Effectiveness of low-molecular-weight heparin versus unfractionated heparin to prevent pulmonary embolism following major trauma

Byrne, James P.; Geerts, William; Mason, Stephanie; Gomez, David; Hoeft, Christopher; Murphy, Ryan; Neal, Melanie; Nathens, Avery B.

doi:10.1097/ta.0000000000001321

Cited by 54 publications

(57 citation statements)

References 36 publications

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“…Patients with severe lower extremity injuries are at high risk [23]. We recently found that femoral shaft fracture was a strong predictor of PE in a mixed trauma population [24]. Many PE in patients with femur fractures occur within 72 hours of injury [25], likely reflecting the synergistic effect of acute tissue trauma and venous stasis in the lower extremity on formation of early thromboembolism.…”

Section: Discussionmentioning

confidence: 99%

Timing of femoral shaft fracture fixation following major trauma: A retrospective cohort study of United States trauma centers

et al. 2017

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BackgroundFemoral shaft fractures are common in major trauma. Early definitive fixation, within 24 hours, is feasible in most patients and is associated with improved outcomes. Nonetheless, variability might exist between trauma centers in timeliness of fixation. Such variability could impact outcomes and would therefore represent a target for quality improvement. We evaluated variability in delayed fixation (≥24 hours) between trauma centers participating in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) and measured the resultant association with important clinical outcomes at the hospital level.Methods and findingsA retrospective cohort study was performed using data derived from the ACS TQIP database. Adults with severe injury who underwent definitive fixation of a femoral shaft fracture at a level I or II trauma center participating in ACS TQIP (2012–2015) were included. Patient baseline and injury characteristics that might affect timing of fixation were considered. A hierarchical logistic regression model was used to identify predictors of delayed fixation. Hospital variability in delayed fixation was measured using 2 approaches. First, the random effects output of the hierarchical model was used to identify outlier hospitals where the odds of delayed fixation were significantly higher or lower than average. Second, the median odds ratio (MOR) was calculated to quantify heterogeneity in delayed fixation between hospitals. Finally, complications (pulmonary embolism, deep vein thrombosis, acute respiratory distress syndrome, pneumonia, decubitus ulcer, and death) and hospital length of stay were compared across quartiles of risk-adjusted delayed fixation.We identified 17,993 patients who underwent definitive fixation at 216 trauma centers. The median injury severity score (ISS) was 13 (interquartile range [IQR] 9–22). Median time to fixation was 15 hours (IQR 7–24 hours) and delayed fixation was performed in 26% of patients. After adjusting for patient characteristics, 57 hospitals (26%) were identified as outliers, reflecting significant practice variation unexplained by patient case mix. The MOR was 1.84, reflecting heterogeneity in delayed fixation across centers. Compared to hospitals in the lowest quartile of delayed fixation, patients treated at hospitals in the highest quartile of delayed fixation suffered 2-fold higher rates of pulmonary embolism (2.6% versus 1.3%; rate ratio [RR] 2.0; 95% CI 1.2–3.2; P = 0.005) and required greater length of stay (7 versus 6 days; RR 1.15; 95% CI 1.1–1.19; P < 0.001). There was no significant difference with respect to mortality (1.3% versus 0.8%; RR 1.6; 95% CI 1.0–2.8; P = 0.066). The main limitations of this study include the inability to classify fractures by severity, challenges related to the heterogeneity of the study population, and the potential for residual confounding due to unmeasured factors.ConclusionsIn this large cohort study of 216 trauma centers, significant practice variability was observed in delayed fixation of ...

