Are retrievable vena cava filters placed in trauma patients really retrievable?

Approaches for optimizing venous thromboembolism prevention in injured patients: Findings from the consensus conference to implement optimal venous thromboembolism prophylaxis in trauma

ABSTRACT

Venous thromboembolism (VTE) is a major issue in trauma patients. Without prophylaxis, the rate of deep venous thrombosis approaches 60% and even with chemoprophylaxis may be nearly 30%. Advances in VTE reduction are imperative to reduce the burden of this issue in the trauma population. Novel approaches in VTE prevention may include new medications, dosing regimens, and extending prophylaxis to the postdischarge phase of care. Standard dosing regimens of low-molecular-weight heparin are insufficient in trauma, shifting our focus toward alternative dosing strategies to improve prophylaxis. Mixed data suggest that anti-Xa-guided dosage, weight-based dosing, and thromboelastography are among these potential strategies. The concern for VTE in trauma does not end upon discharge, however. The risk for VTE in this population extends well beyond hospitalization. Variable extended thromboprophylaxis regimens using aspirin, low-molecular-weight heparin, and direct oral anticoagulants have been suggested to mitigate this prolonged VTE risk, but the ideal approach for outpatient VTE prevention is still unclear. As part of the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma, a multidisciplinary array of participants, including physicians from multiple specialties, pharmacists, nurses, advanced practice providers, and patients met to attack these issues. This paper aims to review the current literature on novel approaches for optimizing VTE prevention in injured patients and identify research gaps that should be investigated to improve VTE rates in trauma.

Proceedings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma

ABSTRACT

On May 4 and 5, 2022, a meeting of multidisciplinary stakeholders in the prevention and treatment of venous thromboembolism (VTE) after trauma was convened by the Coalition for National Trauma Research, funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health, and hosted by the American College of Surgeons in Chicago, Illinois. This consensus conference gathered more than 40 in-person and 80 virtual attendees, including trauma surgeons, other physicians, thrombosis experts, nurses, pharmacists, researchers, and patient advocates. The objectives of the meeting were twofold: (1) to review and summarize the present state of the scientific evidence regarding VTE prevention strategies in injured patients and (2) to develop consensus on future priorities in VTE prevention implementation and research gaps.To achieve these objectives, the first part of the conference consisted of talks from physician leaders, researchers, clinical champions, and patient advocates to summarize the current state of knowledge of VTE pathogenesis and prevention in patients with major injury. Video recordings of all talks and accompanying slides are freely available on the conference website ( https://www.nattrauma.org/research/research-policies-templates-guidelines/vte-conference/ ). Following this curriculum, the second part of the conference consisted of a series of small-group breakout sessions on topics potentially requiring future study. Through this process, research priorities were identified, and plans of action to develop and undertake future studies were defined.The 2022 Consensus Conference to Implement Optimal VTE Prophylaxis in Trauma answered the National Trauma Research Action Plan call to define a course for future research into preventing thromboembolism after trauma. A multidisciplinary group of clinical champions, physicians, scientists, and patients delineated clear objectives for future investigation to address important, persistent key knowledge gaps. The series of papers from the conference outlines the consensus based on the current literature and a roadmap for research to answer these unanswered questions.

Money well spent? A cost and utilization analysis of prophylactic inferior vena cava filter placement in high-risk trauma patients

BACKGROUND

Inferior vena cava filters (IVCF) for venous thromboembolic prophylaxis in high-risk trauma patients is a controversial practice. Utilization of IVCF prophylaxis was evaluated at a level 1 trauma center. Daily cost of IVCF prophylaxis, time to IVCF, duration between IVCF and chemoprophylaxis, and number of patients needed to treat (NNT) to prevent pulmonary embolism (PE) was calculated.

METHODS

A retrospective review of prophylactic IVCF over a 5-year period (2010-2014). Demographic, physiologic, injury, procedural, and outcome data were abstracted from the administrative trauma database. Medicare fees and days without chemoprophylaxis were used to determine daily IVCF cost. NNT was calculated using PE events in a cohort without IVCF.

RESULTS

Over the 5-year period, 146 patients with mean age 56.3 y (SD ± 24.2), 67.8% male, underwent prophylactic IVCF. Predominant mechanisms of injuries were falls (45.9%) and motor vehicle accidents (20.5%) with median Injury Severity Score of 25 (intraquartile range [IQR] 16-29) and head Abbreviated Injury Score of 3 (IQR 3-5). Most common operative interventions required in 24.7% were orthopedic (25.3%) and neurosurgical (21.9%). Median time to IVCF was 78 h (IQR 48-144). Most common IVCF indications were closed head injury (48.6%) and spinal injuries (30.8%). Median time to administration of chemoprophylaxis was 96 h after IVCF (IQR 24-192) in 57.5%. Median IVCF cost was $759/d (IQR $361-$1897) compared with $4.32 for chemoprophylaxis. PE occurred in 0.26% without IVCF. PE did not occur with prophylactic IVCF. Estimated NNT was 379 (95% CI 265, 661).

CONCLUSIONS

Prophylactic IVCF placement is a costly practice with relatively low benefit. Anticipated time without chemoprophylaxis and patient criteria should be considered before routine IVCF placement.