American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma

Screening ultrasound for deep vein thrombosis detection in high-risk pediatric trauma

PURPOSE

Venous thromboembolism (VTE) is a rare but significant complication among high-risk pediatric trauma patients. The NO CLOT study's primary aim was to evaluate the safety of chemical prophylaxis against VTE in high-risk pediatric trauma patients with a secondary aim of evaluating the use of screening venous duplex ultrasound (sUS) to identify deep vein thrombosis (DVT). We hypothesized that sUS would detect asymptomatic DVT at a high rate in high-risk patients.

METHODS

A prospective multi-institutional study was performed at eight level one pediatric trauma centers from 2019 to 2022. sUS was recommended 7 days after admission for all high-risk trauma patients. Univariate and multivariate analyses were performed.

RESULTS

Of 460 high-risk trauma patients, 64/341 (18.8%) remained admitted on day 7 and underwent sUS. Ten of 64 (15.6%) had a DVT identified on sUS (median of 6.5 [IQR 5.2, 7.0] days after trauma). In 277 patients still admitted on day 7 without sUS performed, 15 (5.4%) developed symptomatic DVT (median of 6.0 [IQR 3.0, 8.0] days after trauma. For the sUS cohort, 9/10 (90%) DVTs were associated with an indwelling central venous line (CVL) and occurred either without chemical prophylaxis use at all in 4/10 (40%) or when initiated more than 24-h post-trauma in 6/10 (60%).

CONCLUSIONS

In this high-risk cohort, most DVTs were identified in the first week following injury; however, the majority were asymptomatic. Use of sUS at 1-week post-injury increases DVT detection; however, the clinical consequences of asymptomatic detection of DVT remain unknown.

LEVEL OF EVIDENCE

III.

A comparative analysis of three risk assessment scales for predicting venous thromboembolism in traumatic brain injury patients

Venous thromboembolism (VTE) is a common complication in patients with traumatic brain injury (TBI). This study aimed to assess the predictive ability of the Caprini score, Risk Assessment Profile for Thromboembolism (RAPT), and Trauma Embolic Scoring System(TESS) for VTE risk assessments in TBI patients. A retrospective analysis of 460 TBI patients was conducted, categorizing them into VTE and non-VTE groups based on imaging results. The three scales were applied to assess VTE risk, and their performance was compared using receiver operating characteristic(ROC) curves and area under the curve(AUC) values. The VTE incidence was 31.7%. The RAPT scale demonstrated the highest AUC (0.826) and optimal cutoff (9.5) with balanced sensitivity (0.753) and specificity (0.771). The Caprini and TESS scales also showed moderate to high predictive value but had lower AUCs. All three scoring scales showed medium to high predictive value for the risk of VTE in patients with TBI. Among them, the RAPT scoring scale offered the highest predictive value for VTE risk in TBI patients, with fewer items, making it easier for clinical implementation. It stands as the most appropriate VTE risk assessment scale for TBI patients at present.

Venous thromboembolism in transfer trauma patients: A global problem

BACKGROUND

As air travel and immobility are risk factors for venous thromboembolism, we aimed to test the hypothesis that internationally transferred trauma patients have a high incidence of venous thromboembolism on arrival.

METHODS

A prospectively maintained registry of all international transferred trauma patients who presented to our level I trauma center from January 2023 to June 2024 was retrospectively reviewed. Patients with either lower extremity venous duplex ultrasound or computed tomography scan of the chest with contrast on arrival were included. The primary outcome was venous thromboembolism, either deep venous thrombosis or pulmonary embolism.

RESULTS

There were 161 consecutive internationally transferred trauma patients; 93% had a screening venous duplex ultrasound on arrival, and 52% had a computed tomography scan of the chest with contrast. Average time from injury to arrival was 3.3 ± 4.3 days. Of those who had screening imaging, 6% had a deep venous thrombosis and 8.3% had a pulmonary embolism. Average Greenfield risk assessment profile was greater for those with than without deep venous thrombosis (10 vs 8, P = .024) and pulmonary embolism (12 vs 8, P = .001). There was no difference in days from injury or flight time for those with or without deep venous thrombosis or for those with or without pulmonary embolism.

CONCLUSION

To our knowledge, this is the first study to demonstrate a 6-8% incidence of venous thromboembolism on arrival in international transfer trauma patients. New protocols should include risk stratification for early thromboprophylaxis in transferring centers and screening admission venous duplex ultrasound and computed tomography scan of the chest at receiving centers.

Venous Thromboembolism Incidence, Risk Factors, and Prophylaxis in Burn Patients: A National Trauma Database Study

Comprehensive studies on the incidence, risk factors, and prophylactic measures related to venous thromboembolism (VTE) are lacking in burn care. This study characterizes VTE risk and existing prevention measures to improve and inform overall patient care in the field of burn care on a national scale. The US National Trauma Data Bank was queried from 2007 to 2021 to identify burn-injured patients. Descriptive statistics and multivariate regression analyses were used to explore the association between demographic/clinical characteristics and VTE risk as well as compare various VTE chemoprophylaxis types. There were 326 614 burn-injured patients included for analysis; 5642 (1.7%) experienced a VTE event during their hospitalization. Patients with VTE were significantly older, had greater body mass indexes and % total body surface area, and were more likely to be male (P < .001). History of smoking, hypertension or myocardial infarction, and/or substance use disorder were significant predictors of VTE (P < .001). Patients who received low molecular weight heparin were less likely to have VTE compared to patients treated with heparin when controlling for other VTE risk factors (odds ratio [OR]: 0.564, 95% confidence interval [95% CI]: 0.523-0.607, P < .001). Longer time to VTE chemoprophylaxis (>6 h) initiation was significantly associated with VTE (OR = 1.04, 95% CI: 1.03-1.07, P < .001). This study sheds light on risk factors and chemoprophylaxis in VTE to help guide clinical practice when implementing prevention strategies in patients with burns. This knowledge can be leveraged to refine risk stratification models, inform evidence-based prevention strategies, and ultimately enhance the quality of care for patients with burns at risk of VTE.

Risk Factors and Preventive Measures of Venous Thromboembolism in Trauma Patients using Trauma Embolic Scoring System: A retrospective chart review

BACKGROUND

Venous thromboembolism (VTE) is a major preventable complication in trauma patients, with varying incidence and risk factors across populations.

AIM/OBJECTIVE

To categorize VTE risk in Korean trauma patients using the Trauma Embolic Scoring System (TESS) and assess the application of prophylaxis by risk level.

METHODS

This retrospective study at Korea University Guro Hospital involved 1913 trauma patients over two years. Data on demographics, injury specifics, and preventive treatments were analyzed using TESS. The study examined general, mechanical, and chemical interventions for VTE prevention.

RESULTS

Of the patients, 1.4% were diagnosed with VTE. The average TESS score was 3.20, indicating lower injury severity but higher percentages of surgeries over 2 h and serious injuries. The findings showed VTE occurrences even in patients with TESS scores below the high-risk threshold, particularly in limb injuries. Nurse-led interventions like early physical activity were most common in the low-risk group, while mechanical prophylaxis like anti-embolism stockings was also predominantly used in this group. Chemical prophylaxis showed consistent administration across groups, with 37.5% of the high-risk group receiving Low Molecular Weight Heparin (LMWH), although only a minority received it within the recommended 48-hour.

CONCLUSIONS

The study reveals a need for vigilant monitoring and intervention across all risk categories, underscoring the importance of tailored VTE prevention guidelines in South Korea. It highlights the role of comprehensive management, including patient education and adherence to updated guidelines.

TWEETABLE ABSTRACT

New study categorizes VTE risk in Korean trauma patients using TESS, showing the need for tailored prophylaxis across risk levels #VTEPrevention #TraumaCare.

DOES WHOLE BLOOD RESUSCITATION INCREASE RISK FOR VENOUS THROMBOEMBOLISM IN TRAUMA PATIENTS? A COMPARISON OF WHOLE BLOOD VERSUS COMPONENT THERAPY IN 3,468 PATIENTS

ABSTRACT

Background: Whole blood (WB) resuscitation has been shown to provide mortality benefit. However, the impact of whole blood transfusions on the risk of venous thromboembolism (VTE) remains unclear. We sought to compare the VTE risk in patients resuscitated with WB versus component therapy (COMP). Methods: Trauma patients aged 18 and older, admitted to two Level 1 trauma centers between 2016 and 2021, who received at least one unit of emergency-release blood products were identified. Clinical and transfusion data were collected. Patients that received any WB during resuscitation were compared to those who received only COMP therapy. The primary outcome was VTE incidence, defined as deep vein thrombosis and/or pulmonary embolism. Results: 3,468 patients met inclusion criteria (WB: 1,775, COMP: 1,693). WB patients were more likely to be male (82 vs. 68%), receive tranexamic acid (21 vs. 16%), and had higher Injury Severity Score (26 vs. 19; all P < 0.001). WB patients exhibited less hospital-free days (11 vs. 15), intensive care unit-free days (23 vs. 25), and 30-day survival (74 vs. 84; all P < 0.001). The WB group had lower VTE incidence (6 vs. 10%, P < 0.001). Logistic regression revealed WB was protective against VTE (OR 0.70, 95% CI 0.54-091, P = 0.009), while red blood cell transfusions and tranexamic acid (TXA) exposure increased VTE risk. Discussion: Using WB as part of resuscitation was associated with a 30% reduction in VTE, while TXA and red blood cell transfusion increased VTE risk. Further research is needed to evaluate VTE risk with empiric use of TXA in the setting of early WB transfusion capability.

