Venous thromboembolism in patients with major trauma

doi:10.1016/S0002-9610(05)81272-3

The American Journal of Surgery

Volume 159, Issue 4, April 1990, Pages 365-369

https://doi.org/10.1016/S0002-9610(05)81272-3 Get rights and content

The risk of venous thromboembolism after trauma is thought to be high, but the specific risk factors and the incidence of venous thromboembolism in the trauma population are poorly defined. Between October 1, 1987, and March 1, 1988, 719 patients were evaluated; 542 had no risk factors and 177 had at least 1 risk factor. No venous thromboembolism occurred in any of the 542 patients without a risk factor, whereas 12 of 177 patients (7%) with at least 1 risk factor had a venous thromboembolism. Pneumatic compression hose was the most common form of prophylaxis used, but it could not be applied to 35% of limbs because of plaster immobilizers, external fixators, complex wounds, or traction. In the high-risk group, 25 patients (14%) received no prophylaxis because of a physical impediment to application of these hose and a contraindication to anticoagulation. Age greater than 45 years was the only risk factor predictive of venous thromboembolism by logistic regression analysis. Patients with more than one risk factor had a significantly higher incidence of venous thromboembolism than those with only one risk factor. We conclude that a selected subgroup of trauma patients appears to be at risk of venous thromboembolism and should receive prophylaxis. Approximately one in seven, high-risk patients cannot receive anticoagulant or mechanical prophylaxis because of their injuries.

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Cited by (221)

