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A Bedside, Single Burr Hole Approach to Multimodality Monitoring in Severe Brain Injury
Published on: March 26, 2019
Current practice variations in venous thromboembolism prophylaxis for adolescents with severe traumatic brain injury:
Morihiro Katsura1, Shingo Fukuma, Shin Miyata
1From the Division of Acute Care Surgery, Department of Surgery (M.K., S.D., M.J.M., K.I., K.M.), Los Angeles General Medical Center, University of Southern California, Los Angeles, California; Human Health Sciences (M.K., S.F.), Kyoto University Graduate School of Medicine, Kyoto; Department of Epidemiology Infectious Disease Control and Prevention (S.F.), Hiroshima University Graduate school of Biomedical and Health Sciences, Hiroshima, Japan; SSM Cardinal Glennon Children's Hospital (S.M.), St. Louis University School of Medicine, Saint Louis, Missouri; and Data Science and AI Innovation Research Promotion Center (T.I.), Shiga University, Shiga, Japan.
Background:
While severe traumatic brain injury (TBI) faces an increased risk of venous thromboembolism (VTE), pharmacological VTE prophylaxis might be significantly delayed because of concerns for TBI progression. We aimed to assess practice variations in the rate and timing of VTE prophylaxis for adolescent patients with severe TBI between different trauma center types.
Methods:
This retrospective cohort study using the American College of Surgeon Trauma Quality Improvement Program database (2017-2021) included patients aged 14 to 18 years with severe TBI. Trauma centers were classified as follows: adult trauma center (ATC), mixed trauma center (MTC), and pediatric trauma center (PTC). We developed a multilevel mixed-effect Poisson regression model to assess the association between trauma center type and the rate and timing of VTE prophylaxis. Effect sizes for fixed effects were reported as adjusted incidence rate ratio (aIRR) with 95% confidence interval (CI). Secondary outcomes included the incidence of VTE and late neurosurgical interventions (>72 hours).
Results:
Of 7,238 eligible patients, pharmacological VTE prophylaxis was performed in 63.1% at ATC, 59.0% at MTC, and 28.5% at PTC. The median time to the initial prophylaxis was 4 days at ATC, 4 days at MTC, and 6 days at PTC ( p < 0.001). In the regression model, treatment at MTC and PTC was associated with decreased likelihood of VTE prophylaxis (aIRR, 0.89 [95% CI, 0.80-0.97] and aIRR, 0.39 [95% CI, 0.32-0.47]) compared with ATC. Treatment at PTC was associated with higher odds of VTE events (odds ratio, 2.04; 95% CI, 1.16-3.60), while there was no significant difference in the rate of late neurosurgical interventions between ATC and PTC (odds ratio, 1.18; 95% CI, 0.68-2.05).
Conclusion:
We observed significant practice variations in the use of pharmacological VTE prophylaxis for adolescent patients with severe TBI between ATC, MTC, and PTC. Further research is warranted to investigate potential drivers of these variations and develop standardized protocols.
Level Of Evidence:
Therapeutic/Care management; Level III.
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