Timing of pharmacologic venous thromboembolism prophylaxis initiation for trauma patients with nonoperatively managed blunt abdominal solid organ injury: a systematic review and meta-analysis

Abstract

Background Blunt abdominal solid organ injury is common and is often managed nonoperatively. Clinicians must balance risk of both hemorrhage and thrombosis. The optimal timing of pharmacologic venous thromboembolism prophylaxis (VTEp) initiation in this population is unclear. The objective was to evaluate early (< 48 h) compared to late initiation of VTEp in adult trauma patients with blunt abdominal solid organ injury managed nonoperatively. Methods Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched from inception to March 2021. Studies comparing timeframes of VTEp initiation were considered. The primary outcome was failure of nonoperative management (NOM) after VTEp initiation. Secondary outcomes included risk of transfusion, other bleeding complications, risk of deep vein thrombosis (DVT) and pulmonary embolism, and mortality. Results Ten cohort studies met inclusion criteria, with a total of 4642 patients. Meta-analysis revealed a statistically significant increase in the risk of failure of NOM among patients receiving early VTEp (OR 1.76, 95% CI 1.01–3.05, p = 0.05). There was no significant difference in risk of transfusion. Odds of DVT were significantly lower in the early group (OR 0.36, 95% CI 0.22–0.59, p < 0.0001). There was no difference in mortality (OR 1.50, 95% CI 0.82–2.75, p = 0.19). All studies were at serious risk of bias due to confounding. Conclusions Initiation of VTEp earlier than 48 h following hospitalization is associated with an increased risk of failure of NOM but a decreased risk of DVT. Absolute failure rates of NOM are low. Initiation of VTEp at 48 h may balance the risks of bleeding and VTE.

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

“…Conversely, there were significantly lower odds of VTE when patients received early VTE prophylaxis (OR 0.51; 95% CI 0.33–0.81). In keeping with the results presented by Murphy et al, the most updated meta-analysis [ 40 ] found a non-statistically significant trend toward an increased risk of failure of NOM among patients receiving early VTE prophylaxis (OR 1.76, 95% CI 1.01–3.05), with no significant difference in risk of transfusion. Conversely, odds of DVT were significantly lower in the early group (OR 0.36, 95% CI 0.22–0.59) but without a difference in mortality (OR 1.50, 95% CI 0.82–2.75).…”

“…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.…”

“…39 Department of Surgery, Radboudumc, Nijmegen, The Netherlands. 40 Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy. 41 Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia.…”

Timing of venous thromboembolism prophylaxis initiation after injury: Findings from the consensus conference to implement optimal VTE prophylaxis in trauma

“…In addition to the published literature delineated above, this clinical and scientific question has triggered sufficient interest and study as to provoke several meta-analyses and systematic reviews 18,19 . The take-home messages of this body of literature are clear.…”

“…In addition to the published literature delineated above, this clinical and scientific question has triggered sufficient interest and study as to provoke several meta-analyses and systematic reviews. 18,19 The take-home messages of this body of literature are clear. Venous thromboembolic event chemoprophylaxis initiation <48 hours of emergency department arrival is associated with a reduction in VTE [8][9][10][11][12][13][14][15] without an increase in failure of nonoperative management [8][9][10][11][12][13][14][15][16][17]19 or need for blood transfusion.…”