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

Abstract

Optimizing prophylaxis against venous thromboembolic events (VTEs) is a critical issue in the care of injured patients. Although these patients are at significant risk of developing VTE, they also present competing concerns related to exacerbation of bleeding from existing injuries. Especially after high-risk trauma, including injuries to the abdominal solid organs, brain, and spine, trauma providers must delineate the time period in which VTE prophylaxis successfully reduces VTE rates without encouraging bleeding. Although existing data are primarily retrospective in nature and further study is required, literature supports early VTE chemoprophylaxis initiation even for severely injured patients. Early initiation is most frequently defined as <48 hours from admission but varies from <24 hours to 72 hours and occasionally refers to time from initial trauma. Prior to chemical VTE prophylaxis initiation in patients at risk for bleeding, an observation period is necessary during which injuries must show themselves to be hemostatic, either clinically or radiographically. In the future, prospective examination of optimal timing of VTE prophylaxis is necessary. Further study of specific subsets of trauma patients will allow for development of effective VTE mitigation strategies based upon collective risks of VTE and hemorrhage progression.

Saudi Critical Care Society clinical practice guidelines on the prevention of venous thromboembolism in adults with trauma: reviewed for evidence-based integrity and endorsed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

“…The WTA defined the timing of early prophylaxis as 12 to 24 h of admission, while the AAST used 48 h as the upper limit [ 4 , 5 ]. A retrospective study measured thrombo-elastography in 304 patients with blunt solid organ injury and found that 13.8% of patients converted to a hypercoagulable state within 48 h [ 20 ].…”

“…Furthermore, the definition of “early” or “late” VTE prophylaxis may vary depending on the injury type. In cases where there is an ongoing risk of hemorrhage or the injury occurs in a confined space, clinicians must consider the potential consequences of bleeding or hematoma expansion when determining the timing of early VTE prophylaxis [ 20 ]. While the existing literature supports early initiation of pharmacologic VTE prophylaxis for severely injured patients, further prospective studies are needed.…”

“…However, the existing data on TBIs and the optimal time for VTE prophylaxis initiation are relatively sparse, and clinical equipoise persists. In cases of TBI, a time cut-off of 72 h is most frequently used in literature [ 20 ]. Another limitation of our work is that our SRs were not registered a priori, as we adopted a rapid SR approach, commonly used in guidelines methodology [ 108 ].…”

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

“…Similarly, studies that support the safety of early initiation of prophylaxis in patients with solid organ or spinal cord injuries are mainly single center or retrospective. 26,57,58 Summarizing the evidence and discussion from the VTE Consensus Conference, Schellenberg et al 72 present their recommendations for future studies to clarify this knowledge gap.…”

Survey of venous thromboembolism prophylaxis in trauma patients: current prescribing practices and concordance with clinical practice guidelines

“…Venous thromboembolism (VTE) prophylaxis with either low-dose unfractionated heparin (UFH) or low molecular weight heparin (LMWH) is recommended for hospitalized trauma patients, with LMWH being preferred for most patients 1–5. Ongoing debate exists regarding the optimal dosing of LMWH, timing of initiation in patients at high risk of hemorrhage, and duration of VTE chemoprophylaxis after discharge 3–18…”