The incidence of thromboembolism in the surgical intensive care unit

The clinical diagnosis of deep venous thrombosis (DVT) is unreliable. Studies have been performed examining the utility of frequent duplex scans. However, these studies included patients outside of the intensive care unit. The incidence of venous thromboembolism and the effect of a less intense surveillance protocol was prospectively examined at a level-1 urban trauma center for a 6 month period. During the study period there were 726 admission to the surgical intensive care unit. Sequential compression devices (SCDs) were used for DVT prophylaxis in 93 per cent of the admissions. A total of 114 duplex scans were ordered: 42 per cent for surveillance and the rest for evaluation of a clinical indication. Twelve DVTs were discovered (11% overall DVT rate). No patient on subcutaneous heparin or low-molecular-weight heparin developed a DVT or pulmonary embolism (PE). Four patients suffered a PE; however, none were found to have a lower extremity DVT on duplex ultrasound and all received SCD prophylaxis. Overall, proper use of DVT prophylaxis for intensive care unit days 1-14 was 77 per cent. The incidence of venous thromboembolism in a group of patients at overall high risk was low. A program of DVT surveillance with duplex ultrasound was not cost-effective.     

A potentially expanded role for enoxaparin in preventing venous thromboembolism in high risk blunt trauma patients

BACKGROUND: Venous thromboembolism (VTE) is a frequent and potentially life-threatening complication after trauma. The purpose of this study is to investigate the effectiveness of enoxaparin in preventing deep venous thrombosis (DVT) and pulmonary embolism (PE) after injury in patients who are at high risk for developing VTE. STUDY DESIGN: A prospective single-cohort observational study was initiated for seriously injured blunt trauma patients admitted to a Level I trauma center during a 7-month period. Patients were eligible for the study if time hospitalized was > or = 72 hours, Injury Severity Score (ISS) was > or = 9, enoxaparin was started within 24 hours after admission, and one or more of the following high risk criteria were met: age > 50 years, ISS > or = 16, presence of a femoral vein catheter, Abbreviated Injury Score (AIS) > or = 3 for any body region, Glasgow Coma Scale (GCS) Score < or = 8, presence of major pelvic, femur, or tibia fracture, and presence of direct blunt mechanism venous injury. Patients with closed head injuries and nonoperatively treated solid abdominal organ injuries were also potential participants. The primary outcomes measured were thromboembolic events--either a documented lower extremity DVT by duplex color-flow doppler ultrasonography or a PE documented by rapid infusion CT pulmonary angiography or conventional pulmonary angiography. RESULTS: There were 118 patients enrolled in the study. Two patients (2%) developed DVT, one of which was proximal to the calf (95% confidence interval, 0% to 6%). Two of 12 patients (17%) with splenic injuries who received enoxaparin failed initial nonoperative management. There were no other bleeding complications, and no clinical evidence or documented episodes of PE. One patient died from multiple system organ failure. CONCLUSIONS: Enoxaparin is a practical and effective method for reducing the incidence of VTE in high risk, seriously injured patients. This study supports further investigation into the safety of enoxaparin prophylaxis in patients with closed head injuries and nonoperatively treated solid abdominal organ injuries.     

Surveillance venous scans for deep venous thrombosis in multiple trauma patients

The high reported incidence of deep venous thrombosis (DVT) in trauma patients has prompted surveillance venous duplex scanning of the lower extremities. We report our retrospective experience with 183 multiple trauma patients who were admitted to the surgical intensive care unit and underwent 261 surveillance venous scans. There were 122 men and 61 women whose average age was 38 years. All patients were treated prophylactically with either extremity pneumatic compression or subcutaneous heparin to prevent DVT. Most (87%) patients suffered blunt trauma and had either head (3%), spinal (3%), intra-abdominal (9%), or lower extremity (17%) injuries or a combination of injuries (68%). Almost two thirds of the patients had no symptoms suggestive of possible DVT. Of the 261 venous scans performed, 239 (92%) were normal, 16 (6%) were positive for proximal lower extremity DVT, and six (2%) showed thrombus limited to the calf veins. Patients with symptoms of lower extremity DVT were significantly more likely to have proximal DVT compared to those without symptoms (15% vs. 5%,p <0.05).Patients with spinal injuries also had a higher incidence of proximal DVT (18% vs. 6%,p <0.05).At current hospital charges, the cost to identify each proximal DVT was $6688. If surveillance duplex scans were performed on all trauma patients in the surgical intensive care unit, the national annual expense would be $300,000,000. Routine DVT surveillance is expensive and should be reserved for symptomatic patients or those with spinal injuries.Presented at the Nineteenth Annual Meeting of the Peripheral Vascular Surgery Society, Seattle, Wash., June 5, 1994.     

