Venous thromboembolism risk after spinal cord injury: A secondary analysis of the CLOTT study

The Effectiveness and Safety of Chemoprophylaxis in the Surgical Management of Spinal Trauma: A Systematic Review and Meta-Analysis

OBJECTIVE

Chemoprophylaxis for preventing venous thromboembolism (VTE) in spine surgery is debated due to effectiveness and safety concerns. Guidelines lack consensus on regimens and timing for spinal trauma. We examined chemoprophylaxis in spine trauma surgery to further guide surgeon decision-making.

METHODS

This systematic review and meta-analysis searched PubMed, CINAHL, MEDLINE, and Web of Science until March 14, 2024, for articles on chemoprophylaxis and spine trauma surgery. A random-effects meta-analysis compared VTE events by chemoprophylaxis use and timing.

RESULTS

Fourteen observational studies (n = 13,754 patients; mean age: 41.74 ± 9.09 years; mean follow-up: 76.98 ± 213.45 days) were included. The total VTE prevalence was 6.28% (425/6771). VTE prevalence was 4.08% (143/3502) with chemoprophylaxis and 8.62% (282/3269) without. Meta-analysis showed no significant VTE difference between patients with (n = 516; 3.88%) and without chemoprophylaxis (n = 528; 5.68%) (P = 0.119, relative risk [RR]: 1.03; 95% confidence interval [CI]: [0.99, 1.08]). No significant difference in postoperative bleeding was found between patients with (3.01% of 722 patients) and without chemoprophylaxis (5.74% of 766 patients) (P = 0.549, RR: 1.00; 95% CI: [0.99, 1.02]). Comparing early (n = 305; 5.90%) and late chemoprophylaxis (n = 271; 8.86%) showed no significant VTE difference (P = 0.289, RR: 1.06; 95% CI: [0.96, 1.14]). Postoperative bleeding was also not significantly different between early (n = 305; no complications) and late chemoprophylaxis (2.58%) (P = 0.328, RR: 1.14; 95% CI: [0.88, 1.48]).

CONCLUSIONS

No significant association was found between chemoprophylaxis use or timing and VTE risk after spine trauma surgery, though this finding may be underpowered. Chemoprophylaxis did not appear to significantly increase postoperative bleeding.

Lower red blood cell count is a risk factor for higher D-dimer level in patients with spinal cord injury: A five year retrospective cross-sectional study

OBJECTIVES

This study aims to elucidate the relationship between red blood cell (RBC) count and D-dimer levels in patients with spinal cord injury, with the goal of identifying potential therapeutic targets for minimizing D-dimer levels.

STUDY DESIGN

An observational, retrospective, cross-sectional, single center study.

SETTING

Individuals with SCI (576 cases) admitted to a rehabilitation medicine department.

OUTCOME MEASURES

After exclusions, we divided the participants (n = 308) into two groups based on their D-dimer levels: Group 1 (≤0.5  mg/L, n = 64) and Group 2 (>0.5  mg/L, n = 244). Key variables such as deep vein thrombosis (DVT), anticoagulant therapy, pulmonary infection, injury characteristics, and hematological parameters were analyzed for their association with RBC counts and D-dimer levels.

RESULTS

DVT and anticoagulant therapy emerged as significant covariates. A comprehensive analysis identified a negative linear correlation between RBC counts and D-dimer levels, markedly more pronounced in Group 2. For every 1.00 × 1012/L increase in RBC, D-dimer levels decreased by 1.93  mg/L in Group 2, compared to a 0.02  mg/L decrease in Group 1.

CONCLUSIONS

Higher RBC counts might be associated with lower D-dimer levels in patients with SCI, especially in those with higher initial D-dimer levels. This association highlights a potential therapeutic focus on managing RBC counts to decrease D-dimer level, which may mitigate the risk of DVT formation in patients with SCI.

Does preperitoneal packing increase venous thromboembolim risk among trauma patients? A prospective multicenter analysis across 17 level I trauma centers

INTRODUCTION

Pelvic fractures are associated with a high risk of venous thromboembolism (VTE). Among treatment options, including pelvic angioembolization (PA), preperitoneal pelvic packing (PPP), and pelvic open reduction internal fixation (ORIF), PPP has been postulated as a VTE risk factor. We aimed to characterize the risk of VTE among pelvic fracture patients receiving PPP, PA or ORIF.