Thromboembolism prophylaxis timing is associated with center mortality in traumatic brain injury: A Trauma Quality Improvement Program retrospective analysis

BACKGROUND

Timing of venous thromboembolism chemoprophylaxis (VTEPPx) in traumatic brain injury (TBI) is complex given concerns for potential worsening of hemorrhage. While timing of VTEPPx for TBI patients is known to vary at the patient level, to our knowledge, variation at the hospital level and correlation with quality metrics have not been quantified in a cohort of nonneurosurgical patients.

METHODS

This was a retrospective cohort study of the Trauma Quality Improvement database from 2018 to 2021. The primary outcome was variation in VTEPPx timing. This was ascertained by empirical Bayesian methodology using multilevel mixed-effects logistic regression. Secondary outcomes included the association of risk-adjusted VTEPPx timing and hospital characteristics such as volume and risk-adjusted mortality, which was assessed through Pearson's correlation coefficient ( r ). Risk-adjusted mortality was similarly calculated using multilevel mixed-effects modeling.

RESULTS

Of 132,028 patients included in the current study, 38.7% received care at centers in the earliest quartile of VTEPPx timing, classified as Early (others labeled Delayed ). Patients receiving care at Early centers presented with severe TBI at a similar rate to Delayed (17.4% vs. 19.0%; absolute standardized mean difference, 0.04). Early center patients more commonly received unfractionated heparin as opposed to low-molecular-weight heparin compared with Delayed (40.5% vs. 27.6%; absolute standardized mean difference, 0.28). At the center level, 12% of observed variation in VTEPPx was attributable to differential hospital practices. Overall trauma volume ( r = -0.22, p < 0.001) and TBI volume ( r = -0.19, p < 0.001) were inversely associated with risk-adjusted VTEPPx timing. In addition, centers initiating VTEPPx earlier had lower overall ( r = 0.17, p < 0.001) and TBI-related mortality ( r = 0.17, p < 0.001).

CONCLUSION

There is significant center-level variation in timing of VTEPPx among TBI patients. Earlier VTEPPx was associated with improved center outcomes overall and among TBI patients, supporting usage of VTEPPx timing as a holistic measure of quality.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Anti-xa guided enoxaparin thromboprophylaxis is associated with less thromboembolism than fixed dose dalteparin in trauma patients admitted to intensive care

BACKGROUND

Venous Thromboembolism (VTE) is a common, preventable complication in trauma. Low-molecular-weight heparin (LMWH) is recommended for VTE prophylaxis (VTEp). We investigated whether switching from fixed-dose dalteparin to anti-Xa-guided enoxaparin prophylaxis reduces VTE without increasing the risk of bleeding among hospitalized trauma patients.

METHODS

This observational study compared injured patients admitted one year before (pre-P) and after (post-P) implementing a new VTEp protocol. The protocol was introduced as a performance improvement project (subcutaneous enoxaparin 30 mg twice daily), with dose calibration to peak plasma Anti-Xa level measured after the 3rd dose. The primary outcomes were the rate of VTE and bleeding.

RESULTS

After protocol implementation (post-P), 305 patients were compared to 350 pre-protocol patients (pre-P). Anti-Xa levels were measured in 83% of post-P and none in the pre-P. 40% had low levels of anti-Xa, suggesting inadequate prophylaxis, and enoxaparin doses were accordingly increased. 51% attained the desired anti-Xa levels, 9% had higher levels, and LMWH doses were subsequently reduced. VTE incidence after protocol implementation decreased from 4 to 1.3% (OR 0.31; 95% CI 0.1-0.9, P = 0.03) without increasing the bleeding rate. The time intervals between two consecutive PE events were significantly longer after protocol implementation. Among TBI patients, the rate of VTE was lower. However, it did not reach statistical significance. 75% of patients with VTE had low anti-Xa levels, while 20% of those with bleeding had high anti-Xa levels.

CONCLUSION

Among adult patients in the trauma ICU, compared to a fixed dose dalteparin, enoxaparin prophylaxis with dose calibration according to peak anti-Xa levels was associated with lower VTE rates without increasing the risk of bleeding. About 40% of patients who received initial enoxaparin doses of 30 mg twice daily had anti-Xa levels suggestive of inadequate prophylaxis. Calibrating LMWH dosing may improve VTEp following traumatic injury.

Management of post-injury anticoagulation in the traumatic brain injury patient: A scoping review

Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality among trauma patients. The care of these patients continues to be a complex endeavor with prevention of associated complications, often requiring as much attention as that of the treatment of the primary injury. Paramount among these are venous thromboembolic events (VTE) due to their high incidence, additive effect on the risk of morbidity and mortality, and the careful balance that must be utilized in their diagnosis and treatment to prevent progression of the brain injury itself. In this review, we have synthesized the most recent major studies detailing the ideal choice of chemoprophylactic agent, the timing of initiation, and continued monitoring and management strategies through the hospital course and beyond. Additional discussion is provided for subpopulations in which management can vary significantly, including the elderly, critically ill, and obese. Ultimately, current literature supports the use and safety of low molecular weight heparin over unfractionated heparin, especially when dosed using newer assays including anti-Xa levels. The timing of prophylaxis remains important, as the risk of VTE increases with each day that prophylaxis is held. Consensus findings favor initiation within 24-72 h, in the absence of documented progression, life threatening bleeding, or need for major surgical intervention. Despite available data, there continues to be significant variability in practice patterns which we hope to address with this review.

Comparison of Different Thromboprophylaxis Regimens in Elderly Patients Following Hip Arthroplasty

Aims/Background Deep venous thrombosis (DVT) represents a significant postoperative complication after artificial femoral head replacement, with the incidence increasing proportionally with patient age. This study aimed to evaluate the effect of early postoperative use of intermittent pneumatic compression devices (IPC), followed by the combined use of low molecular weight heparin (LMWH) after 48 hours, for the prevention of postoperative lower limb DVT in elderly patients undergoing hip arthroplasty. Methods The retrospective study included 100 elderly patients who underwent unilateral femoral head replacement. The control group (n = 55) received combined LMWH initiated 12 hours postoperatively, while the observation group (n = 45) started combined LMWH 48 hours postoperatively. Changes in coagulation parameters, perioperative complications, and the incidence of postoperative lower limb DVT were compared between the two groups. Results Coagulation parameters showed significant changes post-intervention in both groups, with no statistically significant inter-group differences observed post-intervention (p > 0.05). The incidence of postoperative lower limb DVT did not differ significantly between the two groups (p > 0.05). However, the observation group demonstrated significantly lower postoperative blood loss, incidence of periwound hematoma, and transfusion rates compared to the control group (p < 0.05). Conclusion The sequential application of IPC in the early postoperative period, followed by combined LMWH administration after 48 hours, demonstrates comparable efficacy in preventing lower limb DVT formation in elderly patients undergoing hip arthroplasty when compared to the initiation of combined LMWH starting 12 hours postoperatively. In addition, this approach significantly reduces the risk of postoperative bleeding and exhibits a high safety profile.

Association of prolonged emergency department length of stay and venous thrombo-embolism prophylaxis and outcomes in trauma: A nation-wide secondary analysis

INTRODUCTION

The impact of prolonged emergency department length of stay (EDLOS) on appropriately timed pharmacological venous thromboembolism prophylaxis (VTEp) and VTE outcomes is unknown in trauma.

METHODS

Retrospective cohort study of adult patients admitted to civilian trauma centers participating in the American College of Surgeons' TQIP (2019-2021). Patients with severe solid organ, head, or spine injury, early hemorrhage control intervention, pre-existing home anticoagulation or bleeding disorder, inter-facility transfer or early discharge, and injury severity score ≤9 were excluded. Primary exposure was prolonged EDLOS ≥12 h from ED arrival to physical transfer to the wards. Primary outcome was time to first pharmacological VTEp, censored at 24 and 48 h.

RESULTS

A total of 191,031 patients were included, 3,827 remained in the ED ≥12 h. The median time to VTEp was 25 h (IQR 12-43). Prolonged EDLOS was associated with a 34 % and 21 % decrease in timely administration of VTEp at 24 (aHR 0.66, 95 % CI 0.61-0.72, P < 0.001) and 48 h (aHR 0.79, 95 % CI 0.74-0.84, P < 0.001), respectively. After propensity score matching, associations persisted at 24 (aHR 0.69, 95 % CI 0.61-0.77, P < 0.001) and 48 h (aHR 0.80, 95 % CI 0.74-0.86, P < 0.001). Absent VTEp by 24 h was associated with increased VTE odds (aOR 1.84, 95 % CI 1.62-2.08, P < 0.001).

CONCLUSION

Prolonged EDLOS delayed pharmacological VTEp in a nation-wide cohort of trauma patients. Absent VTEp, consequently, increased risk of in-hospital VTE, although future study is needed to validate these findings. Timely transfer of stable trauma patients to the floor may improve outcomes by facilitating appropriately timed VTEp administration and decreasing ED overcrowding.

Venous thromboembolism chemoprophylaxis after severe polytrauma: timing and type of prophylaxis matter

In this review, we provide recommendations as well as summarize available data on the optimal time to initiate venous thromboembolism chemoprophylaxis after severe trauma. A general approach to the severe polytrauma patient is provided as well as in-depth reviews of three high-risk injury subgroups: patients with traumatic brain injury, solid organ injury, and pelvic fractures.

The acute phase management of traumatic spinal cord injury (tSCI) with polytrauma: A narrative review

Introduction

Traumatic spinal cord injury (tSCI) is frequently observed in polytrauma patients.

Research question

What is the optimal strategy to manage tSCI in the setting of polytrauma?

Material and methods

This narrative review focuses on: 1) extraspinal damage control surgery and resuscitation, 2) the perioperative protection of the injured spine during emergency surgery, 3) imaging and timing of spinal surgery in polytrauma, 4) early interventions for skin, bowel and bladder, and 5) the multidisciplinary approach to tSCI polytrauma patients.