Venous thromboembolism in trauma patients

Serial venous duplex scans (VDS) were done in 507 trauma patients with at least one risk factor (RF) for venous thromboembolism (VTE) during a 2-year study period. Deep vein thrombosis (DVT) was detected in 31 (6.1%) patients. This incidence was 3.1 per cent in low (1-2 RFs), 3.4 per cent in moderate (3-5 RFs), and 7.7 per cent in high (> or =6 RFs) VTE scores (P = 0.172). Incidence was statistically different (3% vs. 7.2%, P = 0.048) on reanalyzing patients in two risk categories, low-risk (1-4 RFs) and high-risk (> or =5 RFs). Only 4 of 16 RFs had statistically higher incidence of DVT in patients with or without RFs: previous VTE (27.3% vs. 5.6%, odds ratio (OR) 6.628, P = 0.024), spinal cord injury (22.6% vs. 5%, OR 5.493, P = 0.001), pelvic fractures (11.4% vs. 5.1%, OR 2.373, P = 0.042), and head injury with a greater than two Abbreviated Injury Score (10.5% vs. 4.2%, OR 2.639, P = 0.014). On reanalyzing patients with > or =5 RFs vs. <5RFs, obesity (14.3 vs. 6.1%, P = 0.007), malignancy (5.6% vs. 0.6%, P = 0.006), coagulopathy (10.8% vs. 1.8%, P = 0.000), and previous VTE (3.2% vs. 0%, P = 0.019) were significant on univariate analysis. Patients with DVT had 3.70 +/- 1.75 RFs and a 9.61 +/- 4.93 VTE score, whereas, patients without DVT had 2.66 +/- 1.50 RFs and a 6.83 +/- 3.91 VTE score (P = 0.000). DVTs had a direct positive relationship with higher VTE scores, length of stay, and number of VDS (>1 r, P < or = 0.001). Increasing age was a weak risk factor (0.03 r, P = 0.5). First two VDS diagnosed 77 per cent of DVTs. Patients with injury severity score of > or =15 and 25 had higher DVTs compared with the ones with lower injury severity score levels (P < or = 0.05). Pulmonary embolism was silent in 63 per cent and DVTs were asymptomatic in 68 per cent.     

Efficacy and Safety of Mechanical IVC Filtration for Preventing Pulmonary Embolism in High-Risk Orthopedic Patients Undergoing Total Hip or Knee Arthroplasty

BackgroundTo determine the efficacy and safety of inferior vena cava (IVC) filters in preventing pulmonary embolism (PE) in high-risk patients undergoing hip or knee arthroplasty.Methods2857 hip or knee arthroplasty procedures between January 2013 and December 2018 were retrospectively reviewed. Patients with a preoperative history of venous thromboembolism (VTE), either PE or deep venous thrombosis (DVT), were categorized as high-risk patients. The incidence of overall VTE, PE, and DVT were compared between patients with filters and those without. The subgroup analysis was also performed by patient risk, and filter status and the incidence of VTE, PE, and DVT were compared. Variables such as filter placement, history of hypercoagulability etcetra were evaluated as risk factors for the development of postoperative VTE.ResultsIn the high-risk group, the use of IVC filters was significantly associated with a lower incidence of pulmonary embolism (0.8% vs 5.5%, P = .028). When compared with the low-risk group, the high-risk group had significantly higher incidence of PE (3.8% vs 2.0%, P = .038), DVT (11.6% vs 5.3%, P < .001), and overall VTE (15.0% vs 6.8%, P < .001). The history of VTE was associated with postoperative VTE (P < .001), PE (P = .042), and DVT (P < .001). There was no significant correlation between filter placement and postoperative VTE, DVT, or PE in the low-risk group. Filter retrieval was successful in 100% (96/96) of attempted patients with no complications.ConclusionThe use of IVC filters is significantly associated with a lower incidence in pulmonary embolism in high-risk arthroplasty patients. High-risk patients demonstrated an incidence of postoperative VTE over two times greater than other patients. Prophylactic placement of IVC filters in hip/knee arthroplasty is safe.     

