Association of timing of initiation of pharmacologic venous thromboembolism prophylaxis with outcomes in trauma patients

Abstract

BACKGROUND Patients are at a high risk for developing venous thromboembolism (VTE) following traumatic injury. We examined the relationship between timing of initiation of pharmacologic prophylaxis with VTE complications. METHODS Trauma quality collaborative data from 34 American College of Surgeons Committee on Trauma–verified levels I and II trauma centers were analyzed. Patients were excluded if they were on anticoagulant therapy at the time of injury, had hospitalization <48 hours, or received no or nonstandard pharmacologic VTE prophylaxis (heparin drip). Patient comparison groups were based on timing of initiation of VTE prophylaxis relative to hospital presentation (0 to <24 hours, 24 to <48 hours, ≥48 hours). Risk-adjusted rates of VTE events were calculated accounting for patient factors including type of pharmacologic agent in addition to standard trauma patient confounders. A sensitivity analysis was performed excluding patients who received blood in the first 4 hours and/or patients with a significant traumatic brain injury. RESULTS Within the 79,386 patients analyzed, there were 1,495 (1.9%) who experienced a VTE complication and 1,437 (1.8%) who died. After adjusting for type of prophylaxis and patient factors, the risk of a VTE event was significantly increased in the 24- to <48-hour (odds ratio, 1.26; 95% confidence interval, 1.09–1.47; p = 0.002) and ≥48-hour (odds ratio, 2.35; 95% confidence interval, 2.04–2.70; p < 0.001) cohorts relative to patients initiated at 0 to <24 hours. These VTE event findings remained significant after exclusion of perceived higher-risk patients in a sensitivity analysis. CONCLUSION Early initiation of pharmacologic VTE prophylaxis in stable trauma patients is associated with lower rates of VTE. LEVEL OF EVIDENCE Diagnostic, level III.

Trauma-induced coagulopathy

“…Low molecular weight heparin (LMWH) has been shown to be superior to unfractionated heparin (UFH) in this cohort, with improved survival and fewer thromboembolic complications 286 . Owing to patient immobility and the hypercoagulable state, thromboprophylaxis is administered as soon as possible after the bleeding risk has subsided, and individual patient factors must guide the choice of UFH or LMWH 287,288 .…”

Timing of venous thromboembolic pharmacological prophylaxis in traumatic combined subdural and subarachnoid hemorrhage

“…It is important to note that there is evidence that an even earlier VTEp (<24 h) may be safe and more effective. [25][26][27] In the present study, 626 patients (8.5%) received VTEp before 24 h. This small proportion precludes any meaningful further analysis. Future studies should investigate if an even earlier VTEp may be safe and more effective, especially in patients with TBI.…”

Efficacy and Safety of Low Molecular Weight Heparin Versus Unfractionated Heparin for Prevention of Venous Thromboembolism in Trauma Patients

“…In particular, the risk and benefit determination of pharmacologic thromboprophylaxis is dependent predominantly on definitions of VTE events and bleeding outcomes (Supplement, http://links.lww.com/SLA/D373). However, we demonstrate in this review that the definitions for these outcomes are frequently either not reported due to limitations of large administrative datasets, [28][29][30][31][32][33][34] subjectively determined without a reported clinical rationale 15,16,27 or inconsistent across studies. 15,16,26,27,33 For example, the use of screening ultrasounds will increase the DVT detection rate and often identify distal DVTs that are prognostically less significant than proximal DVTs.…”