Venous thromboembolism after trauma: A never event?

Chad M. Thorson, Mark L. Ryan, Robert M. Van Haren, Emiliano Curia, Jose M. Barrera, Gerardo A. Guarch, Alexander M. Busko, Nicholas Namias, Alan S. Livingstone, Kenneth G. Proctor

Research output: Contribution to journalArticle

35 Citations (Scopus)

Abstract

Objective: Rates of venous thromboembolism as high as 58% have been reported after trauma, but there is no widely accepted screening protocol. If Medicare adds venous thromboembolism to the list of "preventable complications," they will no longer reimburse for treatment, which could have devastating effects on many urban centers. We hypothesized that prescreening with a risk assessment profile followed by routine surveillance with venous duplex ultrasound that could identify asymptomatic venous thromboembolism in trauma patients. Design: Prospective, observational trial with waiver of consent. Setting: Level I trauma center intensive care unit. Patients: At admission, 534 patients were prescreened with a risk assessment profile. Interventions: Patients (n = 106) with risk assessment profile scores >10 were considered high risk and received routine screening venous duplex ultrasound within 24 hrs and weekly thereafter. RESULTS:: In prescreened high-risk patients, 20 asymptomatic deep vein thrombosis were detected with venous duplex ultrasound (19%). An additional ten venous thromboembolisms occurred, including six symptomatic deep vein thrombosis and four pulmonary emboli, resulting in an overall venous thromboembolism rate of 28%. The most common risk factors discriminating venous thromboembolism vs. no venous thromboembolism were femoral central venous catheter (23% vs. 8%), operative intervention >2 hrs (77% vs. 46%), complex lower extremity fracture (53% vs. 32%), and pelvic fracture (70% vs. 47%), respectively (all p < .05). Risk assessment profile scores were higher in patients with venous thromboembolism (19 ± 6 vs. 14 ± 4, p = .001). Risk assessment profile score (odds ratio 1.14) and the combination of pelvic fracture requiring operative intervention >2 hrs (odds ratio 5.75) were independent predictors for development of venous thromboembolism. The rates of venous thromboembolism for no chemical prophylaxis (33%), unfractionated heparin (29%), dalteparin (40%), or inferior vena cava filters (20%) were not statistically different (p = .764). Conclusions: Medicare's inclusion of venous thromboembolism after trauma as a "never event" should be questioned. In trauma patients, high-risk assessment profile score and pelvic fracture with prolonged operative intervention are independent predictors for venous thromboembolism development, despite thromboprophylaxis. Although routine venous duplex ultrasound screening may not be cost-effective for all trauma patients, prescreening using risk assessment profile yielded a cohort of patients with a high prevalence of venous thromboembolism. In such high-risk patients, routine venous duplex ultrasound and/or more aggressive prophylactic regimens may be beneficial.

Original languageEnglish (US)
Pages (from-to)2967-2973
Number of pages7
JournalCritical care medicine
Volume40
Issue number11
DOIs
StatePublished - Nov 1 2012
Externally publishedYes

Fingerprint

Medical Errors
Venous Thromboembolism
Wounds and Injuries
Medicare
Venous Thrombosis
Dalteparin
Vena Cava Filters
Central Venous Catheters
Trauma Centers
Patient Admission
Thigh
Embolism
Intensive Care Units
Heparin
Lower Extremity

Keywords

  • risk assessment profile
  • thromboembolism
  • trauma
  • venous thrombosis

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

Thorson, C. M., Ryan, M. L., Van Haren, R. M., Curia, E., Barrera, J. M., Guarch, G. A., ... Proctor, K. G. (2012). Venous thromboembolism after trauma: A never event? Critical care medicine, 40(11), 2967-2973. https://doi.org/10.1097/CCM.0b013e31825bcb60

Venous thromboembolism after trauma : A never event? / Thorson, Chad M.; Ryan, Mark L.; Van Haren, Robert M.; Curia, Emiliano; Barrera, Jose M.; Guarch, Gerardo A.; Busko, Alexander M.; Namias, Nicholas; Livingstone, Alan S.; Proctor, Kenneth G.

In: Critical care medicine, Vol. 40, No. 11, 01.11.2012, p. 2967-2973.