Incidence and propagation of infrageniculate deep venous thrombosis in trauma patients

BACKGROUND: The incidence and propagation of thrombosis involving vessels distal to the popliteal vein has not been clearly defined in trauma patients. Our aim was to determine the incidence and rate of propagation of infrageniculate deep venous thrombosis (DVT) in a trauma population and identify potential risk factors specific to propagation. METHODS: Retrospective review of all trauma admissions between the years 2001 and 2003 was conducted. Only those 18 years or older with an isolated infrageniculate DVT who underwent a lower extremity venous duplex scan during admission were included in the study. Nature of injury, injury severity score (ISS), method of DVT prophylaxis, thrombus location, and risk factors for hypercoagulable states were recorded. RESULTS: During the study period, 698 trauma admissions were included, and 109 (15.7%) with infrageniculate DVT were identified. Thirty-nine (35.7%) had thrombus propagation (14 suprageniculate and 25 infrageniculate) with a mean ISS of 27.6. Seventy (64.3%) had infrageniculate DVT without propagation and a mean ISS of 19.6. Thirty-eight (97%) patients with propagating infrageniculate DVT had received mechanical prophylaxis, and 33 (84%) also received chemical prophylaxis. The 14 patients with suprageniculate thrombus propagation were the most severely injured (mean ISS = 35.1). Elevated ISS, operation, age < or =62 years, and intensive care unit admission were positively correlated with propagation of infrageniculate DVT. CONCLUSION: The incidence and propagation of infrageniculate DVT in an aggressively prophylaxed trauma population are greater than previously reported. The clinical significance of isolated infrageniculate DVT remains to be determined, but when associated with a multiple injury trauma, the patient may be at risk for future suprageniculate DVT formation and may benefit from therapeutic anticoagulation.     

Venous Thromboembolism Prophylaxis after Head and Spinal Trauma: Intermittent Pneumatic Compression Devices Versus Low Molecular Weight Heparin

Although there are alternative methods and drugs for preventing venous thromboembolism (VTE), it is not clear which modality is most suitable and efficacious for patients with severe (stable or unstable) head/spinal injures. The aim of this study was to compare intermittent pneumatic compression devices (IPC) with low-molecular-weight heparin (LMWH) for preventing VTE. We prospectively randomized 120 head/spinal traumatized patients for comparison of IPC with LMWH as a prophylaxis modality against VTE. Venous duplex color-flow Doppler sonography of the lower extremities was performed each week of hospitalization and 1 week after discharge. When there was a suspicion of pulmonary embolism (PE), patients were evaluated with spiral computed tomography. Patients were analyzed for demographic features, injury severity scores, associated injuries, type of head/spinal trauma, complications, transfusion, and incidence of deep venous thrombosis (DVT) and PE. Two patients (3.33%) from the IPC group and 4 patients (6.66%) from the LMWH group died, with their deaths due to PE. Nine other patients also succumbed, unrelated to PE. DVT developed in 4 patients (6.66%) in the IPC group and in 3 patients (5%) in the LMWH group. There was no statistically significant difference regarding a reduction in DVT, PE, or mortality between groups (p = 0.04, p > 0.05, p > 0.05, respectively). IPC can be used safely for prophylaxis of VTE in head/spinal trauma patients.     

Thromboembolism following multiple trauma.

