A critical evaluation of venous thromboembolism risk assessment models used in patients with lower limb cast immobilisation

Watson, Ultan; Hickey, Ben; Jones, Helen M.F.; Perera, Anthony

doi:10.1016/j.fas.2015.08.003

Cited by 12 publications

(5 citation statements)

References 21 publications

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“…In addition, stratified thromboprophylaxis may be able to select out patients at highest risk and maximize potential clinical and cost effectiveness. Several risk assessment models (RAM) have already been derived for use in this patient population, aiming to tailor thromboprophylaxis strategies at presumed high risk and limit financial costs, opportunity costs, and side effects . The current evidence base for RAMs is very limited, and estimates of sensitivity and specificity are subject to substantial uncertainty .…”

Section: Discussionmentioning

confidence: 99%

Pharmacological thromboprophylaxis to prevent venous thromboembolism in patients with temporary lower limb immobilization after injury: systematic review and network meta‐analysis

Horner

Stevens

Pandor

et al. 2020

Journal of Thrombosis and Haemostasis

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Background: Thromboprophylaxis has the potential to reduce venous thromboembolism (VTE) following lower limb immobilization resulting from injury. Objectives:We aimed to estimate the effectiveness of thromboprophylaxis, compare different agents, and identify any factors associated with effectiveness. Methods:We undertook a systematic review and network meta-analysis (NMA) of randomized trials reporting VTE or bleeding outcomes that compared thromboprophylactic agents with each other or to no pharmacological prophylaxis, for this indication. An NMA was undertaken for each outcome or agent used, and a series of study-level network meta-regressions examined whether population characteristics, type of injury, treatment of injury, or duration of thromboprophylaxis were associated with treatment effect. Results: Data from 6857 participants across 13 randomized trials showed that, compared with no treatment, low molecular weight heparin (LMWH) reduced the risk of any VTE (odds ratio [OR]: 0.52; 95% credible interval [CrI]: 0.37-0.71), clinically detected deep vein thrombosis (DVT) (OR: 0.39; 95% CrI: 0.12-0.94) and pulmonary embolism (PE) (OR: 0.16; 95% CrI: 0.01-0.74), whereas fondaparinux reduced the risk of any VTE (OR: 0.13; 95% CrI: 0.05-0.30) and clinically detected DVT (OR: 0.10; 95% CrI: 0.01-0.86), with inconclusive results for PE (OR: 0.40; 95% CrI: 0.01-7.53).Conclusions: Thromboprophylaxis with either fondaparinux or LMWH appears to reduce the odds of both asymptomatic and clinically detected VTE in people with temporary lower limb immobilization following an injury. Treatment effects vary by outcome and are not always conclusive. We were unable to identify any treatment effect modifiers other than thromboprophylactic agent used.

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Section: Discussionmentioning

confidence: 99%

Pharmacological thromboprophylaxis to prevent venous thromboembolism in patients with temporary lower limb immobilization after injury: systematic review and network meta‐analysis

Horner

Stevens

Pandor

et al. 2020

Journal of Thrombosis and Haemostasis

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“…To personalize thromboprophylaxis treatment in patients with lower-limb immobilization, two specific VTE risk assessment models (RAMs) have been developed [12,13]. Furthermore, two studies published a list of predictors in which case thromboprophylaxis should be considered [14].…”

Section: Introductionmentioning

confidence: 99%

Clinical risk assessment model to predict venous thromboembolism risk after immobilization for lower-limb trauma

