Updated guidelines to reduce venous thromboembolism in trauma patients: A Western Trauma Association critical decisions algorithm

Ley, Eric J.; Brown, Carlos V R; Moore, Ernest E.; Sava, Jack; Peck, Kimberly A.; Ciesla, David J.; Sperry, Jason L.; Rizzo, Anne G.; Rosen, Nelson G.; Brasel, Karen J.; Kozar, Rosemary A.; Inaba, Kenji; Martin, Matthew J.

doi:10.1097/ta.0000000000002830

Cited by 156 publications

(290 citation statements)

References 103 publications

(196 reference statements)

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“…It is appropriate to withhold chemical prophylaxis in patients with active bleeding or coagulopathy, or hemodynamic instability resulting from those conditions. 6 Delaying initiation of enoxaparin should be minimized to the shortest acceptable time period, since the early trauma-induced coagulopathy soon gives way to a hypercoagulable state. 25 86 In the setting of trauma coagulopathy, enoxaparin may be considered after completing the initial resuscitation, even though laboratory parameters of coagulation have not yet normalized.…”

Section: Other High-risk Scenarios and When To Hold Vte Prophylaxismentioning

confidence: 99%

“… 87 Intermittent pneumatic compression as a means of mechanical prophylaxis is an important adjunct in conditions that prohibit chemical prophylaxis, especially in patients with moderate-to-high VTE risk. 6 …”

Section: Other High-risk Scenarios and When To Hold Vte Prophylaxismentioning

confidence: 99%

“…[3][4][5] Increased and uninterrupted enoxaparin doses, guided by anti-Xa levels and/or weight, are considered safe and associated with lower VTE rates. [6][7][8][9][10] Individual patient variables dictate when, how or if VTE prophylaxis is provided across the spectrum of traumatic injuries. Overall, the quality of published research on this topic is mixed with many studies suffering from small numbers, heterogeneous populations, retrospective design, and potential bias.…”

Section: Introductionmentioning

confidence: 99%

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Venous thromboembolism prophylaxis in the trauma intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Rappold

Sheppard

Carmichael

et al. 2021

Trauma Surg Acute Care Open

104

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Venous thromboembolism (VTE) is a potential sequela of injury, surgery, and critical illness. Patients in the Trauma Intensive Care Unit are at risk for this condition, prompting daily discussions during patient care rounds and routine use of mechanical and/or pharmacologic prophylaxis measures. While VTE rightfully garners much attention in clinical patient care and in the medical literature, optimal strategies for VTE prevention are still evolving. Furthermore, trauma and surgical patients often have real or perceived contraindications to prophylaxis that affect the timing of preventive measures and the consistency with which they can be applied. In this Clinical Consensus Document, the American Association for the Surgery of Trauma Critical Care Committee addresses several practical clinical questions pertaining to specific or unique aspects of VTE prophylaxis in critically ill and injured patients.

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Section: Other High-risk Scenarios and When To Hold Vte Prophylaxismentioning

confidence: 99%

Section: Other High-risk Scenarios and When To Hold Vte Prophylaxismentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Venous thromboembolism prophylaxis in the trauma intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Rappold

Sheppard

Carmichael

et al. 2021

Trauma Surg Acute Care Open

104

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“…This was a multicenter, cross-sectional, descriptive, observational, survey-based study in which self-administered questionnaires were used to assess the practice variation amongst intensivists, trauma surgeons, general surgeons, spine orthopedic surgeons, and neurosurgeons practicing in Saudi Arabia regarding the PVTE-Px initiation time and dose in multiple trauma patients focusing on TBI, SCI, and NOR/ conservatively managed solid organ injuries. Some of the survey questions were obtained from previous studies with some modifications to include SCI, and conservatively managed solid organ injuries [14], [supplementary file 1] . Once Institutional review board (IRB) approval was obtained, the survey link was distributed through email by the perspective secretaries of each national society as described below in the inclusion criteria.…”

Section: Methodsmentioning

confidence: 99%

“…Despite the general coherency of this rationale, there is considerable uncertainty about the optimal timing of safe initiation of PVTE-Px. In addition, there is variation in clinical practice guideline recommendations regarding this topic and a review has been previously published [9,10,11,12,13,14],…”

Section: Introductionmentioning

confidence: 99%

Timing and Dose of Pharmacological Thromboprophylaxis in Adult Trauma Patients: Perceptions, Barriers, and Experience of Saudi Arabia Practicing Physicians