The true incidence of thromboembolic complications following multiple trauma is unknown, and no method of prophylaxis has been shown to be both safe and effective in managing seriously injured patients. In this prospective study, 113 trauma patients were assigned on admission to receive either low-dose heparin (LDH), (5,000 U subcutaneously every 12 hours) or to wear sequential compression devices (SCDs) as prophylaxis against the development of deep venous thrombosis (DVT). Both groups of patients were serially studied with duplex venous ultrasound imaging to detect thrombus in the veins of the thigh. Ventilation-perfusion lung scans and pulmonary angiograms were performed when pulmonary embolism (PE) was suspected clinically. There were 12 patients who had thromboembolic complications, including 9 of 76 in the SCD group (12%) and 3 of 37 in the LDH group (8%). Five patients had DVT only, four had PE without detectable DVT, and three had both DVT and PE. None of the patients with PE died, and there were no major complications associated with either method of prophylaxis. Compared with the patients who did not develop DVT/PE, those with thromboembolic complications were older (49 +/- 23 vs. 36 +/- 17 years, p less than 0.02), spent more hospital days immobilized (24 +/- 15 vs. 10 +/- 13 days, p less than 0.001), received more transfusions (11 +/- 12 vs. 3 +/- 5 U, p less than 0.001) and had clotting abnormalities on admission, as demonstrated by prolonged PTT values (39 +/- 28 vs. 26 +/- 5 seconds, p less than 0.001). It appears that there is an identifiable subgroup of injured patients at highest risk for PE who warrant both prophylaxis and close surveillance for DVT.     

Prophylaxis against venous thromboembolism in orthopedic surgery

Venous thromboembolism (VTE), which is manifested as deep vein thrombosis (DVT) and pulmonary embolism (PE), represents a significant cause of death, disability, and discomfort. They are frequent complications of various surgical procedures. The aging population and the survival of more severely injured patients may suggest an increasing risk of thromboembolism in the trauma patients. Expanded understanding of the population at risk challenges physicians to carefully examine risk factors for VTE to identify high-risk patients who can benefit from prophylaxis. An accurate knowledge of evidence-based risk factors is important in predicting and preventing postoperative DVT, and can be incorporated into a decision support system for appropriate thromboprophylaxis use. Standard use of DVT prophylaxis in a high-risk trauma population leads to a low incidence of DVT. The incidence of VTE is common in Asia. The evaluation includes laboratory tests, Doppler test and phlebography. Screening Doppler sonography should be performed for surveillance on all critically injured patients to identify DVT. D-Dimer is a useful marker to monitor prophylaxis in trauma surgery patients. The optimal time to start prophylaxis is between 2 hours before and 10 hours after surgery, but the risk of PE continues for several weeks. Thromboprophylaxis includes graduated compression stockings and anticoagulants for prophylaxis. Anticoagulants include Warfarin, which belongs to Vitamin K antagonists, unfractionated heparin, low molecular weight heparins, factor Xa indirect inhibitor Fondaparinux, and the oral IIa inhibitor Melagatran and ximelagatran. Recombinant human soluble thrombomodulin is a new and highly effective antithrombotic agent. Prophylactic placement of vena caval filters in selected trauma patients may decrease the incidence of PE. The indications for prophylactic inferior vena cava filter insertion include prolonged immobilization with multiple injuries, closed head injury, pelvic fracture, spine fracture, multiple long bone fracture, and attending discretion. Multiple-trauma patients are at increased risk for DVT but are also at increased risk of bleeding, and the use of heparin may be contraindicated. Serial compression devices (SCDs) are an alternative for DVT prophylaxis. Compression devices provide adequate DVT prophylaxis with a low failure rate and no device-related complications. Immobilization is one of important reasons of VTE. The ambulant patient is far less Ukely to develop complications of inactivity, not only venous thrombosis, but also contractures, decubitus ulcers, or osteoporosis ( with its associated fatigue fractures), as well as bowel or bladder complications.     

Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank

OBJECTIVE: Venous thromboembolic events (VTE) are potentially preventable causes of morbidity and mortality after injury. We hypothesized that the current clinical incidence of VTE is relatively low and that VTE risk factors could be identified. METHODS: We queried the ACS National Trauma Data Bank for episodes of deep venous thrombosis (DVT) and/or pulmonary embolism (PE). We examined demographic data, VTE risk factors, outcomes, and VTE prophylaxis measures in patients admitted to the 131 contributing trauma centers. RESULTS: From a total of 450,375 patients, 1602 (0.36%) had a VTE (998 DVT, 522 PE, 82 both), for an incidence of 0.36%. Ninety percent of patients with VTE had 1 of the 9 risk factors commonly associated with VTE. Six risk factors found to be independently significant in multivariate logistic regression for VTE were age > or = 40 years (odds ratio [OR] 2.01; 95% confidence interval [CI] 1.74 to 2.32), lower extremity fracture with AIS > or = 3 (OR 1.92; 95% CI 1.64 to 2.26), head injury with AIS > or = 3 (OR 1.24; 95% CI 1.05 to 1.46), ventilator days >3 (OR 8.08; 95% CI 6.86 to 9.52), venous injury (OR 3.56; 95% CI 2.22 to 5.72), and a major operative procedure (OR 1.53; 95% CI 1.30 to 1.80). Vena cava filters were placed in 3,883 patients, 86% as PE prophylaxis, including in 410 patients without an identifiable risk factor for VTE. CONCLUSIONS: Patients who need VTE prophylaxis after trauma can be identified based on risk factors. The use of prophylactic vena cava filters should be re-examined.     