METHODS

We used observational data from a 17-site Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group, a US level I trauma center collaborative working to identify factors associated with posttraumatic VTE, deep venous thrombosis, pulmonary embolism, or pulmonary thrombosis. The CLOTT criteria included age 18 to 40 years with at least one independent VTE risk factor. We compared outcomes of PPP, PA, and pelvic ORIF to reference of no pelvic intervention. Our primary outcome was VTE. A competing risk analysis was performed.

RESULTS

Among 1,387 pelvic fracture patients, VTE incidence was 5.6%. The ORIF patients were most likely to develop VTE (24.7%), while VTE incidence for PPP was 9.0% and 2.6% for PA. After multivariate, risk-competing analysis, none of the three treatment interventions for pelvic fractures were significantly associated with VTE. Initiation of VTE prophylaxis in the first 24 hours of admission independently halved VTE incidence (hazard ratio, 0.55; confidence interval, 0.33-0.91).

CONCLUSION

Pelvic fracture interventions do not appear to be independent risk factors for VTE in our study. Initiation of VTE pharmacoprophylaxis within the first 24 hours of admission remains critical to significantly decreasing VTE formation in this high-risk population.

LEVEL OF EVIDENCE

Therapeutic Study; Level III.

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.

Development and validation of a novel screening tool for deep vein thrombosis in patients with spinal cord injury: A five-year cross-sectional study

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

Deep vein thrombosis (DVT) presents a significant risk of complication in patients with spinal cord injury (SCI), necessitating accurate screening methods. While the Caprini Risk Assessment Model (Caprini RAM) has seen extensive use for DVT screening, its efficacy remains under scrutiny.

SETTING

First Affiliated Hospital of China University of Science and Technology.

METHODS

We created and evaluated three nomograms for their effectiveness in DVT screening. Model 1 incorporated variables such as age, D-dimer level, red blood cell (RBC) counts, platelet counts, presence of type 2 diabetes mellitus, high blood pressure, mode and level of injury, degree of impairments, and Caprini scores. Model 2 was derived from Caprini scores alone, and Model 3 focused on independent risk factors. We assessed these models using the area under the curve (AUC) of the receiver operating characteristic (ROC), calibration curves, and decision curve analysis (DCA), employing bootstrap resampling tests (500 iterations) to determine their accuracy, discriminative ability, and clinical utility. Internal validation was performed on a separate cohort. Nomogram was established with well-fitted calibration curves for model 1, 2 and 3(AUC = 0.808, 0.751 and 0.797; 95%CI = 0.76-0.86, 0.70-0.80 and 0.75-0.84; respectively), indicating model 1 outperformed the others in prediction DVT risk, followed by model 3 and 2. These findings were consistent in the validation cohort, with DCA further corroborating our conclusions.

CONCLUSION

A nomogram integrating clinical data with Caprini RAM provides a superior option for DVT screening in SCI patients within rehabilitation settings, outperforming Caprini RAM.

Venous Thromboembolism Rates in Trauma Patients Significantly Increase With Missed Prophylactic Enoxaparin Doses

Background: Current literature demonstrates prophylactic enoxaparin to be efficacious in reducing venous thromboembolism (VTE) rates without significantly increasing risk for bleeding complications. Despite this evidence, prophylactic enoxaparin doses are frequently withheld for surgery or procedures. This exploratory study aims to quantify the risk of a VTE event in trauma patients associated with missed doses of prophylactic enoxaparin. Methods: This retrospective cohort study evaluated trauma patients admitted to our Level 1 trauma center from January 1, 2012 to January 31, 2021. A 1:1 propensity match with ten variables was performed to compare patients receiving prophylactic enoxaparin that had a VTE and those that did not. The primary outcome was a VTE event. Results: 493 patients met inclusion criteria; 1:1 propensity score matching was performed resulting in a cohort of 184 patients. The percentage of patients that missed a prophylactic enoxaparin dose in the VTE group was higher than the no VTE group (34.8% vs 21.7%, P = 0.049). This is consistent when examining total missed doses (P = 0.038) and consecutively missed doses (P = 0.035). The odds of having a VTE for patients that missed at least one dose or more of enoxaparin are nearly two times greater (OR 1.92, 95% CI 0.997, 3.7). Conclusion: Missing enoxaparin doses significantly increases the risk of VTE in matched populations. Most prophylactic enoxaparin doses were held for procedures, and not for bleeding events. Trauma teams should carefully weigh the risk of bleeding complications associated with continuing enoxaparin prophylaxis against the significant thromboembolic risk of withholding it.