Results

Damage control resuscitation (DCR) and damage control surgery (DCS), aim to prevent/correct post-traumatic physiological derangements to minimize bleeding until definitive hemostasis is achieved. Spinal protection during emergency surgery is of paramount importance to reduce secondary insults to the injured spine. Imaging, especially magnetic resonance imaging (MRI), is useful for decision-making regarding surgical management of the injured spine. Early decompressive surgery (within 24 h from trauma) is associated with better neurological outcomes. Early consultation with a physical medicine and rehabilitation physician is beneficial to optimize recovery. A close collaboration between different medical specialties involved in the early management of tSCI patients with polytrauma is advisable to improve outcome.

Discussion and conclusion

This narrative review aims to collate basic knowledge regarding acute phase management of tSCI patients in the context of polytrauma. More evidence and data form well-powered studies are necessary in this setting.

Medical Clinics of North America-Periprocedural Antithrombotics: Prophylaxis and Interruption

Anticoagulation management in the surgical patient requires clinical expertise and careful attention. For patients already receiving anticoagulation for a defined indication (ie, stroke prevention for atrial fibrillation, treatment of venous thromboembolism (VTE), or presence of a mechanical heart valve), understanding how to manage these agents by weighing the risks of thromboembolic events and bleeding is paramount. Additionally, prevention of VTE in the surgical patient involves the identification of patient-specific and procedure-specific risk factors for both VTE and bleeding. With this information, as well as familiarity with the several antithrombotic options available, an appropriate prophylaxis strategy can be employed.

Evaluation of Timing of Pharmacologic Venous Thromboembolism Prophylaxis Initiation in Trauma Patients at a Level One Trauma Center

Background: Major trauma is a risk factor for venous thromboembolism (VTE). Trauma guidelines recommend prompt initiation of pharmacologic VTE prophylaxis. While early initiation is recommended, delays in therapy can occur. Objective: The aim of this study was to evaluate the compliance of pharmacologic VTE prophylaxis initiation timing with trauma guidelines and impact on rates of VTE, bleeding and in-hospital mortality. Methods: This retrospective cohort study included patients admitted to a trauma unit between January 1, 2020 and December 1, 2021. Patients were stratified by injury type and categorized as either compliant or non-compliant based on timing of initiation. Rates of VTE, bleeding, and in-hospital mortality were collected. Results: Of the 300 patients, 259 (86.3%) were compliant. Reasons for non-compliance included bleeding (19.5%) and pending evaluation for intervention such as nerve block procedure (12.2%) and surgical operation (4.9%). There were no differences in VTE (4.8% vs 1.2%, P = .139) or bleeding (4.6% vs 0%, P = N/A) between groups. There was a higher rate of in-hospital mortality in the non-compliant group (12.2% vs 2.3%, P = .009). Upon multivariate logistic regression, the ICU setting was identified as a risk factor for noncompliance (P = .020, OR = .45). Conclusion: Initiating pharmacologic VTE prophylaxis in concordance with trauma guidelines led to low observed rates of VTE and bleeding. In evaluating reasons for noncompliance, we identified areas of improvement for initiation including minimizing inappropriate delays in therapy.

Venous Thromboembolism Prevention in Rehabilitation: A Review and Practice Suggestions

ABSTRACT

Venous thromboembolism is a frequent complication of acute hospital care, and this extends to inpatient rehabilitation. The timely use of appropriate thromboprophylaxis in patients who are at risk is a strong, evidence-based patient safety priority that has reduced clinically important venous thromboembolism, associated mortality and costs of care. While there has been extensive research on optimal approaches to venous thromboembolism prophylaxis in acute care, there is a paucity of high-quality evidence specific to patients in the rehabilitation setting, and there are no clinical practice guidelines that make recommendations for (or against) thromboprophylaxis across the broad spectrum of rehabilitation patients. Herein, we provide an evidence-informed review of the topic with practice suggestions. We conducted a series of literature searches to assess the risks of venous thromboembolism and its prevention related to inpatient rehabilitation as well as in major rehabilitation subgroups. Mobilization alone does not eliminate the risk of venous thromboembolism after another thrombotic insult. Low molecular weight heparins and direct oral anticoagulants are the principal current modalities of thromboprophylaxis. Based on the literature, we make suggestions for venous thromboembolism prevention and include an approach for consideration by rehabilitation units that can be aligned with local practice.

Optimal Timing for Initiation of Thromboprophylaxis After Hepatic Angioembolization

OBJECTIVE

To evaluate the optimal timing of thromboprophylaxis (TPX) initiation after hepatic angioembolization in trauma patients.

BACKGROUND

TPX after hepatic trauma is complicated by the risk of bleeding, but the relative risk after hepatic angioembolization is unknown.

METHODS

Patients who underwent hepatic angioembolization within 24 hours were retrospectively identified from the 2017 to 2019 American College of Surgeons Trauma Quality Improvement Project data sets. Cases with <24-hour length of stay and other serious injuries were excluded. Venous thromboembolism (VTE) included deep venous thrombosis and PE. Bleeding complications included hepatic surgery, additional angioembolization, or blood transfusion after TPX initiation. Differences were tested with univariate and multivariate analyses.

RESULTS

Of 1550 patients, 1370 had initial angioembolization. Bleeding complications were higher in those with TPX initiation within 24 hours (20.0% vs 8.9%, P <0.001) and 48 hours (13.2% vs 8.4%, P =0.013). However, VTE was higher in those with TPX initiation after 48 hours (6.3% vs 3.3%, P =0.025). In the 180 patients with hepatic surgery before angioembolization, bleeding complications were higher in those with TPX initiation within 24 hours (72% vs 20%, P <0.001), 48 hours (50% vs 17%, P <0.001), and 72 hours (37% vs 14%, P =0.001). Moreover, deep venous thrombosis was higher in those with TPX initiation after 96 hours (14.3% vs 3.1%, P =0.023).

CONCLUSIONS

This is the first study to address the timing of TPX after hepatic angioembolization in a national sample of trauma patients. For these patients, initiation of TPX at 48 to 72 hours achieves the safest balance in minimizing bleeding while reducing the risk of VTE.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Venous Thromboembolism Prophylaxis in High-Risk Pediatric Trauma Patients

Importance

The indications, safety, and efficacy of chemical venous thromboembolism prophylaxis (cVTE) in pediatric trauma patients remain unclear. A set of high-risk criteria to guide cVTE use was recently recommended; however, these criteria have not been evaluated prospectively.

Objective

To examine high-risk criteria and cVTE use in a prospective multi-institutional study of pediatric trauma patients.

Design, Setting, and Participants

This cohort study was completed between October 2019 and October 2022 in 8 free-standing pediatric hospitals designated as American College of Surgeons level I pediatric trauma centers. Participants were pediatric trauma patients younger than 18 years who met defined high-risk criteria on admission. It was hypothesized that cVTE would be safe and reduce the incidence of VTE.

Exposures

Receipt and timing of chemical VTE prophylaxis.

Main Outcomes and Measures

The primary outcome was overall VTE rate stratified by receipt and timing of cVTE. The secondary outcome was safety of cVTE as measured by bleeding or other complications from anticoagulation.

Results

Among 460 high-risk pediatric trauma patients, the median (IQR) age was 14.5 years (10.4-16.2 years); 313 patients (68%) were male and 147 female (32%). The median (IQR) Injury Severity Score (ISS) was 23 (16-30), and median (IQR) number of high-risk factors was 3 (2-4). A total of 251 (54.5%) patients received cVTE; 62 (13.5%) received cVTE within 24 hours of admission. Patients who received cVTE after 24 hours had more high-risk factors and higher ISS. The most common reason for delayed cVTE was central nervous system bleed (120 patients; 30.2%). There were 28 VTE events among 25 patients (5.4%). VTE occurred in 1 of 62 patients (1.6%) receiving cVTE within 24 hours, 13 of 189 patients (6.9%) receiving cVTE after 24 hours, and 11 of 209 (5.3%) who had no cVTE (P = .31). Increasing time between admission and cVTE initiation was significantly associated with VTE (odds ratio, 1.01; 95% CI, 1.00-1.01; P = .01). No bleeding complications were observed while patients received cVTE.

Conclusions and Relevance

In this prospective study, use of cVTE based on a set of high-risk criteria was safe and did not lead to bleeding complications. Delay to initiation of cVTE was significantly associated with development of VTE. Quality improvement in pediatric VTE prevention may center on timing of prophylaxis and barriers to implementation.

Association of timing and agent for venous thromboembolism prophylaxis in patients with severe traumatic brain injury on venous thromboembolism events, mortality, neurosurgical intervention, and discharge disposition

BACKGROUND

Trauma patients are at increased risk for venous thromboembolism events (VTEs). The decision of when to initiate VTE chemoprophylaxis (VTEP) and with what agent remains controversial in patients with severe traumatic brain injury (TBI).

METHODS

This comparative effectiveness study evaluated the impact of timing and agent for VTEP on outcomes for patients with severe TBI (Abbreviated Injury Scale head score of 3, 4, or 5). Data were collected at 35 Level 1 and 2 trauma centers from January 1, 2017, to June 1, 2022. Patients were placed into analysis cohorts: no VTEP, low-molecular-weight heparin (LMWH) ≤48 hours, LMWH >48 hours, heparin ≤48 hours, and heparin >48 hours. Propensity score matching accounting for patient factors and injury characteristics was used with logistic regression modeling to evaluate in-hospital mortality, VTEs, and discharge disposition. Neurosurgical intervention after initiation of VTEP was used to evaluate extension of intracranial hemorrhage.