Amer

Bawazeer

Maghrabi

et al. 2021

Preprint

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BackgroundPharmacological venous thromboembolism prophylaxis (PVTE-Px) in trauma care is challenging and frequently delayed until post injury bleeding risk is perceived to be sufficiently low; yet data for optimal initiation time is lacking. This study assessed practice pattern of PVTE-Px initiation time and dose in traumatic brain injury (TBI), spinal cord injury (SCI), and non-operative (NOR) solid organ injuries.MethodsMulticenter, cross sectional, observational, survey-based study involving intensivists, trauma surgeons, general surgeons, spine orthopedics, and neurosurgeons practicing in trauma centers. The data of demographics, PVTE-Px timing and dose, and five clinical case scenarios were obtained. Analyses were stratified by early initiators vs. late initiators and logistic regression models were used to identify factors associated with early initiation of PVTE-Px.ResultsOf 102 physicians (29 % response rate), most respondents were intensivists (63.7%) and surgeons (who are general and trauma surgeons) (22.5%); majority were consultants (58%), practicing at level 1 trauma centers (40.6%) or academic teaching hospitals (45.1%). A third of respondents (34.2%) indicated that decision to initiate PVTE-Px in TBI and SCI was made by a consensus between surgical, critical care, and neurosurgical services. For patients with NOR solid organ injuries, 34.2% of respondents indicated trauma surgeons initiated the decision on PVTE-Px timing. About 53.7% of the respondents considered their PVTE-Px practice as appropriate, half used combined mechanical and PVTE-Px (57.1%), 52% preferred enoxaparin (40 mg once daily), and only 6.5% used anti-Xa level to guide enoxaparin prophylactic dose. Responses to clinical cases varied. For TBI and TBI with intracranial pressure monitor, 40.3% and 45.6% of the respondents were early initiators with stable repeated head computed tomography [CT], respectively. For SCI, most respondents were early initiators without repeated CT spine (36.8%). With regards to NOR solid organ injuries [gunshot wound to the liver and grade IV splenic injuries], 49.1% and 36.4% of respondents were early initiators without a repeat CT abdomen.ConclusionsVariations were observed in PVTE-Px initiation time influenced by trauma type. Our findings suggested enoxaparin is preferred in a standard prophylactic dose. More robust data from randomized trials are needed and the use of clinicians’ judgment is recommended.Key MessagesIdeal time to initiate therapy, agent selection, dosing, and monitoring of pharmacological venous thromboembolism prophylaxis (PVTE-Px) for trauma patients is challenging.Variations were observed in PVTE-Px initiation time influenced by trauma type.Our study results are relatively in line with the recent evidence-based clinical literatureOur findings suggested limited awareness of augmented renal clearance (ARC) and utilization of serum anti-factor-Xa (anti-Xa) level.

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Adverse Outcomes With Early Venous Thromboembolism Prophylaxis in Neurosurgical Trauma Patients—Are We Crossing the Blood-Brain Barrier?

2022

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The risk of worsening traumatic brain injury (TBI) by initiating venous thromboembolism (VTE) chemoprophylaxis creates a conundrum for medical practitioners involved in trauma and neurosurgery. A resurgence of evidence has reexamined the timing of VTE prophylaxis and has strongly advocated that early (24 to 72 hours postinjury) administration is safe and not associated with increased bleeding or mortality for those with radiologically proven stable intracranial injuries. 1,2 However, this research largely fails to adequately examine the subgroup of patients undergoing neurosurgical intervention and who are thus high risk by the Modified Berne-Norwood Criteria. 3 Logic serves that these patients may be categorically different in their response to VTE prophylaxis not only owing to the severity of their injury but risk of periprocedural hemorrhage. However, many current guidelines cite weak or inadequate data to make substantial recommendations regarding VTE prophylaxis, and none differentiate this population of patients from the larger group of those with TBI. [4][5][6] Here, Byrne and colleagues 7 present some of the first data examining the risks and benefits of VTE prophylaxis, specifically in patients with TBI undergoing neurosurgical interventions.The authors used the Trauma Quality Improvement Program database to examine early pharmacologic VTE prophylaxis in patients with TBI undergoing emergent neurosurgical intervention within the first 24 hours of presentation. Craniotomy/craniectomy, intracranial monitor/drain insertion, or both were considered as urgent neurosurgical interventions. As this was a retrospective database study, the authors used repeat neurosurgical intervention or in-hospital mortality as a surrogate marker for clinically significant worsening of intracranial hemorrhage. It is not surprising that early initiation of VTE prophylaxis led to decreased thromboembolic events. They demonstrated an 8% increase in odds of VTE with each additional day prophylaxis was delayed. What was surprising was that earlier ini-

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Updated guidelines to reduce venous thromboembolism in trauma patients: A Western Trauma Association critical decisions algorithm

Cited by 156 publications

References 103 publications

Venous thromboembolism prophylaxis in the trauma intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Venous thromboembolism prophylaxis in the trauma intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Timing and Dose of Pharmacological Thromboprophylaxis in Adult Trauma Patients: Perceptions, Barriers, and Experience of Saudi Arabia Practicing Physicians

Adverse Outcomes With Early Venous Thromboembolism Prophylaxis in Neurosurgical Trauma Patients—Are We Crossing the Blood-Brain Barrier?

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