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When is It Safe to Start VTE Prophylaxis After Blunt Solid Organ Injury? A Prospective Study from a Level I Trauma
Morgan Schellenberg1, Kenji Inaba2, Subarna Biswas2
1Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower C5L100, Los Angeles, CA, 90033, USA. morgan.schellenberg@med.usc.edu.
Insights
Early venous thromboembolism (VTE) prophylaxis after blunt solid organ injury is safe and effective. Initiating VTE prophylaxis within 48 hours reduced deep vein thrombosis (DVT) rates without increasing bleeding complications.
Area of Science:
- Trauma Surgery
- Vascular Surgery
- Critical Care Medicine
Background:
- The optimal timing for initiating venous thromboembolism (VTE) prophylaxis following blunt solid organ injury remains debated.
- Previous retrospective studies suggested that initiating prophylaxis within 48 hours is safe.
- This study prospectively evaluated early VTE prophylaxis in patients with nonoperative blunt solid organ injuries.
Purpose of the Study:
- To assess the safety and efficacy of early VTE prophylaxis initiation after nonoperative blunt solid organ injury.
- To compare VTE event rates, bleeding complications, and need for interventions between early and late prophylaxis groups.
- To identify predictors for delayed VTE prophylaxis initiation.
Main Methods:
- A prospective study screened patients over 15 years old admitted after blunt trauma.
- Patients with diagnosed solid organ injury (liver, spleen, kidney) managed nonoperatively were included.
- Groups were divided into early (≤48 hours) and late (>48 hours) VTE prophylaxis initiation, with outcomes compared using univariate and multivariate analyses.
Main Results:
- 118 patients were analyzed; 52% received early prophylaxis (≤48 hours).
- Early prophylaxis was associated with a significantly lower deep vein thrombosis (DVT) rate (0% vs. 9%, p=0.024).
- Pulmonary embolism (PE) rates, post-prophylaxis transfusion needs, and interventions for bleeding were similar between groups. Traumatic brain injury (TBI) was a predictor for late prophylaxis.
Conclusions:
- Early initiation of VTE prophylaxis (≤48 hours) after nonoperative blunt solid organ injury is safe and effective.
- Early prophylaxis significantly reduces DVT incidence without increasing bleeding risks or the need for interventions.
- These findings support the adoption of early VTE prophylaxis in this patient population.
Background:
The optimal timing of VTE prophylaxis initiation after blunt solid organ injury is controversial. Retrospective studies suggest initiation ≤48 h is safe. This prospective study examined the safety and efficacy of early VTE prophylaxis initiation after nonoperative blunt solid organ injury.
Methods:
All patients >15 years of age presenting after blunt trauma (12/01/16-11/30/17) were prospectively screened. Patients were included if solid organ injury (liver, spleen, kidney) was diagnosed on admission CT scan and nonoperative management was planned. ED deaths, transfers, patients with pre-existing bleeding disorders or home antiplatelet/anticoagulant medications, and those who did not receive VTE prophylaxis were excluded. Demographics, injury/clinical data, type/timing of VTE prophylaxis initiation, and outcomes were collected. Patients were dichotomized into study groups based on VTE prophylaxis initiation time: Early (≤48 h) vs Late (>48 h after admission). Prophylaxis initiation was at the discretion of the attending trauma surgeon. The primary study outcome was VTE event rate. Secondary outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, need for and volume of post-prophylaxis blood transfusion, need for delayed (post-prophylaxis) interventional radiology (IR) or operative intervention, failure of nonoperative management, and mortality. Outcomes were compared with univariate analysis. Multivariate analysis with logistic regression determined independent predictors of late VTE prophylaxis initiation.
Results:
After exclusions, 118 patients were identified. Median ISS was 22 [IQR 14-26]. Median AAST grade of injury was 2 [IQR 2-3] for liver, 2 [IQR 1-3] for spleen, and 3 [IQR 2-3] for kidney. Compared to late prophylaxis patients (n = 57, 48%), early prophylaxis patients (n = 61, 52%) had significantly fewer DVTs (n = 0, 0% vs n = 5, 9%, p = 0.024) but similar rates of PE (n = 2, 3% vs n = 3, 5%, p = 0.672). TBI was the only significant risk factor for late prophylaxis (OR 0.22, p = 0.015). No patient in either group required delayed intervention (operative or IR) for bleeding. There was no difference in volume of post-prophylaxis blood transfusion.
Conclusions:
In this prospective study of patients with nonoperative blunt solid organ injuries, early (≤48 h) initiation of VTE prophylaxis resulted in a lower incidence of DVTs without an associated increase in bleeding or need for intervention. Early initiation of VTE prophylaxis is likely to be safe and beneficial for patients with blunt solid organ injury.
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