Administering DVT Prophylaxis Sooner Than 48 Hours Does Not Increase Failure of Nonoperative Management of High-Grade (Grades III-V) Splenic Injuries

Abstract

Splenic injuries are mostly treated with nonoperative management (NOM) with observation to monitor for continued hemorrhage and holding early chemical DVT prophylaxis to reduce the risk of NOM failure. Eberle et al demonstrated chemoprophylaxis prior to 72 hours didn’t increase failure rate of NOM. We chose to extrapolate this finding and compare outcomes in high-grade splenic injuries (HGSI) with chemoprophylaxis before and after 48 hours. From January 2013 to December 2017, 104 patients with HGSI received chemoprophylaxis with unfractionated heparin (UH) or low molecular weight heparin (LMWH) within 72 hours of diagnosis. Of these, 8 patients received chemoprophylaxis within 24 hours, 46 between 24 and 48 hours, and 50 patients between 48 and 72 hours. This population consisted of 70 males and 34 females, with an average age of 40.1 years. The average ISS was 23 and the majority (77%) were grade 3 injuries. We observed 6 failures of NOM: 1 in the <24 hour group, 3 in the 24-48 hour group, and 2 in the 48-72 hour group. There was no statistically significant difference between the <24 hour and >24 groups or between the <48 hour and 48-72 hour groups. A linear regression analysis created a model describing the time to initiation of DVT prophylaxis using age, sex, splenic injury grade, and ISS; the failure rate decreased by 0.00002% for each hour prior to giving DVT prophylaxis, with a P value of .111. We conclude a noninferiority statement that DVT prophylaxis prior to 48 hours does not increase the risk of NOM failure.

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

“…There was also no difference in the volume of post-prophylaxis blood transfusion. Similarly, Griffard et al [ 38 ] demonstrated that administering DVT prophylaxis sooner than 48 h does not increase failure of NOM of AAST Grade III–V splenic injuries. In their prospective study, the authors included 104 high-grade (AAST III–V) splenic trauma patients who received prophylaxis with UH or LMWH within 72 h of diagnosis.…”

“…Studies demonstrating the need for timely DVT prophylaxis initiation showed that a delay in initiation > 4 days is associated with a threefold VTE risk increase [34]. Several prospective and retrospective studies have demonstrated that VTE prophylaxis administration 24-48 h after arrival to the hospital is associated with reduced rates of VTE without increased need for blood transfusion or failure of NOM [35][36][37][38][39]. The 2017 WSES guidelines stated that LMWH-based prophylactic anticoagulation should be started as soon as possible from splenic trauma, including patients treated with NOM [1].…”

“…The 2017 WSES guidelines stated that LMWH-based prophylactic anticoagulation should be started as soon as possible from splenic trauma, including patients treated with NOM [1]. Our systematic review of the literature regarding this topic retrieved 15 studies, of which two were systematic reviews and meta-analyses [40,41], two were prospective cohort studies [35,38], and 11 were retrospective cohort studies [27,28,36,37,[42][43][44][45][46][47][48]. To date, two systematic reviews and meta-analyses demonstrated that patients undergoing NOM for blunt solid organ injury could be safely and effectively prescribed early VTE prophylaxis.…”

“…37 Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy. 38 Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal. 39 Department of Surgery, Radboudumc, Nijmegen, The Netherlands.…”