Saudi Critical Care Society clinical practice guidelines on the prevention of venous thromboembolism in adults with trauma: reviewed for evidence-based integrity and endorsed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

Abstract

Background To develop evidence-based clinical practice guidelines on venous thromboembolism (VTE) prevention in adults with trauma in inpatient settings. Methods The Saudi Critical Care Society (SCCS) sponsored guidelines development and included 22 multidisciplinary panel members who completed conflict-of-interest forms. The panel developed and answered structured guidelines questions. For each question, the literature was searched for relevant studies. To summarize treatment effects, meta-analyses were conducted or updated. Quality of evidence was assessed using the Grading Recommendations, Assessment, Development, and Evaluation (GRADE) approach, then the evidence-to-decision (EtD) framework was used to generate recommendations. Recommendations covered the following prioritized domains: timing of pharmacologic VTE prophylaxis initiation in non-operative blunt solid organ injuries; isolated blunt traumatic brain injury (TBI); isolated blunt spine trauma or fracture and/or spinal cord injury (SCI); type and dose of pharmacologic VTE prophylaxis; mechanical VTE prophylaxis; routine duplex ultrasonography (US) surveillance; and inferior vena cava filters (IVCFs). Results The panel issued 12 clinical practice recommendations—one, a strong recommendation, 10 weak, and one with no recommendation due to insufficient evidence. The panel suggests starting early pharmacologic VTE prophylaxis for non-operative blunt solid organ injuries, isolated blunt TBIs, and SCIs. The panel suggests using low molecular weight heparin (LMWH) over unfractionated heparin (UFH) and suggests either intermediate–high dose LMWH or conventional dosing LMWH. For adults with trauma who are not pharmacologic candidates, the panel strongly recommends using mechanical VTE prophylaxis with intermittent pneumatic compression (IPC). The panel suggests using either combined VTE prophylaxis with mechanical and pharmacologic methods or pharmacologic VTE prophylaxis alone. Additionally, the panel suggests routine bilateral lower extremity US in adults with trauma with elevated risk of VTE who are ineligible for pharmacologic VTE prophylaxis and suggests against the routine placement of prophylactic IVCFs. Because of insufficient evidence, the panel did not issue any recommendation on the use of early pharmacologic VTE prophylaxis in adults with isolated blunt TBI requiring neurosurgical intervention. Conclusion The SCCS guidelines for VTE prevention in adults with trauma were based on the best available evidence and identified areas for further research. The framework may facilitate adaptation of recommendations by national/international guideline policymakers.

Thrombosis prophylaxis following trauma

“…Guidelines for thrombosis prophylaxis in critically ill trauma patients typically recommend the administration of subcutaneous low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) [10][11][12][13]. The timing of initiation is tailored to each patient, but pharmacologic prophylaxis should typically be started within 24-72 h posttrauma in the absence of ongoing bleeding.…”

“…The pharmacologic thrombosis prophylaxis strategies currently in practice involve administering dalteparin, enoxaparin, and UFH in standardised doses [12,13]. However, the application of these one-size-fits-all doses, especially given the subcutaneous route of administration, presents challenges.…”

A Challenging Case of Anticoagulation: Acute Traumatic Brain Injury Complicated by Multifocal Venous Thromboembolism

“…Evidence also suggests that UFH and LMWH can reduce cerebral edema and improve neurological recovery by inhibiting the recruitment of leukocytes [29,30] . For the prevention of VTE events, most experts and studies prefer LMWH over UFH, as LMWH has a similar risk of bleeding but a lower incidence of DVT and is associated with reduced mortality [31][32][33][34] .…”

Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department

“…The efficacy of pharmacological prophylaxis in preventing thromboembolic events after TBI is well established in the updated Brain Trauma Foundation guideline [67]. In a recent SR [104] and GL [105], the authors concluded that low-molecular-weight heparin (LMWH) or UFH can be safely administered as early as 24-48 h post-injury for patients with low-hemorrhagic-risk TBI and stable pictures upon repeated imaging. However, TBI patients receiving OAT were excluded from the selected studies.…”