Early venous thromboembolism prophylaxis in patients with trauma intracranial hemorrhage: Analysis of the prospective multicenter Consortium of Leaders in Traumatic Thromboembolism study

Impact of implementing a venous thromboembolism guideline and electronic health records order set on venous thromboembolism rates in trauma patients: A multicenter study

BACKGROUND

Appropriate chemical prophylaxis can reduce the risk of venous thromboembolism (VTE) in trauma patients. A system-wide VTE clinical practice guideline (CPG) and electronic health record (EHR)-based VTE prophylaxis order set were implemented. The CPG provided guidelines based on bleeding risk, recommended earlier initiation of chemical prophylaxis, and favored low-molecular-weight heparin (LMWH). The purpose of this study was to evaluate the impact of VTE CPG and prophylaxis order set on the rate of VTE.

METHODS

A retrospective review was performed on trauma patients 15 years or older admitted to three trauma centers between July 2018 and December 2021. Exclusion criteria included burn injury, readmission, length of stay <2 days, and withdrawal of care. The VTE CPG and EHR order set were implemented in November 2020, and a pre-implementation/postimplementation (POST) comparison was conducted.

RESULTS

A total of 12,479 patients were included. There were no differences in age, sex, and Injury Severity Score. The POST group had a higher usage of LMWH (64.0 vs. 67.5%, p < 0.01), a lower rate of no prophylaxis (17.2 vs. 12.5%, p < 0.01), and a shorter time to prophylaxis (29.4 vs. 25.9 hours, p < 0.01). The rates of VTE (1.6 vs. 1.0%, p < 0.01) and deep vein thrombosis (1.1 vs. 0.7%, p = 0.03) were lower in the POST group. There was no difference in the rate of pulmonary embolism (0.6 vs. 0.4%, p = 0.06). The POST group had a higher mortality (0.7 vs. 1.1%, p = 0.03) on univariable analysis, but there were no differences between groups on adjusted analysis. Independent predictors of VTE were longer time to VTE prophylaxis, higher Injury Severity Score, ventilator-associated pneumonia, and longer hospital length of stay. Use of LMWH and postintervention period were protective from VTE.

CONCLUSIONS

The implementation of a system-wide VTE CPG and EHR-based prophylaxis order set were associated with a reduced incidence of VTE in trauma patients without an associated mortality difference.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

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.

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.

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.

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 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.

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.

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.

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.

Early venous thromboembolism chemoprophylaxis in traumatic brain injury requiring neurosurgical intervention: Safe and effective

BACKGROUND

Traumatic brain injury patients who require neurosurgical intervention are at the highest risk of worsening intracranial hemorrhage. This subgroup of patients has frequently been excluded from prior research regarding the timing of venous thromboembolism chemoprophylaxis. This study aims to assess the efficacy and safety of early venous thromboembolism chemoprophylaxis in patients with traumatic brain injuries requiring neurosurgical interventions.

METHODS

This is a single-center retrospective review (2016-2020) of traumatic brain injury patients requiring neurosurgical intervention admitted to a level I trauma center. Interventions included intracranial pressure monitoring, subdural drain, external ventricular drain, craniotomy, and craniectomy. Exclusion criteria included neurosurgical intervention after chemoprophylaxis initiation, death within 5 days of admission, and absence of chemoprophylaxis. The total population was stratified into Early (≤72 hours of intervention) versus Late (>72 hours after intervention) chemoprophylaxis initiation.

RESULTS

A total of 351 patients met the inclusion criteria, of whom 204 (58%) had early chemoprophylaxis initiation. Overall, there were no significant differences in baseline and admission characteristics between cohorts. The Early chemoprophylaxis cohort had a statistically significant lower venous thromboembolism rate (5% vs 13%, P < .001) with no increased risk of worsening intracranial hemorrhage (10% vs 13%, P = .44) or neurosurgical reintervention (8% vs 10%, P = .7). On subgroup analysis, a total of 169 patients required either a craniotomy or a craniectomy before chemoprophylaxis. The Early chemoprophylaxis cohort had statistically significant lower venous thromboembolism rates (2% vs 11%, P < .001) with no increase in intracranial hemorrhage (8% vs 11%, P = .6) or repeat neurosurgical intervention (8% vs 10%, P = .77).

CONCLUSION

Venous thromboembolism prophylaxis initiation within 72 hours of neurosurgical intervention is safe and effective. Further prospective research is warranted to validate the results of this study.