RESULTS

Of 12,879 patients, 32% had no VTEP, 36% had LMWH, and 32% had heparin. Overall mortality was 8.3% and lowest among patients receiving LMWH ≤48 hours (4.1%). Venous thromboembolism event rates were lower with use of LMWH (1.6% vs. 4.5%; odds ratio, 2.98; 95% confidence interval, 1.40-6.34; p = 0.005) without increasing mortality or neurosurgical interventions. Venous thromboembolism event rates were lower with early prophylaxis (2.0% vs. 3.5%; odds ratio, 1.76; 95% confidence interval, 1.15-2.71; p = 0.01) without increasing mortality ( p = 1.0). Early VTEP was associated with more nonfatal intracranial operations ( p < 0.001). However, patients undergoing neurosurgical intervention after VTEP initiation had no difference in rates of mortality, withdrawal of care, or unfavorable discharge disposition ( p = 0.7, p = 0.1, p = 0.5).

CONCLUSION

In patients with severe TBI, LMWH usage was associated with lower VTE incidence without increasing mortality or neurosurgical interventions. Initiation of VTEP ≤48 hours decreased VTE incidence and increased nonfatal neurosurgical interventions without affecting mortality. Low-molecular-weight heparin is the preferred VTEP agent for severe TBI, and initiation ≤48 hours should be considered in relation to these risks and benefits.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Prognostic factors associated with venous thromboembolism following traumatic injury: A systematic review and meta-analysis

INTRODUCTION

Trauma patients are at increased risk of venous thromboembolism (VTE), including deep venous thrombosis and/or pulmonary embolism. We conducted a systematic review and meta-analysis summarizing the association between prognostic factors and the occurrence of VTE following traumatic injury.

METHODS

We searched the Embase and Medline databases from inception to August 2023. We identified studies reporting confounding adjusted associations between patient, injury, or postinjury care factors and risk of VTE. We performed meta-analyses of odds ratios using the random-effects method and assessed individual study risk of bias using the Quality in Prognosis Studies tool.

RESULTS

We included 31 studies involving 1,981,946 patients. Studies were predominantly observational cohorts from North America. Factors with moderate or higher certainty of association with increased risk of VTE include older age, obesity, male sex, higher Injury Severity Score, pelvic injury, lower extremity injury, spinal injury, delayed VTE prophylaxis, need for surgery, and tranexamic acid use. After accounting for other important contributing prognostic variables, a delay in the delivery of appropriate pharmacologic prophylaxis for as little as 24 to 48 hours independently confers a clinically meaningful twofold increase in incidence of VTE.

CONCLUSION

These findings highlight the contribution of patient predisposition, the importance of injury pattern, and the impact of potentially modifiable postinjury care on risk of VTE after traumatic injury. These factors should be incorporated into a risk stratification framework to individualize VTE risk assessment and support clinical and academic efforts to reduce thromboembolic events among trauma patients.

LEVEL OF EVIDENCE

Systematic Review and Meta-Analysis; Level III.

Evaluating chemical venous thromboembolism prophylaxis in trauma patients at a single Australian center

PURPOSE

Trauma patients are at an elevated risk of developing venous thromboembolism (VTE), with the subsequent mortality in patients requiring intensive care unit admission ranging from 25% to 38%. There remains significant variability in clinical practice related to VTE prophylaxis in trauma patients due to the frequent presence of contraindications impacting the timing and consistency of application. This study aimed to assess the effectiveness of the current practice of chemical VTE prophylaxis in trauma patients at a single Australian center.

METHODS

A prospective review was conducted on patients admitted to the ACT Trauma Service (Canberra, Australia) from July to November 2022. The included patients were 18 years or older, without a direct contraindication to anticoagulation, who received chemical VTE prophylaxis with low-molecular-weight heparin (enoxaparin) for at least three doses and underwent subsequent testing of anti-factor Xa (aFXa) levels.

RESULTS

During the study period, 187 patients were admitted, of whom 63 were included in the study. Of these, 47 patients achieved therapeutic levels of anticoagulation as determined by their aFXa levels, while 16 were subtherapeutic. The only statistically significant difference between the two groups was in weight, with patients in the subtherapeutic group weighing an average of 91.9 kg compared to 79.1 kg in the therapeutic group (P<0.05).

CONCLUSIONS

A fixed-dose enoxaparin regimen was utilized, with limited individualization based on patient factors, such as injuries, comorbidities, and other biological factors. Sixteen patients (25%) had subtherapeutic VTE prophylaxis, as measured by aFXa levels. Higher weight was significantly correlated with inadequate VTE prophylaxis dosing. While age, sex, and smoking status might play important roles in clinical decision-making, weight-based dosing of low-molecular-weight heparin may be more effective in achieving adequate VTE prophylaxis.

Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study

BACKGROUND

In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI.

METHODS

Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest.

RESULTS

984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant.

CONCLUSION

In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH.

LEVEL OF EVIDENCE

Level III, Therapeutic Care Management.

A pragmatic, stepped-wedge, hybrid type II trial of interoperable clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury

BACKGROUND

Venous thromboembolism (VTE) is a preventable medical condition which has substantial impact on patient morbidity, mortality, and disability. Unfortunately, adherence to the published best practices for VTE prevention, based on patient centered outcomes research (PCOR), is highly variable across U.S. hospitals, which represents a gap between current evidence and clinical practice leading to adverse patient outcomes. This gap is especially large in the case of traumatic brain injury (TBI), where reluctance to initiate VTE prevention due to concerns for potentially increasing the rates of intracranial bleeding drives poor rates of VTE prophylaxis. This is despite research which has shown early initiation of VTE prophylaxis to be safe in TBI without increased risk of delayed neurosurgical intervention or death. Clinical decision support (CDS) is an indispensable solution to close this practice gap; however, design and implementation barriers hinder CDS adoption and successful scaling across health systems. Clinical practice guidelines (CPGs) informed by PCOR evidence can be deployed using CDS systems to improve the evidence to practice gap. In the Scaling AcceptabLE cDs (SCALED) study, we will implement a VTE prevention CPG within an interoperable CDS system and evaluate both CPG effectiveness (improved clinical outcomes) and CDS implementation.

METHODS

The SCALED trial is a hybrid type 2 randomized stepped wedge effectiveness-implementation trial to scale the CDS across 4 heterogeneous healthcare systems. Trial outcomes will be assessed using the RE2-AIM planning and evaluation framework. Efforts will be made to ensure implementation consistency. Nonetheless, it is expected that CDS adoption will vary across each site. To assess these differences, we will evaluate implementation processes across trial sites using the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework (a determinant framework) using mixed-methods. Finally, it is critical that PCOR CPGs are maintained as evidence evolves. To date, an accepted process for evidence maintenance does not exist. We will pilot a "Living Guideline" process model for the VTE prevention CDS system.

DISCUSSION

The stepped wedge hybrid type 2 trial will provide evidence regarding the effectiveness of CDS based on the Berne-Norwood criteria for VTE prevention in patients with TBI. Additionally, it will provide evidence regarding a successful strategy to scale interoperable CDS systems across U.S. healthcare systems, advancing both the fields of implementation science and health informatics.

TRIAL REGISTRATION

Clinicaltrials.gov - NCT05628207. Prospectively registered 11/28/2022, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05628207 .

Severe Traumatic Brain Injury and Pulmonary Embolism: Risks, Prevention, Diagnosis and Management

Severe traumatic brain injury (sTBI) is a silent epidemic, causing approximately 300,000 intensive care unit (ICU) admissions annually, with a 30% mortality rate. Despite worldwide efforts to optimize the management of patients and improve outcomes, the level of evidence for the treatment of these patients remains low. The concomitant occurrence of thromboembolic events, particularly pulmonary embolism (PE), remains a challenge for intensivists due to the risks of anticoagulation to the injured brain. We performed a literature review on sTBI and concomitant PE to identify and report the most recent advances on this topic. We searched PubMed and Scopus for papers published in the last five years that included the terms "pulmonary embolism" and "traumatic brain injury" in their title or abstract. Exclusion criteria were papers referring to children, non-sTBI populations, and post-acute care. Our search revealed 75 papers, of which 38 are included in this review. The main topics covered include the prevalence of and risk factors for pulmonary embolism, the challenges of timely diagnosis in the ICU, the timing of pharmacological prophylaxis, and the treatment of diagnosed PE.

National Analysis of Outcomes for Adult Trauma Patients With Isolated Severe Blunt Traumatic Brain Injury Following Venous Thromboembolism Prophylaxis

INTRODUCTION

We aim to evaluate the association of early versus late venous thromboembolism (VTE) prophylaxis on in-hospital mortality among patients with severe blunt isolated traumatic brain injuries.

METHODS

Data from the American College of Surgeons Trauma Quality Program Participant Use File for 2017-2021 were analyzed. The target population included adult trauma patients with severe isolated traumatic brain injury (TBI). VTE prophylaxis types (low molecular weight heparin and unfractionated heparin) and their administration timing were analyzed in relation to in-hospital complications and mortality.

RESULTS

The study comprised 3609 patients, predominantly Caucasian males, with an average age of 48.5 y. Early VTE prophylaxis recipients were younger (P < 0.01) and more likely to receive unfractionated heparin (P < 0.01). VTE prophylaxis later than 24 h was associated with a higher average injury severity score and longer intensive care unit stays (P < 0.01). Logistic regression revealed that VTE prophylaxis later than 24 h was associated with significant reduction of in-hospital mortality by 38% (odds ratio 0.62, 95% confidence interval 0.40-0.94, P = 0.02). Additionally, low molecular weight heparin use was associated with decreased mortality odds by 30% (odds ratio 0.70, 95% confidence interval 0.55-0.89, P < 0.01).

CONCLUSIONS

VTE prophylaxis later than 24 h is associated with a reduced risk of in-hospital mortality in patients with severe isolated blunt TBI, as opposed to VTE prophylaxis within 24 h. These findings suggest the need for timely and appropriate VTE prophylaxis in TBI care, highlighting the critical need for a comprehensive assessment and further research concerning the safety and effectiveness of VTE prophylaxis in these patient populations.

