Determining the impact of culture on venous thromboembolism prevention in trauma patients: A Southwestern Surgical Congress Multicenter trial.

Venous thromboembolism (VTE) remains one of the principal causes of morbidity and death in trauma patients that survive the first 24 h. Recent literature on VTE prevention focuses on choice of chemoprophylaxis, specifically unfractionated heparin (UFH) versus low molecular weight heparin (LMWH). This singular focus on a multifactorial process may be inadequate to fully understand the optimal approach to VTE prevention. We hypothesized that variations in care between trauma centers could be used to identify key components of VTE prevention associated with better outcomes. A 50 question survey of VTE management for years 2014-2016 was sent to 15 trauma centers. The survey included: demographics of the trauma centers, type and timing of chemoprophylaxis, ambulation expectations, and complementary services (geriatric trauma service (GTS), mobility teams, physical and occupational therapy (PT/OT)). Each center submitted their American College of Surgeons Trauma Quality Improvement Program (TQIP) Benchmark Report for Spring 2017. TQIP data included: mortality, observed rates of deep vein thrombosis (DVT) and pulmonary embolus (PE), and time to VTE prophylaxis. The survey and TQIP reports were blinded for analysis; descriptive statistics were utilized. The top DVT & PE TQIP performers were used to identify potential aspects of better care on the survey responses. The institutions' DVT and PE rates were then compared for these responses using Wilcoxon-Rank-Sum test. Fifteen trauma centers (13 Level-1, 2 Level-2) completed the survey; the centers admitted 1050-7200 trauma patients per year (median 3000). The majority of centers were University-affiliated (11 of 15) with general surgery residencies (14 of 15), Acute Care Surgery or Surgical Critical Care Fellowships, (9 of 15) and critical care boarded-surgeons only on-call (9 of 15). Few have geriatric trauma services (3 of 15) or mobility teams (1 of 15). Half the trauma centers have dedicated PT/OT teams for trauma or weekend coverage. With a total of 20,878 TQIP patients analyzed, the average observed DVT and PE rates were 1.27% (range 0.1-5.2%) and 0.68% (range 0-1.6%), respectively. Weekly lower extremity surveillance duplex (2 of 15) increased DVT detection (4.15% vs 0.80%, p = 0.034) but did not decrease PE rates (1.05% vs 0.62%, p = 0.229). Great variance was seen in choice, dosing and timing of chemoprophylaxis: UFH,4 LMWH daily,1 LMWH twice-daily,5 LMWH weight-based dosing,4 and LMWH anti-Xa dosing.1 The top 3 performers for DVT and PE all used different types of chemoprophylaxis. These top performers had a prominent culture of mobility: dedicated PT/OT teams for trauma or weekends and an expectation to ambulate 3-times per day. Weekend PT/OT teams were associated with lower DVT rates (median 0.40%, range 0.10-1.10% vs 1.30%, 0.60-5.20%, p = 0.018), and ambulation 3-times per day was associated with lower PE rates (median 0.20%, range 0.00-0.20% vs 0.80%, 0.40-1.60%, p < 0.005). Considerable variation in VTE chemoprophylaxis exists among trauma centers. "Best practices" in this area requires further investigation. An expectation of mobility and investment in mobility resources may serve to decrease VTE rates in trauma patients compared to a singular focus on type of chemoprophylaxis administered.

Regner JL ，Shaver CN ，SWSC Multicenter Trials Group 《-》

A tale of two centers: Is low-molecular-weight heparin really superior for prevention of posttraumatic venous thromboembolism?

Low-molecular-weight heparin (LMWH) is widely used for venous thromboembolism chemoprophylaxis following injury. However, unfractionated heparin (UFH) is a less expensive option. We compared LMWH and UFH for prevention of posttraumatic deep venous thrombosis (DVT) and pulmonary embolism (PE). Trauma patients 15 years or older with at least one administration of venous thromboembolism chemoprophylaxis at two level I trauma centers with similar DVT-screening protocols were identified. Center 1 administered UFH every 8 hours for chemoprophylaxis, and center 2 used twice-daily antifactor Xa-adjusted LMWH. Clinical characteristics and primary chemoprophylaxis agent were evaluated in a two-level logistic regression model. Primary outcome was incidence of DVT and PE. There were 3,654 patients: 1,155 at center 1 and 2,499 at center 2. The unadjusted DVT rate at center 1 was lower than at center 2 (3.5% vs. 5.0%; p = 0.04); PE rates did not significantly differ (0.4% vs. 0.6%; p = 0.64). Patients at center 2 were older (mean, 50.3 vs. 47.3 years; p < 0.001) and had higher Injury Severity Scores (median, 10 vs. 9; p < 0.001), longer stays in the hospital (mean, 9.4 vs. 7.0 days; p < 0.001) and intensive care unit (mean, 3.0 vs. 1.3 days; p < 0.001), and a higher mortality rate (1.6% vs. 0.6%, p = 0.02) than patients at center 1. Center 1's patients received their first dose of chemoprophylaxis earlier than patients at center 2 (median, 1.0 vs. 1.7 days; p < 0.001). After risk adjustment and accounting for center effects, primary chemoprophylaxis agent was not associated with risk of DVT (odds ratio, 1.01; 95% confidence interval, 0.69-1.48; p = 0.949). Cost calculations showed that UFH was less expensive than LMWH. Primary utilization of UFH is not inferior to LMWH for posttraumatic DVT chemoprophylaxis and rates of PE are similar. Given that UFH is lower in cost, the choice of this chemoprophylaxis agent may have major economic implications. Prognostic and epidemiological, level II; Therapeutic, level III.

