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Schellenberg M, Owattanapanich N, Emigh B, Van Gent JM, Egodage T, Murphy PB, Ball CG, Spencer AL, Vogt KN, Keeley JA, Doris S, Beiling M, Donnelly M, Ghneim M, Schroeppel T, Bradford J, Breinholt CS, Coimbra R, Berndtson AE, Anding C, Charles MS, Rieger W, Inaba K. When is it safe to start venous thromboembolism prophylaxis after blunt solid organ injury? A prospective American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg 2024; 96:209-215. [PMID: 37872669 DOI: 10.1097/ta.0000000000004163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial, as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests that VTEp ≤48 hours is safe and effective. This study was undertaken to validate this clinical practice. METHODS Blunt trauma patients presenting to 19 participating trauma centers in North America were screened over a 1-year study period beginning between August 1 and October 1, 2021. Inclusions were age older than 15 years; ≥1 liver, spleen, or kidney injury; and initial nonoperative management. Exclusions were transfers, emergency department death, pregnancy, and concomitant bleeding disorder/anticoagulation/antiplatelet medication. A priori power calculation stipulated the need for 1,158 patients. Time of VTEp initiation defined study groups: Early (≤48 hours of admission) versus Late (>48 hours). Bivariate and multivariable analyses compared outcomes. RESULTS In total, 1,173 patients satisfied the study criteria with 571 liver (49%), 557 spleen (47%), and 277 kidney injuries (24%). The median patient age was 34 years (interquartile range, 25-49 years), and 67% (n = 780) were male. The median Injury Severity Score was 22 (interquartile range, 14-29) with Abbreviated Injury Scale Abdomen score of 3 (interquartile range, 2-3), and the median American Association for the Surgery of Trauma grade of solid organ injury was 2 (interquartile range, 2-3). Early VTEp patients (n = 838 [74%]) had significantly lower rates of VTE (n = 28 [3%] vs. n = 21 [7%], p = 0.008), comparable rates of nonoperative management failure (n = 21 [3%] vs. n = 12 [4%], p = 0.228), and lower rates of post-VTEp blood transfusion (n = 145 [17%] vs. n = 71 [23%], p = 0.024) when compared with Late VTEp patients (n = 301 [26%]). Late VTEp was independently associated with VTE (odd ratio, 2.251; p = 0.046). CONCLUSION Early initiation of VTEp was associated with significantly reduced rates of VTE with no increase in bleeding complications. Venous thromboembolism chemoprophylaxis initiation ≤48 hours is therefore safe and effective and should be the standard of care for patients with blunt solid organ injury. LEVEL OF EVIDENCE Therapeutic and Care Management; Level III.
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Affiliation(s)
- Morgan Schellenberg
- From the Division of Acute Care Surgery (M.S., N.O., B.E., K.I.), LAC+USC Medical Center, University of Southern California, Los Angeles, California; Division of Acute Care Surgery (J.-M.V.G., W.R.), University of Texas Health Sciences Center at Houston, Houston, Texas; Division of Trauma (T.E.), Cooper University Hospital, Camden, New Jersey; Division of Acute Care Surgery (P.B.M.), Froedtert Hospital, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Acute Care Surgery (C.G.B.), Foothills Medical Center, University of Calgary, Calgary, Alberta; Division of Acute Care Surgery (A.L.S.), Atrium Health Wake Forest Baptist Medical Center, Wake Forest University, Winston-Salem, North Carolina; Division of Acute Care Surgery (K.N.V.), London Health Sciences Center, University of Western Ontario, London, Ontario, Canada; Division of Trauma/Acute Care Surgery/Surgical Critical Care (J.A.K.), Harbor UCLA Medical Center, University of California Los Angeles, Los Angeles, California; Division of Acute Care Surgery (S.D.), Grant Medical Center, Columbus, Ohio; Division of Acute Care Surgery (M.B.), Oregon Health and Science University, Portland, Oregon; Division of Acute Care Surgery (M.D.), University of California Irvine, Irvine, California; Program in Trauma (M.G.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Division of Acute Care Surgery, UC Health Memorial Hospital (T.S.), University of Colorado Springs, Colorado Springs, Colorado; Division of Acute Care Surgery (J.B.), Dell Medical School, The University of Texas Austin, Austin, Texas; Division of Trauma, Acute Care Surgery, and Surgical Critical Care (C.S.B.), West Virginia University, Morgantown, West Virginia; Division of Acute Care Surgery (R.C.), Riverside University Health System Medical Center, University of California Riverside, Riverside; Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery (A.E.B.), University of California-San Diego, San Diego, California; Division of Acute Care Surgery (C.A.), Texas Tech University Health Sciences Center, Texas Tech University, Lubbock, Texas; and Division of Acute Care Surgery (M.S.C.), Ascension Medical Group St. John, Tulsa, Oklahoma
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