Surveillance Venous Duplex Is Not Clinically Useful after Total Joint Arthroplasty When Effective Deep Venous Thrombosis Prophylaxis Is Used

The early detection of deep venous thrombosis (DVT) and treatment with systemic anticoagulation to prevent pulmonary embolism (PE) are essential in the management of patients undergoing total joint arthroplasty (TJA). However, improvements in prophylactic measures have significantly decreased the occurrence of DVT in these patients. The purpose of this study was to determine whether routine postoperative duplex surveillance for DVT remains clinically useful. The medical records of all patients undergoing total knee or total hip arthroplasty between October 1997 and January 2002 at a University Hospital and its Veterans Affairs (VA) affiliate were reviewed. The type of operation and occurrence of complications (e.g., DVT, PE, and hemorrhage) were noted. All patients were treated postoperatively with both enoxaparin 30 mg b.i.d. and bilateral lower extremity sequential compression devices (SCDs). A venous duplex scan was performed prior to discharge. Three hundred ninety-eight patients underwent 441 TJAs for 149 hips and 292 knees. The average age was 65 years (range, 23-95). Venous duplex scans were performed within 1 week (median, 4 days) of operation. Initial inpatient scans revealed acute, ipsilateral DVT in five patients (1.3%). Three patients experienced documented PE—one as an inpatient and two after hospital discharge; both outpatients had negative in-hospital duplex scans. One of the 398 patients did not have a duplex scan as an inpatient and returned 6 weeks later with a popliteal DVT. Complications included one upper gastrointestinal hemorrhage, and one patient died postoperatively of unknown causes. These data demonstrate that routine postoperative venous duplex scans rarely found DVT (5 of 398 patients) after TJA when effective prophylaxis was used. Furthermore, surveillance scanning did not enable reliable prediction of PE. Therefore, we conclude that postoperative inpatient surveillance duplex scans for DVT provide very minimal benefit and that a routine screening program is not clinically useful for patients managed with effective DVT prophylaxis.Presented at the Twenty-eighth Annual Meeting of the Peripheral Vascular Surgery Society, Chicago, IL, June 7, 2003.     

The risk assessment profile score identifies trauma patients at risk for deep vein thrombosis

BACKGROUND: The identification of trauma patients at risk for the development of deep venous thrombosis (DVT) at the time of admission remains difficult. The purpose of this study is to validate the risk assessment profile (RAP) score to stratify patients for DVT prophylaxis. METHODS: All patients admitted from November 1998 thru May 1999 were evaluated for enrollment. We prospectively assigned patients as low risk or high risk for DVT using the RAP score. High-risk patients received both pharmacologic and mechanical prophylaxis. Low-risk patients received none. Surveillance duplex Doppler scans were performed each week of hospitalization or if symptoms developed. Hospital charges for prophylaxis were used to determine the savings in the low-risk group. Statistical differences between the risk groups for each factor of the RAP and development of DVT were determined by the chi-squared test, with significance at a probability value of less than .05. RESULTS: There were 102 high-risk (64%) and 58 low-risk (36%) individuals studied. Eleven of the high-risk group (10.8%) experienced the development of DVT (asymptomatic, 64%). None of the low-risk group was diagnosed with DVT. Five of the 16 RAP factors were statistically significant for DVT. Eliminating prophylaxis and Doppler scans in low-risk patients resulted in a total savings of $18,908 in hospital charges. CONCLUSIONS: The RAP score correctly identified trauma patients at increased risk for the development of DVT. Despite prophylaxis, the high-risk group warrants surveillance scans. Withholding prophylaxis in low-risk patients can reduce hospital charges without risk.     