Evaluation of the impact of bundled nursing strategies on the prevention of venous thromboembolism in patients with cerebral hemorrhage

To investigate the effectiveness and value of bundled nursing strategies for venous thromboembolism prevention in nonsurgical patients with cerebral hemorrhage, 200 patients who underwent treatment for cerebral hemorrhage in our hospital from January 2023 to July 2023 were chosen as the study subjects. Patients were divided into control group and experimental group according to different treatment methods. For patients in the control group, regular care was used, while for patients in the observation group, bundled care was used for intervention. This study used a venous thromboembolism risk factor assessment form to assess the probability of patients suffering from venous thromboembolism. It used the incidence of venous thromboembolism, disease cognition level, coagulation function, fibrinolysis, changes in blood routine, exercise ability, improvement in quality of life, and patient satisfaction with nursing mode as detection indicators to obtain the changes in various indicator values and patient satisfaction scores under different nursing interventions. Prior to nursing intervention, the significant statistical differences did not exist (P > .05) between the control group and the observation group in terms of general information, number of venous thromboembolism risk levels, degree of disease cognition, coagulation function, blood routine, exercise ability, quality of life, and fibrinolysis indicators. After a period of nursing intervention, the significant statistical difference existed (P < .05) between the control group and the observation group in terms of general information, number of venous thromboembolism risk levels, degree of disease cognition, coagulation function, blood routine, exercise ability, quality of life, and fibrinolysis indicators. In the patient satisfaction score, the satisfaction scores of male and female patients with general care were 0.865 and 0.878, respectively, and the satisfaction scores for bundled care were 0.942 and 0.965, respectively. In conclusion, bundled care can better improve the coagulation status and blood routine indexes of nonsurgical patients with cerebral hemorrhage compared with ordinary care, thus contributing to better prevention of venous thromboembolism in nonsurgical patients with cerebral hemorrhage.

Associations of RBC counts and incidence of DVT in patients with spinal cord injury: a five year observational retrospective study

BACKGROUND

The role of red blood cell (RBC) counts as potential independent risk factors for deep vein thrombosis (DVT) in patients with spinal cord injury (SCI) remains uncertain. This study aims to clarify the associations between RBC counts and DVT incidence among this population.

METHODS

A retrospective analysis was performed on 576 patients with SCI admitted to the rehabilitation medicine department from January 1, 2017 to December 31, 2021. After exclusions, 319 patients were analyzed, among which 94 cases of DVT were identified.

RESULTS

Mode of injury, D-dimer and anticoagulant therapy were significant covariates (P < 0.05). Age, fibrinogen, D-dimer, anticoagulant therapy and American Spinal Cord Injury Association impairment scale (AIS) grades were associated with RBC counts and DVT incidence (P < 0.05). Adjusting for these factors, a 1.00 × 10^12/L increase in RBC counts correlated with a 45% decrease in DVT incidence (P = 0.042), revealing a "U" shaped relationship with a pivot at 4.56 × 10^12/L (P < 0.05).

CONCLUSION

RBC counts below 4.56 × 10^12/L serve as a protective factor against DVT, while counts above this threshold pose a risk. These findings could inform the development of DVT prevention strategies for patients with SCI, emphasizing the need for targeted monitoring and management of RBC counts.

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.

Considerations for Contraception Following Spinal Cord Injury: A Systematic Review

Introduction

Counseling and education on women's health, specifically contraception, following spinal cord injury (SCI) is an important component of care for women with SCI. While a plethora of available contraceptive options exists, research in this area is scarce.

Objectives

This systematic review assesses the quality and quantity of research on contraception for individuals with SCI.

Methods

Literature searches of three medical databases were performed to identify articles that addressed contraception and family planning for women with SCI. Articles were then screened in a two-stage selection process and evaluated for content.

Results

Of 165 articles, 21 were identified that fit the inclusion criteria. The majority (66%) of articles were literature reviews or professional practice guidelines. Fourteen (66%) included information on short-acting hormonal oral contraception, 11 (52%) included information on long-acting reversible contraception, 15 (71%) included information on barrier methods, 6 (29%) included information on fertility awareness, 9 (43%) included information on permanent contraception, and one (5%) included information on emergency contraception.