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Section: Discussionmentioning

confidence: 99%

Timing of femoral shaft fracture fixation following major trauma: A retrospective cohort study of United States trauma centers

et al. 2017

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“…Overall, the rate of VTE events among admitted patients with trauma at our centre, 3%, is in keeping with the published literature. 2,4,11 However, in the current study, we identified important areas of potential improvement that may lead to decreasing this number even further. One out of 5 patients did not receive any VTE prophylaxis within 24 hours of admission to the trauma service, and only one-third received pharmacologic prophylaxis.…”

Section: Discussionmentioning

confidence: 81%

“…9 However, studies have shown the superiority of LMWH compared to unfractionated heparin in prevention of VTE after major trauma. [9][10][11] Despite strong evidence and guidelines advocating for the routine use of pharmacologic prophylaxis, compliance rates vary widely. Currently, to our knowledge, there are no reported Canadian studies looking at compliance with the use of VTE prophylaxis within the first 24 hours in patients with trauma.…”

Section: Discussionmentioning

confidence: 99%

“…9 Furthermore, a higher risk of pulmonary embolism in these patients was shown when initiation of VTE pharmacologic prophylaxis occurred beyond the first day of admission. 11 Interestingly, not all patients for whom any type of VTE prophylaxis was ordered received it. Our study was not able to provide information on the cause of this; however, Machado-Aranda and colleagues 19 showed that a regi men of single daily dosing of LMWH is less likely to have challenges with missed doses.…”

Section: Discussionmentioning

confidence: 99%

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Venous thromboembolism prophylaxis and the impact of a thrombosis service at a Canadian level 1 trauma centre

Engels

Thomas

Coates

et al. 2019

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Background: Venous thromboembolism (VTE) is a common and serious complication seen in patients with trauma. Guidelines recommend the routine use of pharmacologic prophylaxis; however, compliance rates vary widely. The aim of this study was to describe the clinical practice related to VTE prophylaxis in the first 24 hours after injury at our level 1 Canadian trauma centre and the impact of a thrombosis consultation service. Methods: We performed a retrospective review of the health records of adult patients with trauma admitted between Jan. 1, 2012, and June 30, 2013. The rate of VTE was ascertained. The use of an initial prophylactic regimen, potential contraindications to prophylaxis and involvement of the thrombosis service were determined. Results: A total of 633 patients were included, 459 men and 174 women with a mean age of 47.4 years. The mean Injury Severity Score was 15.8. The overall VTE rate was 2.8%. A total of 514 patients (81.2%) received VTE prophylaxis, mechanical in 302 (47.7%) and pharmacologic in 231 (36.5%) (19 patients received both types). The thrombosis service was involved in the care of 164 patients (25.9%). Patients seen by the thrombosis service were more likely to receive VTE prophylaxis than those not seen by the service (145 [88.4%] v. 369 [78.7%], p < 0.01). Conclusion: Compliance with VTE prophylaxis administration was suboptimal, and opportunities for improvement exist. The involvement of a thrombosis consultation service appears to improve compliance with VTE prophylaxis, and augmented use of this service may improve clinical outcomes. Contexte : La thromboembolie veineuse (TEV) est une complication grave et fréquente chez les patients vus en traumatologie. Les lignes directrices recommandent l'utilisation systématique d'une prophylaxie pharmacologique; par contre, les taux de conformité aux lignes directrices varient beaucoup. Le but de cette étude était de décrire la pratique clinique en matière de thromboprophylaxie dans notre centre de traumatologie canadien de niveau 1 au cours des 24 premières heures suivant un traumatisme et l'impact d'un service de prévention des thromboses.

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“…Finally, it has been well known that pulmonary embolism (PE) is a leading cause of delayed mortality in patients with severe injury (15). In this guideline, pharmacological thromboprophylaxis was recommended within 24 h after bleeding has been controlled (Grade 1B) (11).…”

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confidence: 99%

Dealing with Traumatic Coagulopathy: A Long Way to Go

Feng¹,

Wang²

2017

J Anesth Perioper Med

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Effectiveness of low-molecular-weight heparin versus unfractionated heparin to prevent pulmonary embolism following major trauma

Abstract: Therapeutic study, level III.

Cited by 54 publications

References 36 publications

Timing of femoral shaft fracture fixation following major trauma: A retrospective cohort study of United States trauma centers

Timing of femoral shaft fracture fixation following major trauma: A retrospective cohort study of United States trauma centers

Venous thromboembolism prophylaxis and the impact of a thrombosis service at a Canadian level 1 trauma centre

Dealing with Traumatic Coagulopathy: A Long Way to Go

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