et al. 2020

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Background: Patients with lower-limb trauma requiring immobilization have an increased risk of venous thromboembolism (VTE). While thromboprophylaxis for all patients seems not effective, targeted thromboprophylaxis in high risk patients may be an appropriate alternative. Therefore, we aimed to develop and validate a risk assessment model for VTE risk: the TRiP(cast) score (Thrombosis Risk Prediction following cast immobilization). Methods: In this prediction model study, for development, data were used from the MEGA study (case-control study into the etiology of VTE) and for validation, data from the POT-CAST trial (randomized trial on the effectiveness of thromboprophylaxis following cast immobilization) were used. Model discrimination was calculated by estimating the Area Under the Curve (AUC). For model calibration, observed and predicted risks were assessed. Findings: The TRiP(cast) score includes 14 items; one item for trauma severity (or type), one for type of immobilization and 12 items related to patients' characteristics. Validation analyses showed an AUC of 0.74 (95%CI 0.61À0.87) in the complete dataset (n = 1250) and 0.72 (95%CI 0.60À0.84) in the imputed data set (n = 1435). The calibration plot shows the degree of agreement between the observed and predicted risks (intercept 0.0016 and slope 0.933). Using a cut-off score of 7 points in the POT-CAST trial (incidence 1.6%), the sensitivity, specificity, positive and negative predictive values were 76.1%, 51.2%, 2.5%, and 99.2%, respectively. Interpretation: The TRiP(cast) score provides a helpful tool in daily clinical practice to accurately stratify patients in high versus low-risk categories in order to guide thromboprophylaxis prescribing. To accommodate implementation in clinical practice a mobile phone application has been developed.

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“…Further research is needed in the form of high quality prospective RCT to determine the need for VTE prophylaxis in patients who sustain a fragility fracture of the lower extremity. Although there have been some attempts to create VTE risk assessment tools 303,304 , to this day none have been validated or standardized 305 . Until then, risk stratification based on other medical comorbidities should play a role in shared decision making between the surgeon and the patient in determining the need for VTE prophylaxis in these patients.…”

Section: -Is Routine Vte Prophylaxis Indicated In Patients With Immob...mentioning

confidence: 99%

Recommendations from the ICM-VTE: Trauma

2022

Journal of Bone and Joint Surgery

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The ICM-VTE Trauma Delegates* 1 -What is the most optimal VTE prophylaxis in patients with multiple orthopaedic injuries?Response/Recommendation: Although multiple forms of prophylaxis against venous thromboembolism (VTE) with variable effectiveness are available for patients with multiple orthopedic injuries, low-molecular-weight heparin (LMWH) is considered the most optimal choice based on available literature.Strength of Recommendation: Acceptable.Delegates vote: Agree 86.36% Disagree 9.09% Abstain 4.55% (Strong Consensus).Rationale: VTE events following multiple orthopaedic injuries are associated with significant morbidity and mortality 1,2 . The prevalence of deep venous thrombosis (DVT) in trauma patients without prophylactic treatment can reach up to 60%. Pulmonary embolism (PE) can be a fatal form of VTE with prevalence ranging between 2 -16% 3,4 . VTE can be prevented using different mechanical and chemical prophylaxis agents, therefore, significantly lower the burden on healthcare systems worldwide 1 . The aim of this review is to find the most optimal VTE prophylaxis in patients with multiple orthopaedic injuries.Multiple orthopaedic injuries rarely happen without extraskeletal injuries, therefore, no studies in the current literature addressed VTE prophylaxis in patients with multiple orthopaedic injuries but without extra-skeletal injuries. Most of the available literature is addressing this patient population under different groups including, patients with trauma, poly-trauma, high energy fractures and lower extremity injuries [1][2][3][5][6][7] . The level of evidence varies among the reviewed literature, however, randomized controlled clinical trials in this subject are limited 3,4 .Based on our review, LMWH is considered the most optimal VTE prophylaxis in patients with multiple orthopaedic injuries 1,3,5,6,[8][9][10][11][12][13][14] . Ley et al., recommends using LMWH due to its increased bioavailability, acceptably low bleeding complications and longer plasma half-life 1 . Rogers et al., published in their guidelines for prevention of VTE in trauma patients that LMWH has superior bioavailability when compared to lowdose heparin (LDH) 5 . Knudson et al., concluded in a prospective, randomized trial that LMWH is an extremely effective *A list of the ICM-VTE Trauma Delegates is included in a note at the end of the article. Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G855).

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A critical evaluation of venous thromboembolism risk assessment models used in patients with lower limb cast immobilisation

Cited by 12 publications

References 21 publications

Pharmacological thromboprophylaxis to prevent venous thromboembolism in patients with temporary lower limb immobilization after injury: systematic review and network meta‐analysis

Pharmacological thromboprophylaxis to prevent venous thromboembolism in patients with temporary lower limb immobilization after injury: systematic review and network meta‐analysis

Clinical risk assessment model to predict venous thromboembolism risk after immobilization for lower-limb trauma

Recommendations from the ICM-VTE: Trauma

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