Multi-institutional study of symptomatic deep venous thrombosis and pulmonary embolism in prostate cancer patients undergoing laparoscopic or robot-assisted laparoscopic radical prostatectomy

OBJECTIVES: The true incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing laparoscopic radical prostatectomy is unknown. Our aim was to determine the incidence of symptomatic DVT and PE and the risk factors for these complications. METHODS: Fourteen surgeons from 13 referral institutions from both Europe and the United States provided retrospective data for all 5951 patients treated with laparoscopic radical prostatectomy (LRP), with or without robotic assistance, since the start of their institution's experience. Symptomatic DVT and PE within 90 d of surgery were regarded as venous thromboembolism (VTE). DVT was diagnosed mostly by Doppler ultrasound or contrast venography and PE by lung ventilation/perfusion scan or chest computed tomography or both. Statistical analysis included evaluation of incidence of symptomatic DVT and PE and risk factors as determined by exact methods and logistic regression. RESULTS: Of 5951 patients in the study, 31 developed symptomatic VTE (0.5%; 95% confidence interval [CI], 0.4%, 0.7%). Among patients with an event, 22 (71%) had DVT only, 4 had PE without identified DVT, and 5 had both. Two patients died of PE. Prior DVT (odds ratio [OR]=13.5; 95%CI, 1.4, 61.3), current tobacco smoking (OR=2.8; 95%CI, 1.0, 7.3), larger prostate volume (OR=1.18; 95%CI, 1.09, 1.28), patient re-exploration (OR=20.6; 95%CI, 6.6, 54.0), longer operative time (OR=1.05; 95%CI, 1.02, 1.09), and longer hospital stay (OR=1.05; 95%CI, 1.01, 1.09) were associated with VTE in univariate analysis. Neoadjuvant therapy, body mass index, surgical experience, surgical approach, pathologic stage, perioperative transfusion, and heparin administration were not significant predictors. CONCLUSIONS: The incidence of symptomatic VTE after LRP is low. These data do not support the administration of prophylactic heparin to all patients undergoing LRP, especially those without risk factors for VTE.     

Deep venous thrombosis and pulmonary embolism in trauma patients: an overstatement of the problem?

Deep venous thrombosis (DVT) and pulmonary embolism (PE) affect high-risk trauma patients (HRTP). Accurate incidence and clinical importance of DVT and PE in HRPT may be overstated. We performed a ten-year retrospective analysis of HRTP of the Pennsylvania Trauma Outcome Study. High-risk factors (HRF) included pelvic fracture (PFx), lower extremity fracture (LEFx), severe head injury (CHI) (AIS - head > or =3), and spinal cord injury. HRF alone or in combination, age, Injury Severity Score (ISS), and Glasgow Coma Score (GCS) were examined for association with DVT/PE. A total of 73,419 HRTP were included: 1377 (1.9%) had DVT, 365 (0.5%) had PE. The incidence of DVT in level I trauma centers was 2.2 per cent and was 1.5 per cent in level II centers. The lowest incidence of DVT was 1.3 per cent for isolated LEFx; highest was 5.4% for combined PFx, LEFx, and CHI. Variables associated with DVT included age, ISS, and GCS (all P < 0.001). In logistic regression analysis, only ISS was consistently predictive for DVT and PE. Though increased during the past decade, the overall incidence of DVT in HRTP remains below 3 per cent. Only the combination of multiple injuries or an ISS >30 result in DVT incidence of > or =5 per cent. We believe that current guidelines for screening for DVT may need to be reevaluated.     

Risk of postoperative venous thromboembolism in Indian patients sustaining pelvi-acetabular injury

Most surgeons believe that Asians have a low risk of developing venous thromboembolism (VTE) and routine thromboprophylaxis therapy is not required after major orthopaedic trauma. This study evaluates the postoperative risk of VTE in Indian patients sustaining pelvi-acetabular injury. Fifty-six patients with pelvi-acetabular injury, who underwent open reduction and internal fixation, were prospectively evaluated for VTE in the postoperative period. They were evaluated, both clinically and radiologically (pulmonary CT angiography and indirect venography of lower limb and pelvis veins), until six weeks after surgery. A total of 16 patients developed VTE, of which 12 had proximal deep vein thrombosis (DVT), ten had pulmonary embolism (PE) and only two had distal DVT. Six patients with proximal DVT had associated PE. The risk of development of VTE among Indian patients after pelvi-acetabular injury is high (28.6%) with increasing chances of proximal DVT and PE; hence, administration of routine thromboprophylaxis is fully justified in them.     

