A Systematic Review of the Risks and Benefits of Venous Thromboembolism Prophylaxis in Traumatic Brain Injury

Margolick, Joseph; Dandurand, Charlotte; Duncan, Katrina C.; Chen, Wenjia; Evans, David C.; Sekhon, Mypinder S.; Garraway, Naisan; Griesdale, Donald; Gooderham, Peter; Hameed, S. Morad

doi:10.1017/cjn.2017.275

Cited by 35 publications

(40 citation statements)

References 64 publications

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“…This supports that the initiation time in the early stages is not a significant factor in the development of VTEs in these trauma populations or our study was underpowered to detect the difference. On the other hand, in accordance with other recent studies [28,29], it appears safe to start chemical prophylaxis even at this early stage, even in patients with TBI [30,31]. Furthermore, the timing of the initiation in the patients with VTE was significantly longer at UMCU.…”

Section: Discussionsupporting

confidence: 86%

Venous thromboembolism (VTE) prophylaxis in severely injured patients: an international comparative assessment

Gunning

Maier

Rooij

et al. 2019

Eur J Trauma Emerg Surg

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Purpose Venous thromboembolisms (VTE) are a major concern after acute survival from trauma. Variations in treatment protocols for trauma patients exist worldwide. This study analyzes the differences in the number of VTE events and the associated complications of thromboprophylaxis between two level I trauma populations utilizing varying treatment protocols. Methods International multicenter trauma registry-based study was performed at the University Medical Center Utrecht (UMCU) in The Netherlands (early commencement chemical prophylaxis), and Harborview Medical Center (HMC) in the United States (restrictive early chemical prophylaxis). All severely injured patients (ISS ≥ 16), aged ≥ 18 years, and admitted in 2013 were included. Primary outcomes were VTE [deep venous thrombosis (DVT) (no screening), pulmonary embolism (PE)], and hemorrhagic complications. Results In UMCU, 279 patients were included and in HMC, 974 patients. Overall, 75% of the admitted trauma patients in UMCU and 81% in HMC (p < 0.001) received thromboprophylaxis, of which 100% in and 75% at, respectively, UMCU and HMC consisted of chemical prophylaxis. From these patients, 72% at UMCU and 47% at HMC (p < 0.001) were treated within 48 h after arrival. At UMCU, 4 patients (1.4%) (PE = 3, DVT = 1) and HMC 37 patients (3.8%) (PE = 22, DVT = 16; p = 0.06) developed a VTE. At UMCU, a greater percent of patients with VTE had traumatic brain injuries (TBI). Most VTE occurred despite adequate prophylaxis being given (75% UMCU and 81% HMC). Hemorrhagic complications occurred in, respectively, 4 (1.4%) and 10 (1%) patients in UMCU and HMC (p = 0.570). After adjustment for age, ISS, HLOS, and injury type, no significant difference was demonstrated in UMCU compared to HMC for the development of VTE, OR 2.397, p = 0.102 and hemorrhagic complications, OR 0. 586, p = 0.383. Conclusions A more early commencement protocol resulted in almost twice as much chemical prophylaxis being started within the first 48 h in comparison with a more delayed initiation of treatment. Interestingly, most episodes of VTE developed while receiving recommended prophylaxis. Early chemical thromboprophylaxis did not significantly increase the bleeding complications and it appears to be safe to start early.

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Section: Discussionsupporting

confidence: 86%

Venous thromboembolism (VTE) prophylaxis in severely injured patients: an international comparative assessment

Gunning

Maier

Rooij

et al. 2019

Eur J Trauma Emerg Surg

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“…In a recent large retrospective cohort of TBI patients, rates of VTE were around 4% 111 with ranges reported elsewhere in the literature from 3 to 60%. [111][112][113][114] VTE, especially with progression to pulmonary embolism (PE), can be a devastating complication in these patients. However, the risk of VTE must be balanced with the risks of VTE prophylaxis using anticoagulation and the concern for worsening existing intracranial hemorrhage.…”