Research output: Contribution to journalArticle

Thorson, CM, Ryan, ML, Van Haren, RM, Curia, E, Barrera, JM, Guarch, GA, Busko, AM, Namias, N, Livingstone, AS & Proctor, KG 2012, 'Venous thromboembolism after trauma: A never event?', Critical care medicine, vol. 40, no. 11, pp. 2967-2973. https://doi.org/10.1097/CCM.0b013e31825bcb60
Thorson CM, Ryan ML, Van Haren RM, Curia E, Barrera JM, Guarch GA et al. Venous thromboembolism after trauma: A never event? Critical care medicine. 2012 Nov 1;40(11):2967-2973. https://doi.org/10.1097/CCM.0b013e31825bcb60
Thorson, Chad M. ; Ryan, Mark L. ; Van Haren, Robert M. ; Curia, Emiliano ; Barrera, Jose M. ; Guarch, Gerardo A. ; Busko, Alexander M. ; Namias, Nicholas ; Livingstone, Alan S. ; Proctor, Kenneth G. / Venous thromboembolism after trauma : A never event?. In: Critical care medicine. 2012 ; Vol. 40, No. 11. pp. 2967-2973.
@article{591100e1c9e444ba9127735d630dc774,
title = "Venous thromboembolism after trauma: A never event?",
abstract = "Objective: Rates of venous thromboembolism as high as 58{\%} have been reported after trauma, but there is no widely accepted screening protocol. If Medicare adds venous thromboembolism to the list of {"}preventable complications,{"} they will no longer reimburse for treatment, which could have devastating effects on many urban centers. We hypothesized that prescreening with a risk assessment profile followed by routine surveillance with venous duplex ultrasound that could identify asymptomatic venous thromboembolism in trauma patients. Design: Prospective, observational trial with waiver of consent. Setting: Level I trauma center intensive care unit. Patients: At admission, 534 patients were prescreened with a risk assessment profile. Interventions: Patients (n = 106) with risk assessment profile scores >10 were considered high risk and received routine screening venous duplex ultrasound within 24 hrs and weekly thereafter. RESULTS:: In prescreened high-risk patients, 20 asymptomatic deep vein thrombosis were detected with venous duplex ultrasound (19{\%}). An additional ten venous thromboembolisms occurred, including six symptomatic deep vein thrombosis and four pulmonary emboli, resulting in an overall venous thromboembolism rate of 28{\%}. The most common risk factors discriminating venous thromboembolism vs. no venous thromboembolism were femoral central venous catheter (23{\%} vs. 8{\%}), operative intervention >2 hrs (77{\%} vs. 46{\%}), complex lower extremity fracture (53{\%} vs. 32{\%}), and pelvic fracture (70{\%} vs. 47{\%}), respectively (all p < .05). Risk assessment profile scores were higher in patients with venous thromboembolism (19 ± 6 vs. 14 ± 4, p = .001). Risk assessment profile score (odds ratio 1.14) and the combination of pelvic fracture requiring operative intervention >2 hrs (odds ratio 5.75) were independent predictors for development of venous thromboembolism. The rates of venous thromboembolism for no chemical prophylaxis (33{\%}), unfractionated heparin (29{\%}), dalteparin (40{\%}), or inferior vena cava filters (20{\%}) were not statistically different (p = .764). Conclusions: Medicare's inclusion of venous thromboembolism after trauma as a {"}never event{"} should be questioned. In trauma patients, high-risk assessment profile score and pelvic fracture with prolonged operative intervention are independent predictors for venous thromboembolism development, despite thromboprophylaxis. Although routine venous duplex ultrasound screening may not be cost-effective for all trauma patients, prescreening using risk assessment profile yielded a cohort of patients with a high prevalence of venous thromboembolism. In such high-risk patients, routine venous duplex ultrasound and/or more aggressive prophylactic regimens may be beneficial.",
keywords = "risk assessment profile, thromboembolism, trauma, venous thrombosis",
author = "Thorson, {Chad M.} and Ryan, {Mark L.} and {Van Haren}, {Robert M.} and Emiliano Curia and Barrera, {Jose M.} and Guarch, {Gerardo A.} and Busko, {Alexander M.} and Nicholas Namias and Livingstone, {Alan S.} and Proctor, {Kenneth G.}",
year = "2012",
month = "11",
day = "1",
doi = "10.1097/CCM.0b013e31825bcb60",
language = "English (US)",
volume = "40",
pages = "2967--2973",
journal = "Critical Care Medicine",
issn = "0090-3493",
publisher = "Lippincott Williams and Wilkins",
number = "11",

}

TY - JOUR

T1 - Venous thromboembolism after trauma

T2 - A never event?

AU - Thorson, Chad M.

AU - Ryan, Mark L.

AU - Van Haren, Robert M.

AU - Curia, Emiliano

AU - Barrera, Jose M.

AU - Guarch, Gerardo A.

AU - Busko, Alexander M.

AU - Namias, Nicholas

AU - Livingstone, Alan S.

AU - Proctor, Kenneth G.