Timing of venous thromboembolism prophylaxis initiation and complications in polytrauma patients with high-risk bleeding orthopedic interventions: A nationwide analysis

INTRODUCTION

There are no clear recommendations for the perioperative timing and initiation of venous thromboembolism pharmacologic prophylaxis (VTEp) among polytrauma patients undergoing high-risk bleeding orthopedic operative intervention, leading to variations in VTEp administration. Our study examined the association between the timing of VTEp and VTE complications in polytrauma patients undergoing high-risk operative orthopedic interventions nationwide.

METHODS

We performed a retrospective cohort study of trauma patients 18 years or older who underwent high-risk bleeding operative orthopedic interventions for pelvic, hip, and femur fractures within 24 hours of admission at American College of Surgeons-verified trauma centers using the 2019-2020 American College of Surgeons Trauma Quality Improvement Program databank. We excluded patients with a competing risk of nonorthopedic surgical bleeding. We assessed operative orthopedic polytrauma patients who received VTEp within 12 hours of orthopedic surgical intervention compared with VTEp received beyond 12 hours of intervention. The primary outcome assessed was overall VTE events. Secondary outcomes were orthopedic reinterventions within 72 hours after primary orthopedic surgery, deep venous thromboembolism, and pulmonary embolism rates.

RESULTS

The study included 2,229 patients who underwent high-risk orthopedic operative intervention. The median time to VTEp initiation was 30 hours (interquartile range, 18-44 hours). After adjustment for baseline patient, injury, and hospital characteristics, VTEp initiated more than 12 hours from primary orthopedic surgery was associated with increased odds of VTE (adjusted odds ratio, 2.02; 95% confidence interval, 1.08-3.77). Earlier initiation of prophylaxis was not associated with an increased risk for surgical reintervention (hazard ratio, 0.90; 95% confidence interval, 0.62-1.34).

CONCLUSION

Administering VTEp within 24 hours of admission and within 12 hours of major orthopedic surgery involving the femur, pelvis, or hip demonstrated an associated decreased risk of in-hospital VTE without an accompanying elevated risk of bleeding-related orthopedic reintervention. Clinicians should reconsider delays in initiating or withholding perioperative VTEp for stable polytrauma patients needing major orthopedic intervention.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Initial Hemorrhage Control Procedure for Splenic Injuries May Affect Risk of Venous Thromboembolism

INTRODUCTION

Venous thromboembolism (VTE) continues to be a major cause of morbidity in trauma. It is unclear whether the type of hemorrhage control procedure (i.e., splenectomy versus angioembolization) is associated with an increased risk of VTE. We hypothesize that hemodynamically stable patients undergoing angioembolization for blunt high-grade splenic injuries have lower rates of VTE compared to those undergoing splenectomy.

METHODS

The American College of Surgeons Trauma Quality Program dataset from 2017 to 2019 was queried to identify all patients with American Association for the Surgery of Trauma grade 3-5 blunt splenic injuries. Outcomes including VTE rates were compared between those who were managed with splenectomy versus angioembolization. Propensity score matching (1:1) was performed adjusting for age, sex, initial vital signs, Injury Severity Score, and splenic injury grade.

RESULTS

The analysis included 4698 matched patients (splenectomy [n = 2349] and angioembolization [n = 2349]). The median (interquartile range) age was 41 (27-58) years and 69% were male. Patients were well matched between groups. Angioembolization was associated with significantly lower VTE than splenectomy (2.2% versus 3.4%, P = 0.010) despite less use of VTE chemoprophylaxis (70% versus 80%, P < 0.001), as well as a relative delay in initiation of chemoprophylaxis (44 h versus 33 h, P < 0.001). Hospital and intensive care unit length of stay and mortality were also significantly lower in the angioembolization group.

CONCLUSIONS

Angioembolization is associated with a significantly lower incidence of VTE than splenectomy. Thus, angioembolization should be considered for initial management of hemodynamically stable patients with high-grade blunt splenic injuries in whom laparotomy is not otherwise indicated.

American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for postdischarge venous thromboembolism prophylaxis after trauma

ABSTRACT

Trauma patients are at an elevated risk for developing venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis. In the inpatient setting, prompt pharmacologic prophylaxis is utilized to prevent VTE. For patients with lower extremity fractures or limited mobility, VTE risk does not return to baseline levels postdischarge. Currently, there are limited data to guide postdischarge VTE prophylaxis in trauma patients. The goal of these postdischarge VTE prophylaxis guidelines are to identify patients at the highest risk of developing VTE after discharge and to offer pharmacologic prophylaxis strategies to limit this risk.

The incidence and risk factors of proximal lower extremity deep vein thrombosis without pharmacologic prophylaxis in critically ill surgical Taiwanese patients: A prospective study

Background

Venous thromboembolism (VTE) in critically ill patients has been well-studied in Western countries. Many studies have developed risk assessments and established pharmacological protocols to prevent deep venous thrombosis (DVT). However, the DVT rate and need for pharmacologic VTE prophylaxis in critically ill Taiwanese patients are limited. This study aimed to prospectively determine the DVT incidence, risk factors, and outcomes in critically ill Taiwanese patients who do not receive pharmacologic VTE prophylaxis.

Methods

We conducted a prospective study in a surgical intensive care unit (SICU) of a tertiary academic medical center in Taiwan. Adult patients admitted to SICU from March 2021 to June 2022 received proximal lower extremities DVT surveillance with venous duplex ultrasound. No patient received pharmacologic VTE prophylaxis. The outcomes were the incidence and risk factors of DVT.

Results

Among 501 enrolled SICU patients, 21 patients (4.2%) were diagnosed with proximal lower extremities DVT. In a multivariate regression analysis, hypoalbuminemia (odd ratio (OR) = 6.061, 95% confidence interval (CI): 1.067-34.421), femoral central venous catheter (OR = 4.515, 95% CI: 1.547-13.174), ICU stays more than 10 days (OR = 4.017, 95% CI: 1.270-12.707), and swollen leg (OR = 3.427, 95% CI: 1.075-10.930) were independent risk factors for DVT. In addition, patients with proximal lower extremities DVT have more extended ventilator days (p = 0.045) and ICU stays (p = 0.044).

Conclusion

Our findings indicate critically ill Taiwanese patients have a higher incidence of DVT than results from prior retrospective studies in the Asian population. Physicians who care for this population should consider the specific risk factors for DVT and prescribe pharmacologic prophylaxis in high-risk groups.

When is it safe to start thromboprophylaxis after splenic angioembolization?

BACKGROUND

Thromboprophylaxis after blunt splenic trauma is complicated by the risk of bleeding, but the risk after angioembolization is unknown. We hypothesized that earlier thromboprophylaxis initiation was associated with increased bleeding complications without mitigating venous thromboembolism events.

METHODS

All blunt trauma patients who underwent splenic angioembolization within 24 hours of arrival were identified from the American College of Surgeons Trauma Quality Improvement Program datasets from 2017 to 2019. Cases with <24-hour length of stay, other serious injuries, and surgery before angioembolization were excluded. Venous thromboembolism was defined as deep vein thrombosis or pulmonary embolism. Bleeding complications were defined as splenic surgery, additional embolization, or blood transfusion after thromboprophylaxis initiation. Data were compared with χ2 analysis and multivariate logistic regression at P < .05.

RESULTS

In 1,102 patients, 84% had American Association for the Surgery of Trauma grade III to V splenic injuries, and 73% received thromboprophylaxis. Splenic surgery after angioembolization was more common in those with thromboprophylaxis initiation within the first 24 hours (5.7% vs 1.7%, P = .007), whereas those with the initiation of thromboprophylaxis after 72 hours were more likely to have a pulmonary embolism (2.3% vs 0.2%, P = .001). Overall, venous thromboembolism increased considerably when thromboprophylaxis was initiated after day 3. In multivariate analysis, time to thromboprophylaxis initiation was associated with bleeding (odds ratio 0.74 [95% confidence interval 0.58-0.94]) and venous thromboembolism complications (odds ratio 1.5 [95% confidence interval 1.20-1.81]).

CONCLUSION

This national study evaluates bleeding and thromboembolic risk to elucidate the specific timing of thromboprophylaxis after splenic angioembolization. Initiation of thromboprophylaxis between 24 and 72 hours achieves the safest balance in minimizing bleeding and venous thromboembolism risk, with 48 hours particularly serving as the ideal time for protocolized administration.

Racial Distribution and Associated Outcomes for Patients With and Without Severe-Isolated Traumatic Brain Injuries Following Venous Thromboembolism Prophylaxis

INTRODUCTION

Disparities in venous thromboembolism (VTE) incidence and prophylaxis have been observed across racial groups. This study investigates the relationship between race, injury type, and the timing of VTE prophylaxis in severe trauma patients, both with and without isolated traumatic brain injuries. The primary goal is to analyze how these factors interact and their potential impact on clinical outcomes.

METHODS

A retrospective cohort study of the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) from 2018 to 2021. Patient demographics, injury categories, VTE prophylaxis timing, injury severity, and in-hospital complications were collected. Multivariable regression models explored associations between race, injury type, VTE prophylaxis, and in-hospital mortality. Groups were analyzed by injury profile (isolated TBI vs non-TBI) and then by VTE prophylaxis timing (early ≤24 hours, late >24 hours).

RESULTS

Of 68,504 trauma patients analyzed, the majority were non-Hispanic or Latino (83.3%), White (71.2%), and male (69.6%). Patients receiving late VTE prophylaxis had higher rates of DVT and PE across race groups than patients with early prophylaxis. Logistic regression showed Asian patients with TBI receiving early prophylaxis were significantly more likely to have in-hospital mortality (OR 16.27, CI = 1.11-237.43, P = .04) than other races.