Chemoprophylactic Anticoagulation 72 Hours After Spinal Fracture Surgical Treatment Decreases Venous Thromboembolic Events Without Increasing Surgical Complications
2022, North American Spine Society Journal
Prophylactic anticoagulation is commonly used following operative treatment of spinal fractures to prevent Venous Thromboembolism (VTE) but carries a risk of bleeding complications. The purpose of the study was to compare VTE and bleeding complications for MID (≤72h) versus LATE (>72h) chemoprophylaxis timing after spinal fracture operative intervention.
This is a retrospective review of patients treated for spinal fractures that received anticoagulation chemoprophylaxis between May 2015 and June 2019. Chemoprophylaxis initiation timing (MID vs. LATE) was the primary grouping variable. Patients with traumatic brain injury or evidence of intracranial or intraspinal bleed were excluded. Demographics, injury mechanisms, operative procedures, timing of administration of VTE prophylaxis, Injury Severity Score (ISS) and Spine Abbreviated Injury Scale (AIS), and complications including VTE and bleeding complications were collected. Predictors of VTE were identified using a binary logistic regression.
Eighty-eight patients (65M, 23F) met inclusion criteria. The median age was 55 years, and median Injury Severity Score (ISS) was 14. MID had 68 patients and LATE had 20. Nine patients developed VTE (6 LATE, 3 MID, p<0.01). Three patients developed bleeding complications, and all occurred in the LATE group (p=0.01). ISS (p<0.01) and GCS (p<0.01) also correlated with an increased VTE rate.
Chemoprophylactic anticoagulation at 72 hours in surgically treated spinal fracture patients demonstrates a lower VTE rate without increasing complications. VTE prophylaxis can be initiated at 72 hours following spine fixation to decrease postinjury morbidity and mortality in this high-risk patient population.
Early Thromboprophylaxis in Operative Spinal Trauma Does Not Increase Risk of Bleeding Complications
2021, Journal of Surgical Research
Thromboprophylaxis in patients with spinal trauma is often delayed due to the risk of bleeding and expansion of the intraspinal hematoma (ISH). Our study aimed to assess the safety of early initiation of thromboprophylaxis in patients with operative spinal trauma (OST).
We performed a 2014-2017 retrospective analysis of our level I trauma registry and included all adult patients with isolated OST who received low-molecular-weight heparin (LMWH). Patients were stratified into early (≤48 h) and late (>48 h) initiation of LMWH groups. Outcomes were a decline in hemoglobin level, packed red blood cell transfusion, and progression of ISH. We performed multivariable logistic regression.
We identified a total of 526 patients (early: 332, late: 194). Mean age was 46 ± 22y, and the median spine abbreviated injury scale was 3 [2-4]. After thromboprophylaxis, 1.5% (8) of the patients had progression of ISH and 1% (5) underwent surgical decompression of the spinal canal. There was no difference between the two groups regarding the rate of postprophylaxis ISH progression (1.5% versus 1.6%, P = 0.11) or surgical decompression (0.9% versus 1.1%, P = 0.19). Patients who received LMWH within 48 hrs had a lower incidence of clinically significant deep vein thrombosis (2.4% versus 6.8%, P = 0.02), but no difference in pulmonary embolism (0.6% versus 1.6%, P = 0.33) or mortality (1.2% versus 1.5%, P = 0.41). On regression analysis, there was no difference regarding decline in hemoglobin levels (β = 0.079, [−0.253 to 1.025]; P = 0.23) or number of packed red blood cell units transfused (β = −0.011, [−0.298 to 0.471]; P = 0.35).
Thromboprophylaxis with LMWH within the first 48 h in patients with OST is safe and efficacious. Prospective studies are needed to further validate their risk-benefit ratio.
Level III therapeutic.
“The Utility of Rivaroxaban as Primary Venous Thromboprophylaxis in an Adult Trauma Population”
2019, Journal of Surgical Research
Venous thromboembolism (VTE) is a frequent and morbid complication after injury. Despite utilization of twice-daily enoxaparin, a significant proportion of patients still develop VTE. The purpose of this study was to compare the safety and efficacy of rivaroxaban to enoxaparin for the prevention of VTE in patients with multisystem injuries.
This retrospective cohort analysis evaluated VTE rate in multiply injured patients at a level I trauma Center. Propensity matching was used to compare patients receiving rivaroxaban or enoxaparin. The primary outcome was incidence of VTE during or up to 6 mo after admission. Secondary outcomes included major and minor bleeding, hospital mortality, and hospital length of stay.
A total of 2106 patients were randomly selected from the entire cohort for inclusion. Patients who developed a VTE with no significant difference between groups (14 [1.3%] in the rivaroxaban group and 14 [1.3%] in the enoxaparin group, P = 1) was 1.3%. In addition, there was no difference in deep venous thrombosis (10 [0.9%] in the rivaroxaban group and 12 [1.1%] in the enoxaparin group) or pulmonary embolism (6 [0.6%] in the rivaroxaban group and 2 [0.2%] in the enoxaparin group). Incidence of bleeding, minor or major, was equivalent between groups (P > 0.05). Hospital length of stay and mortality were significantly higher in the enoxaparin group compared with rivaroxaban (11 [1.0%] versus 0 [0%] respectively, P < 0.001).
Rivaroxaban demonstrated a similar incidence of VTE and bleeding complications as enoxaparin. Rivaroxaban may be a safe and effective alternative for VTE prophylaxis in this high-risk population.
Timing and Risk Factors for Venous Thromboembolism After Rotator Cuff Repair in the 30-Day Perioperative Period
2019, Arthroscopy - Journal of Arthroscopic and Related Surgery
To analyze the American College of Surgeons National Surgical Quality Improvement Program database to evaluate the incidence of deep venous thrombosis and pulmonary embolism in patients undergoing rotator cuff repair surgery. In addition, we aim to identify risk factors associated with the development of thromboembolic events following rotator cuff repair.
A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database was performed. Current Procedural Terminology codes were used to identify patients who underwent rotator cuff repair between 2005 and 2017. The presence of deep venous thrombosis or pulmonary embolism during the 30-day perioperative period were the primary outcomes assessed. Logistic regression analysis was performed to identify risk factors for postoperative venous thromboembolic events (VTEs).
