The practice of venous thromboembolism prophylaxis in the major trauma patient

Avery B. Nathens, Megan K. McMurray, Joseph Cuschieri, Emily A. Durr, Ernest E. Moore, Paul E. Bankey, Brad Freeman, Brian G. Harbrecht, Jeffrey L. Johnson, Joseph P. Minei, Bruce A. McKinley, Frederick A. Moore, Michael B. Shapiro, Michael A. West, Ronald G. Tompkins, Ronald V. Maier

Research output: Contribution to journalArticle

89 Scopus citations

Abstract

BACKGROUND: The incidence of venous thromboembolism (VTE) without prophylaxis is as high as 80% after major trauma. Initiation of prophylaxis is often delayed because of concerns of injury-associated bleeding. As the effect of delays in the initiation of prophylaxis on VTE rates is unknown, we set out to evaluate the relationship between late initiation of prophylaxis and VTE. METHODS: Data were derived from a multicenter prospective cohort study evaluating clinical outcomes in adults with hemorrhagic shock after injury. Analyses were limited to patients with an Intensive Care Unit length of stay ≥7 days. The rate of VTE was estimated as a function of the time to initiation of pharmacologic prophylaxis. A multivariate stepwise logistic regression model was used to evaluate factors associated with late initiation. RESULTS: There were 315 subjects who met inclusion criteria; 34 patients (11%) experienced a VTE within the first 28 days. Prophylaxis was initiated within 48 hours of injury in 25% of patients, and another one-quarter had no prophylaxis for at least 7 days after injury. Early prophylaxis was associated with a 5% risk of VTE, whereas delay beyond 4 days was associated with three times that risk (risk ratio, 3.0, 95% CI [1.4-6.5]). Factors associated with late (>4 days) initiation of prophylaxis included severe head injury, absence of comorbidities, and massive transfusion, whereas the presence of a severe lower extremity fracture was associated with early prophylaxis. CONCLUSIONS: Clinicians are reticent to begin timely VTE prophylaxis in critically injured patients. Patients are without VTE prophylaxis for half of all days within the first week of admission and this delay in the initiation of prophylaxis is associated with a threefold greater risk of VTE. The relative risks and benefits of early VTE prophylaxis need to be defined to better direct practice in this high-risk population.

Original languageEnglish (US)
Pages (from-to)557-562
Number of pages6
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume62
Issue number3
DOIs
StatePublished - Mar 1 2007

Keywords

  • Deep venous thrombosis
  • Knowledge translation
  • Prophylaxis
  • Pulmonary embolism
  • Venous thromboembolism

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

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    Nathens, A. B., McMurray, M. K., Cuschieri, J., Durr, E. A., Moore, E. E., Bankey, P. E., Freeman, B., Harbrecht, B. G., Johnson, J. L., Minei, J. P., McKinley, B. A., Moore, F. A., Shapiro, M. B., West, M. A., Tompkins, R. G., & Maier, R. V. (2007). The practice of venous thromboembolism prophylaxis in the major trauma patient. Journal of Trauma - Injury, Infection and Critical Care, 62(3), 557-562. https://doi.org/10.1097/TA.0b013e318031b5f5