CONCLUSION

Patients who received late prophylaxis had higher VTE rates than early prophylaxis, independent of injury pattern or race. Additionally, assessing the implications of race in early VTE prophylaxis for isolated TBI showed that adult Asian patients had 16 times higher odds of in-hospital mortality compared to other races.

Thromboprophylaxis in hospitalized trauma patients: a systematic review and meta-analysis of implementation strategies

Introduction

Venous thromboembolism (VTE) prophylaxis implementation strategies are well-studied in some hospitalized medical and surgical patients. Although VTE is associated with substantial mortality and morbidity in trauma patients, implementation strategies for the prevention of VTE in trauma appear to be based on limited evidence. Therefore, we conducted a systematic review and meta-analysis of published literature on active implementation strategies for VTE prophylaxis administration in hospitalized trauma patients and the impact on VTE events.

Methods

A systematic review and meta-analysis was performed in adult hospitalized trauma patients to assess if active VTE prevention implementation strategies change the proportion of patients who received VTE prophylaxis, VTE events, and adverse effects such as bleeding or heparin-induced thrombocytopenia as well as hospital length of stay and the cost of care. An academic medical librarian searched Medline, Scopus, and Web of Science until December 2022.

Results

Four studies with a total of 1723 patients in the active implementation strategy group (strategies included education, reminders, human and computer alerts, audit and feedback, preprinted orders, and/or root cause analysis) and 1324 in the no active implementation strategy group (guideline creation and dissemination) were included in the analysis. A higher proportion of patients received VTE prophylaxis with an active implementation strategy (OR=2.94, 95% CI (1.68 to 5.15), p<0.01). No significant difference was found in VTE events. Quality was deemed to be low due to bias and inconsistency of studies.

Conclusions

Active implementation strategies appeared to improve the proportion of major trauma patients who received VTE prophylaxis. Further implementation studies are needed in trauma to determine effective, sustainable strategies for VTE prevention and to assess secondary outcomes such as bleeding and costs.

Level of evidence

Systematic review/meta-analysis, level III.

PROSPERO registration number

CRD42023390538.

Impact of a Rounding Checklist Implementation in the Trauma Intensive Care Unit on Clinical Outcomes

We aimed to evaluate the effectiveness of an intensive care unit (ICU) round checklist, FAST HUGS BID (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, Ulcer prophylaxis, Glycemic control, Spontaneous breathing trial, Bowel regimen, Indwelling catheter removal, and De-escalation of antibiotics-abbreviated as FD hereafter), in improving clinical outcomes in patients with severe trauma. We included patients admitted to our trauma ICU from 2016 to 2020 and divided them into two groups: before (before-FD, 2016-2017) and after (after-FD, 2019-2020) implementation of the checklist. We compared patient characteristics and clinical outcomes, including ICU and hospital length of stay (LOS) and in-hospital mortality. Survival analysis was performed using Kaplan-Meier curves and multivariable logistic regression models; furthermore, multiple linear regression analysis was used to identify independent factors associated with ICU and hospital LOS. Compared with the before-FD group, the after-FD group had significantly lower in-hospital mortality and complication rates, shorter ICU and hospital LOS, and reduced duration of mechanical ventilation. Moreover, implementation of the checklist was a significant independent factor in reducing ICU and hospital LOS and in-hospital mortality. Implementation of the FD checklist is associated with decreased ICU and hospital LOS and in-hospital mortality.

'Door-to-prophylaxis' as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury

Objective

Venous thromboembolism (VTE) risk reduction strategies include early initiation of chemoprophylaxis, reducing missed doses, weight-based dosing and dose adjustment using anti-Xa levels. We hypothesized that time to initiation of chemoprophylaxis would be the strongest modifiable risk for VTE, even after adjusting for competing risk factors.

Methods

A prospectively maintained trauma registry was queried for patients admitted July 2017-October 2021 who were 18 years and older and received emergency release blood products. Patients with deep vein thrombosis or pulmonary embolism (VTE) were compared to those without (no VTE). Door-to-prophylaxis was defined as time from hospital arrival to first dose of VTE chemoprophylaxis (hours). Univariate and multivariate analyses were then performed between the two groups.

Results

2047 patients met inclusion (106 VTE, 1941 no VTE). There were no differences in baseline or demographic data. VTE patients had higher injury severity score (29 vs 24), more evidence of shock by arrival lactate (4.6 vs 3.9) and received more post-ED transfusions (8 vs 2 units); all p<0.05. While there was no difference in need for enoxaparin dose adjustment or missed doses, door-to-prophylaxis time was longer in the VTE group (35 vs 25 hours; p=0.009). On multivariate logistic regression analysis, every hour delay from time of arrival increased likelihood of VTE by 1.5% (OR 1.015, 95% CI 1.004 to 1.023, p=0.004).

Conclusion

The current retrospective study of severely injured patients with trauma who required emergency release blood products found that increased door-to-prophylaxis time was significantly associated with an increased likelihood for VTE. Chemoprophylaxis initiation is one of the few modifiable risk factors available to combat VTE, therefore early initiation is paramount. Similar to door-to-balloon time in treating myocardial infarction and door-to-tPA time in stroke, "door-to-prophylaxis time" should be considered as a hospital metric for prevention of VTE in trauma.

Level of evidence

Level III, retrospective study with up to two negative criteria.

Multicenter study evaluating target attainment of anti-Factor Xa levels using various enoxaparin prophylactic dosing practices in adult trauma patients

STUDY OBJECTIVE

Enoxaparin is standard of care for venous thromboembolism (VTE) prophylaxis in adult trauma patients, but fixed-dose protocols are suboptimal. Dosing based on body mass index (BMI) or total body weight (TBW) improves target prophylactic anti-Xa level attainment and reduces VTE rates. A novel strategy using estimated blood volume (EBV) may be more effective based on results of a single-center study. This study compared BMI-, TBW-, EBV-based, and hybrid enoxaparin dosing strategies at achieving target prophylactic anti-Factor Xa (anti-Xa) levels in trauma patients.

DESIGN

Multicenter, retrospective review.

DATA SOURCE

Electronic health records from participating institutions.

PATIENTS

Adult trauma patients who received enoxaparin twice daily for VTE prophylaxis and had at least one appropriately timed anti-Xa level (collected 3 to 6 hours after the previous dose after three consecutive doses) from January 2017 through December 2020. Patients were excluded if the hospital-specific dosing protocol was not followed or if they had thermal burns with > 20% body surface area involvement.

INTERVENTION

Dosing strategy used to determine initial prophylactic dose of enoxaparin.

MEASUREMENTS

The primary end point was percentage of patients with peak anti-Xa levels within the target prophylactic range (0.2-0.4 units/mL).

MAIN RESULTS

Nine hospitals enrolled 742 unique patients. The most common dosing strategy was based on BMI (43.0%), followed by EBV (29.0%). Patients dosed using EBV had the highest percentage of target anti-Xa levels (72.1%). Multiple logistic regression demonstrated EBV-based dosing was significantly more likely to yield anti-Xa levels at or above target compared to BMI-based dosing (adjusted odds ratio (aOR) 3.59, 95% confidence interval (CI) 2.29-5.62, p < 0.001). EBV-based dosing was also more likely than hybrid dosing to yield an anti-Xa level at or above target (aOR 2.30, 95% CI 1.33-3.98, p = 0.003). Other pairwise comparisons between dosing strategy groups were nonsignificant.

CONCLUSIONS

An EBV-based dosing strategy was associated with higher odds of achieving anti-Xa level within target range for enoxaparin VTE prophylaxis compared to BMI-based dosing and may be a preferred method for VTE prophylaxis in adult trauma patients.

Renal vein thrombosis in the course of non-operative treatment of kidney trauma: A rare case report

INTRODUCTION

Venous thromboembolism is widely recognized as a life-threatening complication in trauma, yet renal vein thrombosis (RVT) following trauma is particularly rare.

PRESENTATION OF CASE

We report a case of a 67-year-old man who was brought to the emergency department after falling down a 14-step staircase at home which presented right kidney trauma (parenchyma laceration with a perirenal hematoma) on computed tomography, and hematuria. Considering the patient's hemodynamic stability, a non-operative treatment was initiated, and the patient was referred to the intensive care unit for close observation. On post-trauma day 3, a repeated CT revealed right renal vein thrombosis. After evaluation, it was decided to maintain prophylactic anticoagulation doses of enoxaparin (40 mg/day) due to the elevated risk of bleeding in high-grade renal trauma and planned an inferior vena cava (IVC) filter placement. In the following days, the hematuria resolved spontaneously and an IVC filter was placed. The patient progressed with no complaints, spontaneous diuresis, improvement in laboratory parameters, and cardiovascular stability, which led to his discharge on day 12 with rivaroxaban 10 mg/day. The patient was successfully treated with a non-operative approach, and the RVT disappeared after 35 days.

DISCUSSION

Post-traumatic renal vein thrombosis is a rare occurrence, and due to the infrequent nature of these events, specific management guidelines are not fully established, particularly when thrombosis is confirmed in an acutely injured patient.

CONCLUSION

Conservative therapy seems to play a meaningful role in trauma-related renal vein thrombosis treatment.

Inadequate prophylaxis in patients with trauma: anti-Xa-guided enoxaparin dosing management in critically ill patients with trauma

Venous thromboembolism (VTE) causes significant morbidity in patients with trauma despite advances in pharmacologic therapy. Prior literature suggests standard enoxaparin dosing may not achieve target prophylactic anti-Xa levels. We hypothesize that a new weight-based enoxaparin protocol with anti-Xa monitoring for dose titration in critically injured patients is safe and easily implemented.

