Optimal timing of venous thromboembolic chemoprophylaxis initiation following blunt solid organ injury: meta-analysis and systematic review

Abstract

The need to prevent venous thromboembolism (VTE) following blunt solid organ injury must be balanced against the concern for exacerbation of hemorrhage. The optimal timing for initiation of VTE chemoprophylaxis is not known. The objective was to determine the safety and efficacy of early (≤48 hours) VTE chemoprophylaxis initiation following blunt solid organ injury.METHODS: An electronic search was performed of medical libraries for English-language studies on timing of VTE chemoprophylaxis initiation following blunt solid organ injury published from inception to April 2020. Included studies compared early (≤48 hours) versus late (>48 hours) initiation of VTE chemoprophylaxis in adults with blunt splenic, liver and/or kidney injury.Estimates were pooled using random-effects meta-analysis. Odds ratios were utilized to quantify differences in failure of nonoperative management, need for blood transfusion and rates of VTE. RESULTS:The search identified 2,111 studies. Of these, ten studies comprising 14,675 patients were included. All studies were non-randomized and only one was prospective. The overall odds of failure of nonoperative management were no different between early and late groups, OR 1.09 (95%CI 0.92-1.29). Similarly, there was no difference in the need for blood transfusion either during overall hospital stay, OR 0.91 (95%CI 0.70-1.18), or post prophylaxis initiation, OR 1.23 (95%CI 0.55-2.73). There were significantly lower odds of VTE when patients received early VTE chemoprophylaxis, OR 0.51 (95%CI 0.33-0.81). CONCLUSIONS: Patients undergoing nonoperative management for blunt solid organ injury can be safely and effectively prescribed early VTE chemoprophylaxis. This results in significantly lower VTE rates without demonstrable harm.

Timing of pharmacologic venous thromboembolism prophylaxis initiation for trauma patients with nonoperatively managed blunt abdominal solid organ injury: a systematic review and meta-analysis

“…Importantly, the finding that early VTEp initiation was associated with a statistically significant increase in the rate of failure of NOM differs from the conclusions of a recent systematic review and meta-analysis [ 12 ]. As noted above, the findings were largely driven by the Gaitanidis et al’s study, which was published in January 2021 and therefore could not be included in the review by Murphy et al [ 12 , 13 ].…”

“…Importantly, the finding that early VTEp initiation was associated with a statistically significant increase in the rate of failure of NOM differs from the conclusions of a recent systematic review and meta-analysis [ 12 ]. As noted above, the findings were largely driven by the Gaitanidis et al’s study, which was published in January 2021 and therefore could not be included in the review by Murphy et al [ 12 , 13 ]. It is also important to note that the Gaitanidis et al’s study excluded patients with an extra-abdominal Abbreviated Injury Scale score greater than 3, thereby eliminating an important confounder that can impact the decision to start VTEp [ 13 ].…”

“…Reported rates of failure of NOM due to bleeding are as high as 11–20% for patients with liver and spleen injuries, with most failures occurring within 48 h of injury [ 2 , 11 ]. Recently, a systematic review and meta-analysis including ten studies published prior to April 2020 concluded that VTEp could be safely initiated within 48 h [ 12 ]. However, a 2021 study including 3223 patients with isolated blunt abdominal solid organ injuries conversely found a significantly increased risk of bleeding in those who received VTEp at earlier than 48 h [ 13 ].…”

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

“…To date, two systematic reviews and meta-analyses demonstrated that patients undergoing NOM for blunt solid organ injury could be safely and effectively prescribed early VTE prophylaxis. Murphy et al [ 41 ] included ten studies comprising 14,675 patients that compared early (≤ 48 h) versus late (> 48 h) initiation of VTE chemoprophylaxis in adults with blunt splenic, liver, and/or kidney injury. All studies were non-randomized, and only one was prospective.…”

“…The 2017 WSES guidelines stated that LMWH-based prophylactic anticoagulation should be started as soon as possible from splenic trauma, including patients treated with NOM [1]. Our systematic review of the literature regarding this topic retrieved 15 studies, of which two were systematic reviews and meta-analyses [40,41], two were prospective cohort studies [35,38], and 11 were retrospective cohort studies [27,28,36,37,[42][43][44][45][46][47][48]. To date, two systematic reviews and meta-analyses demonstrated that patients undergoing NOM for blunt solid organ injury could be safely and effectively prescribed early VTE prophylaxis.…”