PY - 2012/11/1

Y1 - 2012/11/1

N2 - Objective: Rates of venous thromboembolism as high as 58% have been reported after trauma, but there is no widely accepted screening protocol. If Medicare adds venous thromboembolism to the list of "preventable complications," they will no longer reimburse for treatment, which could have devastating effects on many urban centers. We hypothesized that prescreening with a risk assessment profile followed by routine surveillance with venous duplex ultrasound that could identify asymptomatic venous thromboembolism in trauma patients. Design: Prospective, observational trial with waiver of consent. Setting: Level I trauma center intensive care unit. Patients: At admission, 534 patients were prescreened with a risk assessment profile. Interventions: Patients (n = 106) with risk assessment profile scores >10 were considered high risk and received routine screening venous duplex ultrasound within 24 hrs and weekly thereafter. RESULTS:: In prescreened high-risk patients, 20 asymptomatic deep vein thrombosis were detected with venous duplex ultrasound (19%). An additional ten venous thromboembolisms occurred, including six symptomatic deep vein thrombosis and four pulmonary emboli, resulting in an overall venous thromboembolism rate of 28%. The most common risk factors discriminating venous thromboembolism vs. no venous thromboembolism were femoral central venous catheter (23% vs. 8%), operative intervention >2 hrs (77% vs. 46%), complex lower extremity fracture (53% vs. 32%), and pelvic fracture (70% vs. 47%), respectively (all p < .05). Risk assessment profile scores were higher in patients with venous thromboembolism (19 ± 6 vs. 14 ± 4, p = .001). Risk assessment profile score (odds ratio 1.14) and the combination of pelvic fracture requiring operative intervention >2 hrs (odds ratio 5.75) were independent predictors for development of venous thromboembolism. The rates of venous thromboembolism for no chemical prophylaxis (33%), unfractionated heparin (29%), dalteparin (40%), or inferior vena cava filters (20%) were not statistically different (p = .764). Conclusions: Medicare's inclusion of venous thromboembolism after trauma as a "never event" should be questioned. In trauma patients, high-risk assessment profile score and pelvic fracture with prolonged operative intervention are independent predictors for venous thromboembolism development, despite thromboprophylaxis. Although routine venous duplex ultrasound screening may not be cost-effective for all trauma patients, prescreening using risk assessment profile yielded a cohort of patients with a high prevalence of venous thromboembolism. In such high-risk patients, routine venous duplex ultrasound and/or more aggressive prophylactic regimens may be beneficial.

AB - Objective: Rates of venous thromboembolism as high as 58% have been reported after trauma, but there is no widely accepted screening protocol. If Medicare adds venous thromboembolism to the list of "preventable complications," they will no longer reimburse for treatment, which could have devastating effects on many urban centers. We hypothesized that prescreening with a risk assessment profile followed by routine surveillance with venous duplex ultrasound that could identify asymptomatic venous thromboembolism in trauma patients. Design: Prospective, observational trial with waiver of consent. Setting: Level I trauma center intensive care unit. Patients: At admission, 534 patients were prescreened with a risk assessment profile. Interventions: Patients (n = 106) with risk assessment profile scores >10 were considered high risk and received routine screening venous duplex ultrasound within 24 hrs and weekly thereafter. RESULTS:: In prescreened high-risk patients, 20 asymptomatic deep vein thrombosis were detected with venous duplex ultrasound (19%). An additional ten venous thromboembolisms occurred, including six symptomatic deep vein thrombosis and four pulmonary emboli, resulting in an overall venous thromboembolism rate of 28%. The most common risk factors discriminating venous thromboembolism vs. no venous thromboembolism were femoral central venous catheter (23% vs. 8%), operative intervention >2 hrs (77% vs. 46%), complex lower extremity fracture (53% vs. 32%), and pelvic fracture (70% vs. 47%), respectively (all p < .05). Risk assessment profile scores were higher in patients with venous thromboembolism (19 ± 6 vs. 14 ± 4, p = .001). Risk assessment profile score (odds ratio 1.14) and the combination of pelvic fracture requiring operative intervention >2 hrs (odds ratio 5.75) were independent predictors for development of venous thromboembolism. The rates of venous thromboembolism for no chemical prophylaxis (33%), unfractionated heparin (29%), dalteparin (40%), or inferior vena cava filters (20%) were not statistically different (p = .764). Conclusions: Medicare's inclusion of venous thromboembolism after trauma as a "never event" should be questioned. In trauma patients, high-risk assessment profile score and pelvic fracture with prolonged operative intervention are independent predictors for venous thromboembolism development, despite thromboprophylaxis. Although routine venous duplex ultrasound screening may not be cost-effective for all trauma patients, prescreening using risk assessment profile yielded a cohort of patients with a high prevalence of venous thromboembolism. In such high-risk patients, routine venous duplex ultrasound and/or more aggressive prophylactic regimens may be beneficial.

KW - risk assessment profile

KW - thromboembolism

KW - trauma

KW - venous thrombosis

UR - http://www.scopus.com/inward/record.url?scp=84868202416&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84868202416&partnerID=8YFLogxK

U2 - 10.1097/CCM.0b013e31825bcb60

DO - 10.1097/CCM.0b013e31825bcb60

M3 - Article

C2 - 22890248

AN - SCOPUS:84868202416

VL - 40

SP - 2967

EP - 2973

JO - Critical Care Medicine

JF - Critical Care Medicine

SN - 0090-3493

IS - 11

ER -