A Prospective Cohort Study of Symptomatic Venous Thromboembolic Events in Foot and Ankle Trauma: The Need for Stratification in Thromboprophylaxis?

The incidence of venous thromboembolic (VTE) events (deep vein thrombophlebitis [DVT] or pulmonary embolism [PE]) in foot and ankle trauma has been low, and the risk/benefit ratio associated with chemoprophylaxis is controversial. We compared the 90-day incidence of VTE events in 3 cohorts: group 1, tendo-Achillis (TA) ruptures managed with full weightbearing in a walker boot; group 2, ankle fractures immobilized non-weightbearing in a below-the-knee cast; and group 3, ankle fractures managed surgically, followed by non-weightbearing in a below-the-knee cast. Data were extracted from 2 prospectively collected trust databases for acute TA ruptures and ankle fractures. VTE risk was assessed using a U.K. national assessment tool. Chemoprophylaxis was prescribed for high-risk patients. The 90-day incidence of symptomatic VTE events was drawn from a trust-wide radiology database. In group 1 (n?=?291), the incidence of VTE events was 4.8% (11 [3.8%] DVT, 3 [1.0%] PE) at a mean of 16.1?±?6.8 days. In group 2 (n?=?227), the incidence of VTE events was 2.2% (5 [2.2%] DVT) at a mean of 33.4?±?11.3 days. In group 3 (n?=?199), the incidence of VTE events was 3.0% (5 [2.5%] DVT, 1 [0.5%] PE) at a mean of 37.2?±?14.2 days. Patients with symptomatic VTE events presented significantly earlier after acute TA rupture compared with after ankle fracture (p?=?.002). We found the overall incidence of VTE events in foot and ankle trauma was low, with a relatively greater incidence of symptomatic VTE events, which occurred earlier, in acute TA ruptures compared with ankle fractures.     

Incidence of venous thromboembolism in patients with traumatic brain injury

BACKGROUND: Traumatic brain injury (TBI) may be a risk factor for venous thromboembolism (VTE). This study was designed to review the incidence of VTE in critically injured patients with an isolated TBI using a standardized venous duplex color-flow Doppler imaging program and to compare it with the overall and high-risk trauma populations. METHODS: Trauma patients who underwent lower-extremity surveillance color-flow Doppler imaging for VTE were identified. Analyses included patient demographics, characteristics of TBI, VTE risk factors, prophylaxis, incidence, location, and patient outcome. RESULTS: A total of 5,787 patients were admitted during the study period. Of these, 539 (9%) were deemed high risk for VTE. The incidence of VTE in patients with isolated TBI (88, 16%) was 25%. All patients and the high-risk population had incidences of 2% and 17%, respectively. CONCLUSIONS: The incidence of VTE in isolated TBI is greatest in patients with intraparenchymal hemorrhage. Early VTE prophylaxis is warranted in TBI patients.     

Acute complications associated with greenfield filter insertion in high-risk trauma patients