In total, 39,825 rotator cuff repairs (RCRs) were performed and 117 (0.3%) VTE events occurred. VTE was identified at a mean of 11.5 ± 7.4 days. A total of 31,615 RCRs were performed arthroscopically. There was no significant difference of VTE between groups comparing arthroscopic RCR VTE 0.3% (94) with open RCR 0.3% (23) (P = .81). RCR in patients with an American Society of Anesthesiologists classification of III or IV was associated with >1.5-fold increase risk of VTE (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.14-2.45). Increased risks of VTE included surgery >80 minutes (OR 2.10, 95% CI 1.42-3.15), performed under general anesthesia (OR 4.38, 95% CI 1.18-36.6), and in the outpatient setting (OR 6.09, 95% CI 1.06-243.7), male sex (OR 1.53, 95% CI 1.01-2.33), bleeding disorders (OR 2.87, 95% CI 1.17-7.05), or dyspnea (OR 1.51, 95% CI 1.02-2.23). The biggest risk for VTE was unplanned reoperation OR 16.6 (95% CI 5.13-53.5).
Venous thromboembolism is a rare complication following rotator cuff repair 0.3%. Understanding the risk factors: duration of surgery >80 minutes, male sex, body mass index >30 kg/m², ASA III or IV, RCR as an inpatient under general anesthesia, bleeding disorder, or dyspnea may be useful in guiding treatment to prevent VTE. The largest risk for VTE is a patient with unplanned reoperation. RCR surgery performed in an outpatient setting resulted in a significantly lower incidence of VTE.
III Retrospective Comparative Study.
A simplified stratification system for venous thromboembolism risk in severely injured trauma patients
2017, Journal of Surgical Research
The objective of this study was to re-evaluate and simplify the Greenfield risk assessment profile (RAP) for venous thromboembolism (VTE) in trauma using information readily available at the bedside.
Retrospective review of 1233 consecutive admissions to the trauma intensive care unit from August 2011-January 2015. Univariate analyses were performed to determine which RAP risk factors were significant contributors to VTE. Multivariable logistic regression was used to develop models for risk stratification. All results were considered statistically significant at P ≤ 0.05.
The study population was as follows: age 44 ± 19, 75% male, 72% blunt, injury severity score 21 ± 13, RAP score 9 ± 5, and 8% mortality. Groups were separated into +VTE (n = 104) and −VTE (n = 1129). They were similar in age, gender, mechanism, and mortality, but injury severity and RAP scores were higher in the +VTE group (all P < 0.0001). The +VTE group had more transfusions and longer time to prophylaxis (all P < 0.05). Receiving four or more transfusions in the first 24 h (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.64-4.13), Glasgow coma score <8 for >4 h (OR, 2.13; 95% CI, 1.28-3.54), pelvic fracture (OR, 2.26; 95% CI, 1.44-3.57), age 40-59 y (OR, 1.70; 95% CI, 1.10-2.63), and >2-h operation (OR, 1.80; 95% CI, 1.14-2.85) predicted VTE with an area under the receiver operator curve of 0.729, which was comparable with 0.740 for the RAP score alone.
VTE risk in trauma can be easily assessed using only five risk factors, which are all readily available at the bedside (transfusion, Glasgow coma scale, pelvic fracture, prolonged operation, and age). This simplified model provides similar predictive ability to the more complicated RAP score. Prospective validation of a simplified risk assessment score is warranted.
Validation of the Caprini risk assessment model for venous thromboembolism in high-risk surgical patients in the background of standard prophylaxis Presented at the Twenty-seventh Annual Meeting of the American Venous Forum, Palm Springs, Calif, February 25-27, 2015.
2016, Journal of Vascular Surgery: Venous and Lymphatic Disorders
We used the Caprini venous thromboembolism risk assessment score to prospectively evaluate if there was a correlation between the Caprini scores and the incidence of postoperative deep vein thrombosis (DVT) in high-risk surgical patients. A second objective was to determine whether patients at extremely high risk need a more effective prophylactic regimen.
This prospective multicenter observational study involved 140 high-risk patients who underwent abdominal (48%) or cranial and/or spinal (52%) surgery. All patients were assessed using the Caprini model and had a mean score of 9.5 ± 2.7 (range, 5-15). Our standard prophylaxis for venous thromboembolism consisted of above-knee graduated compression stockings with 18 to 21 mm Hg pressure and subcutaneous low-dose unfractionated heparin three times per day, starting on the first or second through the fifth postoperative day depending on the risk of bleeding. We performed a duplex ultrasound examination at baseline during the first 12 to 24 hours after surgery and then every 3 to 5 days until discharge to assess the lower limb venous system up to the inferior vena cava. The end point of the study was ultrasound verification of fresh DVT or pulmonary embolism (PE). Verification of PE was made in all cases of DVT using echocardiography, lung scintigraphy, combined single-photon emission computed tomography and X-ray computed tomography, or autopsy.
Fresh postoperative DVT was found in 39 patients (28%). The incidence of DVT was 2% in patients with a Caprini score of 5 to 8, 26% in patients with scores of 9 to 11, and 65% in patients with scores of 12 to 15 (P for trend < .01). The risk for DVT was increased 18.7-fold for patients with scores of 9 to 11 and 98.4-fold for scores of 12 to 15 compared with patients with scores of 5 to 8. The area under the receiver operating characteristic curve was 0.87 (95% confidence interval, 0.81-0.94) and a Caprini score of 11 was the cutoff point that provided the highest sensitivity combined with highest specificity. In the 77 patients with a score of <11, DVT occurred in 2 patients (3%). In contrast, in the 63 patients with a score of ≥11, DVT occurred in 37 patients (59%; P < .01). PE was found in 13 patients (9%) and confirmed with autopsy. In all cases, verified fresh DVT was the source of embolism.
There was a significant correlation between Caprini scores and the incidence of postoperative DVT in high-risk surgical patients. A Caprini score of ≥11 can identify a subgroup of patients at extremely high risk. These patients need a more effective prophylactic regimen.

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^*: From the Division of Trauma, Department of Surgery, University of California, San Diego Medical Center, San Diego, California.

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Venous thromboembolism in patients with major trauma

Injury

Venous thrombosis and pulmonary embolism: a clinico-pathological study in injured and burned patients

Br J Surg

Deep venous thrombosis and pulmonary embolism in trauma patients

J Intensive Care Med

Venous thromboembolism following trauma

J Intensive Care Med

NIH Consensus Development Conference: Prevention of venous thrombosis and pulmonary embolism

JAMA

The effect of regionalization upon the quality of trauma care as assessed by concurrent audit prior to and after institution of a trauma system: a preliminary report

J Trauma

Assessment of coma and impaired consciousness: a practical scale

Lancet

Pulmonary angiography, ventilation lung scanning and venography for clinically-suspected pulmonary embolism in the abnormal perfusion scan

Ann Intern Med