Checchi KD ，Costantini TW ，Badiee J ，Berndtson AE ，Calvo RY ，Rooney AS ，Wessels LE ，Prieto JM ，Sise CB ，Sise MJ ，Martin MJ ，Bansal V ... -  《-》

Unfractionated heparin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in trauma.

Jacobs BN ，Cain-Nielsen AH ，Jakubus JL ，Mikhail JN ，Fath JJ ，Regenbogen SE ，Hemmila MR ... -  《-》

Retrospective Analysis of Low-Molecular-Weight Heparin and Unfractionated Heparin in Pediatric Trauma Patients: A Comparative Analysis.

Chemoprophylaxis with either unfractionated heparin (UFH) or Low-Molecular-Weight Heparin (LMWH) are recommended to prevent Venous Thromboembolism (VTE) after trauma. Experimental work has shown beneficial effects of LMWH in animal models, but it is unknown if similar effects exist in humans. We hypothesized that treatment with LMWH is associated with a survival benefit when compared to UFH. We performed a retrospective analysis of our level I trauma center database from January 2009 to June 2018. Pediatric patients (age < 18) were included if they received either LMWH or UFH during their stay. Outcome measures included mortality, VTE complications, and hospital length of stay (HLOS). A total of 354 patients were included. Patients who received LMWH had lower mortality compared to those who received UFH. After multivariate logistic regression, LMWH was still independently associated with improved survival. No association was found between LMWH and UFH regarding deep vein thrombosis (DVT) or pulmonary embolism (PE) rates. No association was found between LMWH with HLOS. LMWH was associated with improved survival compared to UFH in our pediatric trauma patients. This was independent of injury severity or VTE complications. Further studies are required to understand better the mechanisms by which LMWH improves survival. 3.

Culbert MH ，Hamidi M ，Zeeshan M ，Hanna K ，Romero A ，Joseph B ，O'Keeffe T ... -  《-》

Venous thromboembolism chemoprophylaxis in geriatric trauma patients with isolated severe traumatic brain injury.

Low-molecular-weight-heparin (LMWH) has been shown to be associated with a decreased risk of venous thromboembolism (VTE) and mortality compared to unfractionated heparin (UH) in severe traumatic brain injury (TBI). The aim of this study was to see if this association persists among a subset of patients, namely elderly patients with isolated TBI. This Trauma Quality Improvement Project (TQIP) database study included patients ≥ 65 years old with severe TBI (Abbreviated injury score [AIS] ≥ 3) that received either LMWH or UH for VTE prophylaxis. Patients with associated severe injuries (extracranial AIS ≥ 3), transferals, deaths < 72-h, hospitalization < 2 days, VTE chemoprophylaxis other than UH or LMWH, or with a history of bleeding diathesis were excluded. The association between VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE) with VTE chemoprophylaxis was analyzed with multivariable analysis, subset analyses of different grades of AIS-head injury, and a 1:1 matched LWMH:UH cohort of patients. Out of 14,926 patients, 11,036 (73.9%) received LMWH. Multivariate analysis showed that patients receiving LMWH had a decreased risk of mortality (OR 0.81, 95% CI 0.67-0.97, p < 0.001) but a similar risk of VTE (OR 0.83, 95% CI 0.63-1.08). Analysis according to head-AIS showed that LMWH was associated with a decreased risk of PE in patients AIS-3 but not in AIS 4 or 5. In a 1:1 matched cohort of LMWH:UH patients, the risk of PE, DVT and VTE were all similar but LMWH continued to be associated with a decreased risk of mortality (OR 0.81, CI 0.67-0.97, p = 0.023). LMWH was associated with a decreased risk of overall mortality and reduced risk of PE compared to UH among geriatric patients with a severe head injury.

Condon F ，Grigorian A ，Russell D ，Demetriades D ... -  《-》