1%; odds ratio (OR) 0.39, 95% confidence interval (CI) 0.25 to 0.63) and deep vein thrombosis (DVT) (from about 4% to 1%; OR 0.43, 95% CI 0.24 to 0.76). Compared with pharmacological prophylaxis alone, the use of combined modalities significantly reduced the incidence of DVT (from 4.21% to 0.65%; OR 0.16, 95% CI 0.07 to 0.34) but the included studies were underpowered with regard to PE. The comparison of compression plus pharmacological prophylaxis versus compression plus aspirin showed a non-significant reduction in PE and DVT in favor of the former group. Repeat analysis restricted to the RCTs confirmed the above findings.

AUTHORS' CONCLUSIONS

Compared with compression alone, combined prophylactic modalities decrease significantly the incidence of venous thromboembolism. Compared with pharmacological prophylaxis alone, combined modalities reduce significantly the incidence of DVT but the effect on PE is unknown. The results of the current review support, especially in high-risk patients, the use of combined modalities. More studies on their role in PE prevention, compared with pharmacological prophylaxis alone, are urgently needed.

Economic evaluations of anticoagulants for the prophylaxis of venous thromboembolism following major trauma

Venous thromboembolism is a life-threatening complication in patients following major trauma. These patients are at increased risk of deep-vein thrombosis and pulmonary embolism. In the absence of a major contraindication, anticoagulant prophylaxis with either low-dose unfractionated heparin or low-molecular-weight heparin is recommended. The objectives of this study were to undertake a systematic review and critically evaluate published cost-effectiveness analyses of anticoagulant prophylaxis against deep-vein thrombosis following major trauma. The results of the identified studies varied significantly, from enoxaparin being the dominant strategy based on the cost-per-deep-vein thrombosis averted, to low-dose unfractionated heparin being the dominant strategy based on the cost per life-year gained. In general, the more comprehensive the model, the more favorable the results were towards low-dose unfractionated heparin.

Prevention of Venous Thromboembolism in High-Risk Patients

The prevention of venous thromboembolism (VTE) in patients recovering from major trauma, spinal cord injury (SCI), or other critical illness is often challenging. These patient groups share a high risk for VTE, they often have at least a temporary high bleeding risk, and there are relatively few thromboprophylaxis trials specific to these populations. A systematic literature review has been conducted to summarize the risks and prevention of VTE in these three groups. It is concluded that routine thromboprophylaxis should be provided to major trauma, SCI and critical care patients based on an individual assessment of their thrombosis and bleeding risks. For patients at high risk for VTE, including those recovering from major trauma and SCI, prophylaxis with a low molecular weight heparin (LMWH) should commence as soon as hemostasis has been demonstrated. For critical care patients at lower thrombosis risk, either LMWH or low-dose heparin is recommended. For those with a very high risk of bleeding, mechanical prophylaxis should be instituted as early as possible and continued until pharmacologic prophylaxis can be initiated. The use of prophylactic inferior vena caval filters is strongly discouraged because their potential benefit has not been shown to outweigh the risks or substantial costs. Implementation of thromboprophylaxis in these patients requires a local commitment to this important patient safety priority as well as a highly functional delivery system, based on the use of pre-printed orders, computer prompts, regular audit and feedback, and ongoing quality improvement efforts.