Discussion

This systematic review demonstrates a paucity of evidence-based information on contraception tailored to women with SCI. It highlights a need for research and comprehensive guidelines on primary and emergency contraception in this population.

Management of acute cervical spinal cord injury in the non-specialist intensive care unit: a narrative review of current evidence

Each year approximately one million people suffer spinal cord injury, which has significant physical, psychosocial and economic impacts on patients and their families. Spinal cord rehabilitation centres are a well-established part of the care pathway for patients with spinal cord injury and facilitate improvements in functional independence and reductions in healthcare costs. Within the UK, however, there are a limited number of spinal cord injury centres, which delays admission. Patients and their families often perceive that they are not receiving specialist care while being treated in non-specialist units. This review aimed to provide clinicians who work in non-specialist spinal injury centres with a summary of contemporary studies relevant to the critical care management of patients with cervical spinal cord injury. We undertook a targeted literature review including guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials published in English between 1 June 2017 and 1 June 2023. Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also included. We then summarised the key management themes: acute critical care management approaches (including ventilation strategies, blood pressure management and tracheostomy insertion); respiratory weaning techniques; management of pain and autonomic dysreflexia; and rehabilitation.

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.

Outcomes of Protocol-Driven Venous Thromboembolic Chemo-Prophylaxis in Trauma Patients: A Trauma Quality Improvement Project Analysis

INTRODUCTION

Low molecular weight heparin (LMWH) is the standard for venous thromboembolic (VTE) chemo-prophylaxis in trauma patients; however, inconsistencies in the use of LMWH exist. The objective of this study was to assess VTE outcomes in response to a chemo-prophylaxis protocol guided by patient physiology (eg, creatinine clearance) and comorbidities.

METHODS

ACS TQIP Benchmark Reports at a level 1 trauma center using a patient physiology and comorbidity directed VTE chemo-prophylaxis protocol were analyzed for Spring 2019 to Fall 2021. Patient demographics, VTE rates and pharmacologic VTE prophylaxis type were collected for "All Patients" and "Elderly" (TQIP: age ≥ 55 years) cohorts.

RESULTS

Data was analyzed for 1919183 "All Hospitals" (AH) and 5843 patients single institution (SI) using the physiologic and comorbidity guided VTE chemo-prophylaxis protocol. Elderly subgroup had 701965 (AH) and 2939 (SI) patients. Use of non-LMWH chemo-prophylaxis was significantly higher at SI: All patients = 62.6% SI vs 22.1% (P < .01); Elderly = 68.8% SI vs 28.1% AH (P < .01). VTE, DVT, and PE rates for All Patients and Elderly subgroup were significantly reduced at SI, except Elderly PE which was statistically equivalent.

CONCLUSIONS

Protocol-driven VTE chemo-prophylaxis was associated with significantly lower LMWH use accompanied by significant reductions in All VTE, DVT, PE, and Elderly VTE and DVT with no difference in Elderly PE rates. These results may imply that adherence to a physiologic and comorbidity directed chemo-prophylaxis protocol, rather than LMWH, reduces VTE events in trauma patients. Further investigation to elucidate best practice is warranted.

Implementation science approaches to optimizing venous thromboembolism prevention in patients with traumatic injuries: Findings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma

ABSTRACT

Disease burden of venous thromboembolism (VTE) without pharmacologic prophylaxis is high in trauma patients. Although VTE prophylaxis guidelines exist, studies on real-world use of VTE prophylaxis in trauma shows limited uptake of guideline recommendations. Despite existing guidelines, reports indicate that VTE prophylaxis implementation across trauma centers is lagging. Implementation barriers of VTE prophylaxis in trauma are multifactorial, and VTE prescribing practices require further optimization. Implementation science methods can help standardize and improve care; well-established approaches in medical and surgical hospitalized patients and their effects on clinical outcomes such as VTE and bleeding complications must be investigated because they apply to trauma patients. Nonadministration of VTE prophylaxis medications in hospitalized patients is associated with VTE events and remains a barrier to providing optimal defect-free care. Further investigations are required for VTE prophylaxis implementation across all trauma populations.