Methods

This prospective observational study included patients with trauma admitted to the trauma intensive care unit (ICU) from January 2021 to September 2022. Enoxaparin dosing was adjusted based on anti-Xa levels as standard of care via a performance improvement initiative. The primary outcome was the proportion of subtarget anti-Xa levels (<0.2 IU/mL) on 30 mg two times per day dosing of enoxaparin. Secondary outcomes included the dosing modifications to attain goal anti-Xa levels, VTE and bleeding events, and hospital and ICU lengths of stay.

Results

A total of 282 consecutive patients were included. Baseline demographics revealed a median age of 36 (26-55) years, and 44.7% with penetrating injuries. Of these, 119 (42.7%) achieved a target anti-Xa level on a starting dose of 30 mg two times per day. Dose modifications for subtarget anti-Xa levels were required in 163 patients (57.8%). Of those, 120 underwent at least one dose modification, which resulted in 78 patients (47.8%) who achieved a target level prior to hospital discharge on a higher dose of enoxaparin. Overall, only 69.1% of patients achieved goal anti-Xa level prior to hospital discharge. VTE occurred in 25 patients (8.8%) and major bleeding in 3 (1.1%) patients.

Conclusion

A majority of critically injured patients do not meet target anti-Xa levels with 30 mg two times per day enoxaparin dosing. This study highlights the need for anti-Xa-based dose modification and efficacy of a pharmacy-driven protocol. Further optimization is warranted to mitigate VTE events.

Level of evidence

Therapeutic/care management, level III.

Creatinine clearance predicts the goal enoxaparin dose in traumatic brain injury

BACKGROUND

Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism (VTE). Recent guidelines recommend starting TBI patients on enoxaparin 30 mg twice daily and then considering weight-based dosing. Creatinine clearance may be better than weight for patients when considering high and low enoxaparin dose requirements. We hypothesize that creatinine clearance (CrCl) predicts goal enoxaparin dose better than weight-based dosing.

METHODS

A retrospective review was conducted on patients admitted to an urban, academic Level I trauma center from August 2017 to February 2020. Patients were included if greater than 18 years, admitted longer than 48 hours, and head and neck AIS ≥ 3. Patients were excluded if they did not have TBI, if they received deep vein thrombosis prophylaxis other than enoxaparin 12-hour dosing, if no anti-Xa levels were drawn, or if the goal anti-Xa level was not reached. Patients were grouped into dosing cohorts based on dose of enoxaparin required to reach goal. Pearson's correlation was used to compare mean CrCl and mean weight across dosing cohorts.

RESULTS

A total of 120 patients met inclusion and exclusion criteria, mean age was 47 years and 68% of patients were male. The mean hospital length of stay was 24 days. There were 5 (4.2%) deep vein thrombosis, no pulmonary embolism, and 5 (4.2%) patients died. Mean CrCl increased significantly with increased dosing of enoxaparin, Pearson's correlation coefficient of 0.484 ( p < 0.001). Weight on admission also increased with increasing enoxaparin dose requirements, with Pearson's correlation coefficient of 0.411 ( p < 0.001).

CONCLUSION

Creatine clearance predicts goal enoxaparin dose in TBI better than a weight-based dosing strategy. Further research with a larger patient population is required to validate CrCl values to guide enoxaparin dosing.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS)

BACKGROUND

The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies.

METHODS

A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted.

RESULTS

A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak).

CONCLUSIONS

This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.

Contemporary Use of Prophylactic Inferior Vena Cava Filters in Patients With Severe Traumatic Injuries and High Thromboembolic Event Risk

PURPOSE

The aim of this study was to evaluate the relationship between prophylactic inferior vena cava filter (IVCF) implantation and in-hospital deep vein thrombosis (DVT), pulmonary embolism (PE), and mortality among adults with intracranial, pelvic or lower extremity, and spinal cord injuries.

METHODS

Patients 18 years and older with severe intracranial, pelvic or lower extremity, or spinal cord injuries captured by the Trauma Quality Improvement Program (2010-2019) were identified. IVCFs implanted ≤72 hours after hospital presentation and before performance of lower extremity ultrasonography were defined as prophylactic. Patients were stratified by pharmacologic venous thromboembolism (VTE) prophylaxis status. Logistic regression models estimated prophylactic inferior vena cava (IVC) filtration's effect on selected outcomes and identified attributes associated with prophylactic IVCF implantation.

RESULTS

Of 544,739 included patients, 1.3% (n = 7,247) underwent prophylactic IVCF implantation. Among patients who received pharmacologic VTE prophylaxis, prophylactic IVC filtration compared with expectant management was positively associated with DVT (odds ratio [OR], 4.30; P < .001) and PE (OR, 4.30; P < .001) but not associated with mortality (OR, 0.92; P = .43). Among patients who received no pharmacologic prophylaxis, prophylactic IVC filtration was positively associated with DVT (OR, 4.63; P < .001) and PE (OR, 5.02; P < .001) but negatively associated with mortality (OR, 0.43; P < .001).

CONCLUSIONS

Prophylactic IVC filtration was associated with increased likelihood of VTE among all adults with severe intracranial, pelvic or lower extremity, and spinal cord injuries. In patients who received no pharmacologic VTE prophylaxis, prophylactic IVC filtration was associated with decreased likelihood of in-hospital mortality.

Racial Disparities in Administration of Venous Thromboembolism Prophylaxis After Severe Traumatic Injuries

BACKGROUND

Race is associated with differences in quality of care process measures and incidence of venous thromboembolism (VTE) in trauma patients. We aimed to investigate if racial disparities exist in the administration of VTE prophylaxis in trauma patients.

METHODS

We queried the Trauma Quality Improvement Project database from 2017 to 2019. Patients ages ≥16 years old with ISS ≥15 were included. Patients with no signs of life on arrival, any AIS ≥6, hospital length of stay <1 day, anticoagulant use before admission, or without recorded race were excluded. Patients were grouped by race: white, black, Asian, American Indian, and Native Hawaiian or Pacific Islander. The association between VTE prophylaxis administration and race was determined using a Poisson regression model with robust standard errors to adjust for confounders.

RESULTS

A total of 285,341 patients were included. Black patients had the highest rates of VTE prophylaxis exposure (73.8%), shortest time to administration (1.6 days), and highest use of low molecular weight heparin (56%). Black patients also had the highest incidence of deep vein thrombosis (2.8%) and pulmonary embolism (1.4%). Black patients were 4% more likely to receive VTE prophylaxis than white patients [adj. IRR (95% CI): 1.04 (1.03-1.05), P < .001]. American Indians were 8% less likely to receive VTE prophylaxis [adj. IRR (95% CI): .92 (.88-.97), P < .001] than white patients. No differences between white and Asian or Native Hawaiian or Pacific Islander patients existed.

DISCUSSION

While black patients had the highest incidence of DVT and PE, they had higher administration rates and earlier initiation of VTE prophylaxis. Further work can elucidate modifiable causes of these differences.

Research priorities in venous thromboembolism after trauma: Secondary analysis of the National Trauma Research Action Plan

BACKGROUND

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality during recovery from injury and can result in significant health care costs. Despite advances in the past several decades in our approach to VTE prophylaxis after injury, opportunities exist to improve the delivery and implementation of optimal VTE prophylaxis. Here, we aim to identify consensus research questions related to VTE across all National Trauma Research Action Plan (NTRAP) Delphi expert panels to further guide the research agenda aimed at preventing VTE after injury.

METHODS

This is a secondary analysis of consensus-based research priorities that were collected using a Delphi methodology by 11 unique NTRAP panels that were charged with unique topic areas across the spectrum of injury care. The database of questions was queried for the keywords "VTE," "venous thromboembo," and "DVT" and then grouped into relevant topic areas.

RESULTS

There were 86 VTE-related research questions identified across 9 NTRAP panels. Eighty-five questions reached consensus with 24 rated high priority; 60, medium priority; and 1, low priority. Questions related to the timing of VTE prophylaxis (n = 17) were most common, followed by questions related to risk factors for the development of VTE (n = 16), the effects of tranexamic acid on VTE (n = 11), the approach to dosing of pharmacologic prophylaxis (n = 8), and the pharmacologic prophylactic medication choice for optimal VTE prophylaxis (n = 6).

CONCLUSION

National Trauma Research Action Plan panelists identified 85 consensus-based research questions that should drive dedicated extramural research funding opportunities to support quality studies aimed at optimizing VTE prophylaxis after injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Venous thromboembolic disease in admitted blunt trauma patients: what matters?

BACKGROUND

Venous thromboembolic events (VTE) are a significant cause of morbidity and mortality following traumatic injury. We examined demographic characteristics, chemoprophylaxis, and outcomes of VTE patients with blunt trauma requiring hospitalization.

METHODS

A retrospective review of adult blunt trauma hospitalizations with and without VTE between 2012 and 2019 was conducted. Deaths in the emergency department were excluded. Univariate and multivariable analyses, including machine learning classification algorithms for VTE, were performed.

RESULTS

Of 10,926 admitted adult blunt trauma patients, 177 had VTE events. VTE events occurred at a median of 6 [IQR 3-11] days, with 7.3% occurring within 1 day of admission. VTE patients were more often male, and more often underwent surgery. They had higher injury severity as well as longer intensive care unit and hospital lengths of stay. While VTE occurred throughout the spectrum of injury severity, 27.7% had low injury severity (ISS < = 9). In multivariable analyses, both heparin and enoxaparin had reduced adjusted odds ratios for VTE.

CONCLUSION

Approximately 7.3% of VTE events occurred within one day of admission. A substantial proportion of VTE events occurred in patients with low injury severity (ISS < = 9). Subcutaneous unfractionated heparin and enoxaparin chemoprophylaxis were both inversely associated with VTE. These findings underscore the need for vigilance for VTE identification in blunt trauma patients throughout their hospitalization and VTE prevention efforts.

