When Is It Safe to Start VTE Prophylaxis after Blunt Solid Organ Injury? A Prospective AAST Multi-Institutional Trial

Abstract

Background The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests VTEp ≤48 h is safe and effective. This study was undertaken to validate this clinical practice. Methods Blunt trauma patients presenting to 19 participating trauma centers in North America were screened over a one-year study period beginning between August 1 and October 1, 2021. Inclusions were age > 15 years; ≥1 liver, spleen, or kidney injury; and initial nonoperative management (NOM). Exclusions were transfers, ED death, pregnancy, and concomitant bleeding disorder/anticoagulation/antiplatelet medication. A priori power calculation stipulated the need for 1,158 patients. Time of VTEp initiation defined study groups: Early (≤48 h of admission) vs. Late (>48 h). Bivariate and multivariable analyses compared outcomes. Results In total, 1,173 patients satisfied study criteria with 571 (49%) liver, 557 (47%) spleen, and 277 (24%) kidney injuries. Median patient age was 34 [25-49] years and 67% (n = 780) were male. Median ISS was 22 [14-29] with AIS Abdomen 3 [2-3] and median AAST grade of solid organ injury 2 [2-3]. Early VTEp patients (n = 838, 74%) had significantly lower rates of VTE (n = 28, 3% vs. n = 21, 7%, p = 0.008); comparable rates of NOM failure (n = 21, 3% vs. n = 12, 4%, p = 0.228); and lower rates of post-VTEp blood transfusion (n = 145, 17% vs. n = 71, 23%, p = 0.024) when compared to Late VTEp patients (n = 301, 26%). Late VTEp was independently associated with VTE (OR 2.251, p = 0.046). Conclusion Early initiation of VTE chemoprophylaxis was associated with significantly reduced rates of VTE with no increase in bleeding complications. VTEp initiation ≤48 hours is therefore safe and effective and should be the standard of care for patients with blunt solid organ injury. Level of Evidence II, Therapeutic and Care Management

Venous Thromboembolism Prophylaxis in High-Risk Pediatric Trauma Patients

“…Adult trauma literature has shown that early initiation of cVTE after trauma reduces the incidence of VTE, even in the presence of solid organ injuries and traumatic brain injury . This study also suggests that the greatest reduction in VTE risk may be seen when cVTE is used early following traumatic injury.…”

“…Adult trauma literature has shown that early initiation of cVTE after trauma reduces the incidence of VTE, even in the presence of solid organ injuries and traumatic brain injury. [31][32][33][34] This study also suggests that the greatest reduction in VTE risk may be seen when cVTE is used early following traumatic injury. We found that median (IQR) time from admission to initiation of cVTE was significantly different between patients who developed VTE (4.2 days [2.5-7.5 days]) and those without VTE (2.5 days [1.0-4.0 days]; P = .008).…”

The need for speed: time to first venous thromboembolism prophylaxis in trauma patients matters

“…Despite increasingly detailed efforts to optimize prophylaxis, venous thromboembolism (VTE) remains a leading cause of morbidity and mortality after traumatic injury. Over the last two decades, landmark studies have improved the efficacy of prophylaxis by identifying the utility of anti-Xa guidance for enoxaparin dose adjustment 1 and individualized enoxaparin dosing 2 ; sped the initiation of safe prophylaxis in patients with traumatic brain injury 3 or blunt solid organ injury 4 ; demonstrated the increased VTE risk that occurs when medication doses are missed 5 ; and enlisted patients and nurses in multidisciplinary educational efforts to improve medication adherence. 6 Despite these efforts, morbidity and mortality from VTE remain unacceptably high, and additional improvements are needed.…”