The Practice of Venous Thromboembolism Prophylaxis in the Major Trauma Patient

Department of Surgery, University of Toronto, Toronto, Ontario, Canada
The Journal of trauma (Impact Factor: 2.96). 03/2007; 62(3):557-62; discussion 562-3. DOI: 10.1097/TA.0b013e318031b5f5
Source: PubMed


The incidence of venous thromboembolism (VTE) without prophylaxis is as high as 80% after major trauma. Initiation of prophylaxis is often delayed because of concerns of injury-associated bleeding. As the effect of delays in the initiation of prophylaxis on VTE rates is unknown, we set out to evaluate the relationship between late initiation of prophylaxis and VTE.
Data were derived from a multicenter prospective cohort study evaluating clinical outcomes in adults with hemorrhagic shock after injury. Analyses were limited to patients with an Intensive Care Unit length of stay >or=7 days. The rate of VTE was estimated as a function of the time to initiation of pharmacologic prophylaxis. A multivariate stepwise logistic regression model was used to evaluate factors associated with late initiation.
There were 315 subjects who met inclusion criteria; 34 patients (11%) experienced a VTE within the first 28 days. Prophylaxis was initiated within 48 hours of injury in 25% of patients, and another one-quarter had no prophylaxis for at least 7 days after injury. Early prophylaxis was associated with a 5% risk of VTE, whereas delay beyond 4 days was associated with three times that risk (risk ratio, 3.0, 95% CI [1.4-6.5]). Factors associated with late (>4 days) initiation of prophylaxis included severe head injury, absence of comorbidities, and massive transfusion, whereas the presence of a severe lower extremity fracture was associated with early prophylaxis.
Clinicians are reticent to begin timely VTE prophylaxis in critically injured patients. Patients are without VTE prophylaxis for half of all days within the first week of admission and this delay in the initiation of prophylaxis is associated with a threefold greater risk of VTE. The relative risks and benefits of early VTE prophylaxis need to be defined to better direct practice in this high-risk population.

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    • "For patients who are older than 90 years old, the risk of fatal bleeding is as high as 13%,[27]-[29] especially if they are admitted for severe trauma, hemorrhagic stroke, subdural hematoma, neurosurgery and active gastrointestinal bleeding.[30],[31] Regardless of the causes for a delay in initiating VTE prophylaxis, a delay may turn into omission of VTE prophylaxis altogether during the entire hospital stay of a patient and increases the risk of VTE.[19],[20] "
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    ABSTRACT: Venous thromboembolism (VTE) is the commonest cause of preventable death in hospitalized patients. Elderly patients have higher risk of VTE because of the high prevalence of predisposing co-morbidities and acute illnesses. Clinical diagnosis of VTE in the elderly patient is particularly difficult and, as such, adequate VTE prophylaxis is of pivotal importance in reducing the mortality and morbidities of VTE. Omission of VTE prophylaxis is, however, very common despite continuous education. A simple way to overcome this problem is to implement universal VTE prophylaxis for all hospitalized elderly patients instead of selective prophylaxis for some patients only according to individual's risk of VTE. Although pharmacological VTE prophylaxis is effective for most patients, a high prevalence of renal impairment and drug interactions in the hospitalized elderly patients suggests that a multimodality approach may be more appropriate. Mechanical VTE prophylaxis, including calf and thigh compression devices and/or an inferior vena cava filter, are often underutilized in hospitalized elderly patients who are at high-risk of bleeding and VTE. Because pneumatic compression devices and thigh length stockings are virtually risk free, mechanical VTE prophylaxis may allow early or immediate implementation of VTE prophylaxis for all hospitalized elderly patients, regardless of their bleeding and VTE risk. Although the cost-effectiveness of this Multimodality Universal STat ('MUST') VTE prophylaxis approach for hospitalized elderly patients remains uncertain, this strategy appears to offer some advantages over the traditional 'selective and single-modal' VTE prophylaxis approach, which often becomes 'hit or miss' or not implemented promptly in many hospitalized elderly patients. A large clustered randomized controlled trial is, however, needed to assess whether early, multimodality, universal VTE prophylaxis can improve important clinical outcomes of hospitalized elderly patients.
    Full-text · Article · Jun 2011 · Journal of Geriatric Cardiology
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    • "A small retrospective study of 88 patients with traumatic brain injury observed that only 42% ever received low-molecular weight heparin prophylaxis, and the mean time to initiation of therapy was 14 days [18]. Similarly, a multicentre retrospective study of trauma patients with ICU length of stay greater than seven days found that prophylaxis was initiated within two days in only 25% of patients, and another quarter did not receive prophylaxis until at least one week following injury [19]. Thus, the use and timing of anticoagulation prophylaxis in these patients remains uncertain and controversial, and most are treated with more conservative and less effective measures such as graduated compression stockings, intermittent pneumatic compression devices, and physiotherapy [13,16]. "
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    ABSTRACT: Patients with intracranial hemorrhage due to traumatic brain injury are at high risk of developing venous thromboembolism including deep vein thrombosis (DVT) and pulmonary embolism (PE). Thus, there is a trade-off between the risks of progression of intracranial hemorrhage (ICH) versus reduction of DVT/PE with the use of prophylactic anticoagulation. Using decision analysis modeling techniques, we developed a model for examining this trade-off for trauma patients with documented ICH. The decision node involved the choice to administer or to withhold low molecular weight heparin (LMWH) anticoagulation prophylaxis at 24 hours. Advantages of withholding therapy were decreased risk of ICH progression (death, disabling neurologic deficit, non-disabling neurologic deficit), and decreased risk of systemic bleeding complications (death, massive bleed). The associated disadvantage was greater risk of developing DVT/PE or death. Probabilities for each outcome were derived from natural history studies and randomized controlled trials when available. Utilities were obtained from accepted databases and previous studies. The expected value associated with withholding anticoagulation prophylaxis was similar (0.90) to that associated with the LMWH strategy (0.89). Only two threshold values were encountered in one-way sensitivity analyses. If the effectiveness of LMWH at preventing DVT exceeded 80% (range from literature 33% to 82%) our model favoured this therapy. Similarly, our model favoured use of LMWH if this therapy increased the risk of ICH progression by no more than 5% above the baseline risk. Our model showed no clear advantage to providing or withholding anticoagulant prophylaxis for DVT/PE prevention at 24 hours after traumatic brain injury associated with ICH. Therefore randomized controlled trials are justifiable and needed to guide clinicians.
    Full-text · Article · Apr 2010 · Critical care (London, England)
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    ABSTRACT: 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.
    No preview · Article · Aug 2007 · Expert Review of Pharmacoeconomics & Outcomes Research
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