BACKGROUND: Use of Greenfield filters (GFs) to prevent fatal pulmonary embolism (PE) in trauma patients is generally well accepted. Nonetheless, a surprisingly small number of trauma surgeons insert filters in their patients. Among the reasons cited is fear of complications. METHODS: We observed three femoral arteriovenous fistulae (AVF) in trauma patients who had inferior vena caval placement of filters for PE prophylaxis in one 12-month period (academic year 1999). In an effort to document the magnitude of this problem, we evaluated trauma patients who had a GF inserted in academic year 2000. RESULTS: During that year, 133 consecutive patients (8.6% of trauma admissions) received 133 GFs through a percutaneous approach. The most common isolated indications for GF insertion included closed head injuries (n = 28), multiple long bone fractures (n = 27), pelvic and acetabular fractures (n = 6), spinal cord injuries (n = 16), and vertebral fractures (n = 3). Five patients had documented deep venous thrombosis (DVT) diagnosed by duplex ultrasonography before GF placement, and 11 patients had other indications requiring a filter. There were 37 patients with more than one indication requiring filter placement. Most patients (57%) underwent preinsertion duplex scanning of their lower extremity veins; 77% of patients underwent postinsertion scanning. Filters were inserted an average of 6.8 +/- 0.6 (SE) days after trauma. No AVF were suspected clinically or detected ultrasonographically. No operative or postoperative complications occurred. DVT was observed in 30% of patients despite 92% prophylaxis; there was a 26% incidence of de novo thrombi detected. None of the patients evidenced DVT clinically. CONCLUSION: Our data indicate that complications of GF insertion for prophylaxis against PE from DVT complicating trauma patients continue to be negligible. In addition, the incidence of insertion-site thrombosis may be lower than expected. Moreover, femoral AVF is a rare complication of this procedure.     

Assessing the use of venous thromboembolism risk assessment profiles in the trauma population: is it necessary?

Deep venous thrombosis (DVT) and the subsequent development of venous thromboembolism (VTE) are a significant cause of mortality, morbidity, and cost of care in trauma patients. This study aims to: 1) validate 5 as a critical threshold for high risk; 2) validate risk factors associated with DVT/VTE development; 3) evaluate exogenous estrogen and smoking as risk factors; and 4) analyze daily risk assessment profile (RAP) score changes. We performed a retrospective chart review of trauma patients admitted from January 2001 through December 2005. Univariate odds ratios were performed to assess potential risk factors for VTE. Of the 110 charts reviewed, 31 patients had confirmed DVT/VTE. Three of 26 patients with an RAP score < 5 suffered a VTE; one resulted in death. Significant risk factors included femoral venous line insertion, operation longer than 2 hours, head abbreviated injury score > 2, and Glasgow Coma Scale score < 8. RAP fluctuations were due to a changing Glasgow Coma Scale score, and whether the patient received more than four transfusions, was in surgery for more than 2 hours, or required a femoral venous catheter or major venous repair. The RAP critical value (5) was not validated. We recommend all trauma patients be treated with prophylactic anticoagulants throughout the hospital stay unless clear contraindications exist.     

Utility of Once-Daily Dose of Low-Molecular-Weight Heparin to Prevent Venous Thromboembolism in Multisystem Trauma Patients

Introduction Venous thromboembolism is a preventable cause of death in the severely injured patient. Low-molecular-weight heparins (LMWHs) have been recommended as effective, safe prophylactic agents. However, LMWH use remains controversial in patients at risk for bleeding, those with traumatic brain injury, and those undergoing multiple invasive or operative procedures. We hypothesized that a protocol utilizing once-daily LMWH prophylaxis in high-risk trauma patients, regardless of the need for invasive procedures, is feasible, safe, and effective. Methods From August 1998 to August 2000, all patients admitted to our American College of Surgeons-verified Level I trauma facility following injury were evaluated for deep venous thrombosis (DVT) risk and prospectively followed. Patients at high risk for DVT, including those with stable intracranial injuries, were placed on our institutional protocol and prospectively followed. Patients on the protocol received daily injections of the LMWH, dalteparin; DVT screening was performed with duplex ultrasonography within 48 hours of admission and after 7 to 10 days after injury. Regimen compliance, bleeding complications, DVT rates, and pulmonary embolus (PE) rates were analyzed. Results During the 2-year study period, 6247 trauma patients were admitted; 743 were considered at high risk for DVT. Most of the patients were men (72%), with a mean age of 38.7 years (range 15–89 years) and a mean injury severity score (ISS) of 19.5. Compliance with the daily regimen was maintained in 74% of patients. DVT was detected in 3.9% and PE in 0.8%. The wound complications rate was 2.7%, and the need for unexplained transfusions was 3%. There were no exacerbations of head injury following dalteparin initiation due to bleeding. There were 16 patient deaths; none was caused by PE or late hemorrhage. Conclusions Once-daily dosing of prophylactic LMWH dalteparin is feasible, safe, and effective in high-risk trauma patients. Our protocol allows one to “operate through” systemic prophylaxis and ensures timely prophylaxis for brain-injured and multisystem trauma patients.