The efficacy and safety of aspirin in preventing venous thrombosis in major orthopedic surgery: An updated meta-analysis of randomized controlled trials

BACKGROUND

Major orthopedic surgery, including hip and knee replacement and lower extremity trauma fractures surgery, is associated with a high risk of venous thromboembolism (VTE), especially proximal deep vein thrombosis (DVT), and pulmonary embolism (PE), and is linked with high morbidity and mortality rates. Chemical anticoagulation is routinely used to prevent VTE, with previous meta-analyses reporting on the efficacy and safety of aspirin and other anticoagulants, however, opinions are divided. In the past 2 years, several large randomized controlled trials have been published, therefore, we reanalyzed aspirin efficacy and safety when compared with other anticoagulants in preventing VTE in major orthopedic surgery.

METHODS

Using PubMed, The Cochrane Library, Embase, and Web of Science databases, we conducted a RCT search in August 2023. The main outcomes included VTE, proximal DVT or PE. Additional outcomes included bleeding events, wound complications, wound infections, blood transfusions, and death events.

RESULTS

In total, 17 eligible articles, involving 29,522 patients (15,253 aspirin vs 14,269 other anticoagulant cases), were included. Primary outcomes showed that VTE incidence was more high in the aspirin group when compared with other anticoagulants (risk ratio [RR] = 1.45, 95% confidence interval [CI] = 1.18-1.77, P = .0004) and proximal in the aspirin group the DVT and/or PE incidence was significantly higher in the aspirin group when compared with other anticoagulants (RR = 1.19, 95% CI = 1.02-1.39, P = .03). No significant secondary outcome differences were identified in the aspirin group when compared with other anticoagulants (bleeding events [RR] = 0.83, 95% CI = 0.63-1.10, P = .20); wound complications (RR = 0.45, 95% CI = 0.20-1.04, P = .06); wound infection (RR = 1.08, 95% CI = 0.85-1.38, P = .53); blood transfusion events (RR = 1.00, 95% CI = 0.84-1.19, P = 1.00) and death events (RR = 1.11, 95% CI = 0.78-1.57, P = .55).

CONCLUSIONS

Our updated meta-analysis showed that aspirin was inferior to when compared with other anticoagulants in VTE-related orthopedic major surgery, including proximal DVT and/or PE, and was more likely to form VTE. No differences between groups were identified for bleeding, wound complications, wound infections, transfusion, or death events.

Trauma Patients With Cirrhosis Have a Similar Risk of Unplanned Operation and Decreased Associated Risk of Mortality With Venous Thromboembolism Chemoprophylaxis

INTRODUCTION

Patients with cirrhosis have an increased risk of complications after trauma, including bleeding, unplanned operations, and death. The benefit of venous thromboembolism (VTE) chemoprophylaxis in trauma patients with cirrhosis (CTPs) is not clear, especially since cirrhotic patients are hypercoagulable. We hypothesized that CTPs receiving VTE chemoprophylaxis (vCP) have a lower risk of death with no increased risk for unplanned operations compared to patients with cirrhosis not receiving vCP.

METHODS

The 2017-2019 TQIP database was queried for patients with cirrhosis. Patients on outpatient anticoagulant therapy or with a history of bleeding diathesis, interhospital transfers, severe head injury, deaths < 72 hours, and hospitalization < 2 days were excluded. A multivariable logistic regression analysis was performed.

RESULTS

From 10,011 CTPs, 6,350 (63.4%) received vCP. Compared to patients without vCP, the vCP group had decreased mortality (4.5% vs. 5.5%, P = 0.03) but a similar rate of unplanned operations (1% vs. 0.6%, P = 0.07). This persisted on multivariable analysis, with a decreased associated risk of mortality (OR 0.54, CI 0.42-0.69, P < 0.001), and a similar risk of unplanned operation (P = 0.85).

CONCLUSION

CTPs received VTE chemoprophylaxis in under two-thirds of cases. On multivariable analysis, vCP was associated with a decreased risk of mortality and a similar risk of unplanned operations. These findings suggest that vCP appears safe. Further investigation is needed to confirm this finding.

A majority of trauma-related deep venous thromboses resolve prior to discharge

Post-traumatic DVTs present unique challenges in patient populations with specific high-risk injury patterns. Duplex ultrasound (US) can be used to assess evolution of DVTs and may guide treatment for high-risk patients. We hypothesized that many DVTs resolve during the initial admission. Weekly duplex US are ordered on all trauma inpatients regardless of prior DVT at our facility. We reviewed US and outcomes data on all patients with lower extremity DVTs at our Level I trauma center from January 2012-December 2021. 392 patients were diagnosed with lower extremity DVT by US. 261 (67%) patients received follow-up US with a mean time to repeat US of 6 days. Of these, 91 (35%) patients experienced DVT resolution prior to the first follow-up US, and 141 (54%) patients experienced resolution prior to discharge. Mean time to resolution was 10 days. Over 50% of DVTs resolve before discharge and are detected by US. Further studies and post-discharge follow-up are needed to determine if patients with resolved DVTs can be managed without therapeutic anticoagulation.

Evaluation of a novel blood volume-based enoxaparin dosing guideline for venous thromboembolism prophylaxis in trauma patients

PURPOSE

Fixed-dose and body mass index (BMI)-based enoxaparin regimens provide inadequate venous thromboembolism (VTE) prophylaxis for many trauma patients. The purpose of this study was to evaluate the effectiveness of a novel blood volume (BV)-based enoxaparin guideline vs a historical BMI-based guideline for VTE prophylaxis in trauma patients.

METHODS

This was a retrospective pre/post study completed at a large academic level 1 trauma center. All adult trauma patients admitted from October through December 2019 and August through October 2020 who received prophylactic enoxaparin per guideline were included. The BV dosing was as follows: patients with a BV of 3 to 4.9 L received enoxaparin 30 mg every 12 hours, those with a BV of 5 to 6.9 L received 40 mg every 12 hours, and those with a BV of ≥7 L received 60 mg every 12 hours. The primary outcome was the percentage of patients who attained a target anti-factor Xa (anti-Xa) postdosing level at the first steady-state assessment (0.2 to 0.5 IU/mL).

RESULTS

A total of 241 patients (99 for the BMI group and 142 for the BV group) were included. The study groups had a median age of 38 vs 42 years, a mean BMI of 27.4 vs 27.7 kg/m2, and a mean BV of 5.1 vs 5.1 L, respectively. A total of 63 patients (62.6%) in the BMI group attained target anti-Xa levels compared to 115 patients (81%) in the BV group (P = 0.008). In multivariate regression, the BV-based guideline was the only variable associated with attainment of target anti-Xa levels (adjusted odds ratio, 2.02; P = 0.01). Clinically relevant bleeding and VTE rates were similar between the groups.

CONCLUSION

Dosing prophylactic enoxaparin using a BV-based dosing guideline significantly increased attainment of target anti-Xa levels.

Creatinine Clearance May Predict Goal Enoxaparin Dose in Trauma

BACKGROUND

Guidelines for enoxaparin dosing after trauma recommend an initial dose of 40 mg twice daily for most patients and then adjusting by anti-Xa levels. Previous studies indicated higher enoxaparin doses are necessary with higher levels of creatinine clearance (CrCl). We sought to determine if the goal enoxaparin dose correlates with the admission CrCl to reduce the reliance on measuring anti-Xa levels.

STUDY DESIGN

A retrospective review was conducted of patients admitted to an urban, academic Level 1 trauma center from April 2017 to February 2020. Patients started on enoxaparin who reached goal anti-Xa trough levels were included, and patients were excluded if they did not reach goal anti-Xa levels. Data collection included patient demographics, injury characteristics, admission CrCl, and final enoxaparin dose. CrCl was then correlated with the final enoxaparin dose.

RESULTS

Of 421 patients included, the mean age was 46.6 years and 73% were male. The median goal enoxaparin dose was 40 mg twice daily. The mean CrCl significantly increased with increasing twice-daily doses of enoxaparin (20 mg: 69.2 mL/min; 30 mg: 89 mL/min; 40 mg: 112.8 mL/min; 50 mg: 140.5mL/min; 60 mg: 147.4 mL/min; and 70 mg: 140 mL/min; p < 0.01).

CONCLUSIONS

Admission CrCl may predict the enoxaparin dose required to achieve adequate anti-Xa levels. Our data indicate that CrCls of approximately 70, 90, 110, 140, and 150 mL/min may predict the twice-daily enoxaparin doses of 20, 30, 40, 50, and 60 mg, respectively. CrCl dosing guidance may reduce the time to goal anti-Xa levels and the frequency of anti-Xa measurements. Further research is necessary, and enoxaparin dosing should continue to be monitored by anti-Xa levels.

Preventing thrombotic events in a case of postpartum ovarian artery aneurysm rupture: clinical challenges and management approaches

Ovarian artery aneurysm is a rare asymptomatic condition usually diagnosed when it ruptures. It causes massive bleeding, often in the peripartum period of multiparous women, who are already at an increased risk for thromboembolic events. Balancing the bleeding risk against the thrombotic complications remains unexplored in such cases. A 35-year-old woman presented with hemorrhagic shock 3 days after delivering her seventh healthy child. During the emergent exploratory laparotomy, she responded well to the blood transfusion; the stable retroperitoneal hematoma indicated no need to explore it. A subsequent episode of hemodynamic instability necessitated another laparotomy, during which the hematoma was evacuated and both ovarian arteries were ligated. Shortly thereafter, the patient suffered a pulmonary embolism (PE). In multiparous patients presenting with peripartum retroperitoneal hematoma and hemorrhagic shock, exploring the hematoma and ligating the ovarian and uterine arteries may reduce the risk of PE or the need for reoperation.