Venous thromboembolism (VTE) is a common potential complication after traumatic injury. But typically, injury is associated with bleeding, so the trauma professional has to strike a balance between preventing bleeding and preventing clots.
Solid organ injury (liver and spleen, typically) is a common diagnosis after blunt trauma. Most trauma centers have protocols for VTE prophylaxis which apply to patients with those injuries. Older literature that I wrote about eight years divided the time frames for prophylaxis into early (within 3 days), late (greater than 3 days), and none. The authors of that article found that there was no association with untoward bleeding in the early group. And interestingly, there seemed to be less in that group. Unfortunately, the selection of the groups was biased, and the early VTE prophylaxis group had less severe injuries.
The surgery group at the Massachusetts General Hospital tried to clarify current practice by performing a deep dive into the Trauma Quality Improvement Program database. They searched the database to identify patients with “isolated” liver, spleen, kidney, and pancreas injury. They did this by excluding TBI, femur and pelvic fractures, spinal cord injury, and penetrating trauma. They also excluded patients with other other severe injuries with an abbreviated injury scale score of 3 or more.
The authors stratified patients into three groups: early VTE prophylaxis receiving the drug within 48 hours of arrival, intermediate within 48-72 hours, and late after 72 hours.
Here are the factoids:
- A total of 3,223 patients met inclusion criteria
- Prophylaxis was classified as early in 57%, intermediate in 22%, and late in 21%
- About 3/4 received low molecular weight heparin and the remainder received unfractionated heparin
- Late prophylaxis was associated with a 3x increase in both VTE and pulmonary embolism (PE)
- Intermediate prophylaxis patient had a 2x increase in VTE but no increase in PE
- Early prophylaxis showed a 2x increase in bleeding complications, especially in those with diabetes (?), spleen, and high-grade liver injury
- A total of 60 of the 1,832 patients in the early group had bleeding events: 39 failed nonop mangement and were taken to OR, 8 underwent angioembolization, and 21 received blood transfusions
The authors concluded that early prophylaxis should be considered in patients who do not fall out as higher risk (spleen, high-grade liver, diabetics).
Bottom line: This retrospective study is probably as good as it’s going to get from a data quality standpoint. It’s larger than any single-institution series will ever be, although it suffers from the usual things most large database studies do.
But it does show us strong associations with DVT and PE as the consequences of waiting to start VTE prophylaxis beyond 48 hours. The caveat is to be careful in certain patients, most notably diabetics and those with liver and spleen injuries, as they are at higher risk to develop complications leading to the OR or interventional radiology suite.
I urge all of you to re-examine your VTE prophylaxis guideline and modify it to start your drug of choice as early as possible given the cautions for patients with spleen and high-grade liver injuries. The diabetes thing, well, that’s a mystery to me and I will wait for further confirmation to break those patients out separately.
If you are interested, you can see the Regions Hospital trauma program VTE guideline by clicking here.
- Thromboembolic prophylaxis with low-molecular-weight heparin in patients with blunt solid abdominal organ injuries undergoing nonoperative management: current practice and outcomes. J Trauma 70(1): 141-147, 2011.
- Timing of thromboprophylaxis in patients with blunt abdominal solid organ injuries undergoing nonoperative management. J Trauma pulish ahead of print, October 12, 2020, doi: 10.1097/TA.0000000000002972