Section: Risk Of Venous Thromboembolism In Tbimentioning

confidence: 99%

“…Several recent studies have investigated the impact of earlier (<24 hours from admission) initiation of chemical VTE prophylaxis without demonstration of a significant increase in intracranial hemorrhage progression. 114 However, many of these large systematic reviews and meta-analyses are based on nonrandomized and often retrospective evidence, and there is a need for high-quality randomized evidence to address this common clinical question. Overall, the rates of intracranial hemorrhage progression after initiation of chemoprophylaxis for VTE remain low and are consistently around 3 to 4% across several retrospective studies and systematic reviews, [116][117][118][119] with some as high as 12 to 15%.…”

Section: Timing Of Pharmacologic Prophylaxis Initiation and Risk Of Pmentioning

confidence: 99%

Management and Challenges of Severe Traumatic Brain Injury

Rakhit

Nordness

Lombardo

et al. 2020

Semin Respir Crit Care Med

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Traumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro–Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.

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“…24 A recent meta-analysis of clinical trials and observational trials recommended that use of pharmacological prophylaxis was safe when initiated within 24 to 48 hours of TBI with periodic intracranial imaging to rule out hemorrhage. 25 As per BTF guidelines, use of pharmacological prophylaxis with low molecular weight heparin or low-dose unfractionated heparin in combination with mechanical prophylaxis is to be considered when the benefit is found to outweigh the risk of cerebral bleed. 9 Periodic ultrasonographic examination to rule out DVT is recommended in high-risk patients.…”

Section: Deep Vein Thrombosis Prophylaxis: Risk Of Thrombo-mentioning

confidence: 99%

“…Damage control strategy: Damage control tactics may improve early mortality (control hemorrhage) and delayed mortality (minimize systemic inflammation and organ failure). 25 Damage control refers to an operative strategy predicated on immediately treating only life-threatening injuries and purposefully delaying definitive operative repair of injuries until the patient's physiology has returned to normal. The timing of definitive repair of injuries temporized during damage control surgery is determined by the patient's physiologic status but typically starts 24 to 48 hours after the initial injury.…”

Section: A Definition Of Polytraumamentioning

confidence: 99%

Critical Care Management of Traumatic Brain Injury

Bharadwaj

Naik

2019

Journal of Neuroanaesthesiology and Critical Care

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Traumatic brain injury (TBI) is a significant public health problem. It is the leading cause of death and disability despite advancements in its prevention and treatment. Treatment of a patient with head injury begins on the site of trauma and continues even during her/his transportation to the trauma care center. Knowledge of secondary brain injuries and timely management of those in the prehospital period can significantly improve the outcome and decrease mortality after TBI. Intensive care management of TBI is guided by Brain Trauma Foundation guidelines (4th edition). Seventy percent of blunt trauma patients will also suffer from some degree of head injury. The management of these extracranial injuries may influence the neurological outcomes. Damage control tactics may improve early mortality (control hemorrhage) and delayed mortality (minimize systemic inflammation and organ failure). Neuromonitoring plays an important role in the management of TBI because it is able to assess multiple aspects of cerebral physiology and guide therapeutic interventions intended to prevent or minimize secondary injury. Bedsides, multimodality monitoring predominantly comprises monitoring modalities for cerebral blood flow, cerebral oxygenation, and cerebral electrical activity. Establishing a reliable prognosis early after injury is notoriously difficult. However, TBI is a much more manageable injury today than it has been in the past, but it remains a major health problem.

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A Systematic Review of the Risks and Benefits of Venous Thromboembolism Prophylaxis in Traumatic Brain Injury

Abstract: Literature suggests that administering VTEp 24 to 48 hours postinjury may be safe for patients with low-hemorrhagic-risk TBIs and stable injury on repeat imaging.

Cited by 35 publications

References 64 publications

Venous thromboembolism (VTE) prophylaxis in severely injured patients: an international comparative assessment

Venous thromboembolism (VTE) prophylaxis in severely injured patients: an international comparative assessment

Management and Challenges of Severe Traumatic Brain Injury

Critical Care Management of Traumatic Brain Injury

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