Assessment of the Use of Pharmacologic Venous Thromboembolism Prophylaxis in Post-Traumatic Brain Injury Patients

2020 ◽  
pp. 089719002092981
Author(s):  
Raghad Saadi ◽  
Kimberly Brandt ◽  
Robert Madlinger ◽  
Steven F. Nerenberg
Keyword(s):  
Traumatic Brain Injury ◽  
Venous Thromboembolism ◽  
Brain Injury ◽  
Bleeding Complications ◽  
Optimal Timing ◽  
Linear Regression Models ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Scan Time ◽  
Significant Difference

Background: Traumatic brain injury (TBI) is an independent risk factor for venous thromboembolism (VTE). Prophylaxis (PPX) beyond 48 hours increases VTE risk 3- to 4-fold. Pharmacologic VTE PPX initiation is controversial due to potential bleeding complications. Objective: To evaluate VTE PPX in patients with TBI for practice variation, efficacy, and safety. Methods: Retrospective review from January 2013 to September 2016 in adults admitted to the intensive care unit with moderate to severe TBI. Demographics, time to stable computerized tomography scan, time to PPX initiation, PPX regimen, and incidences of VTE and adverse effects were collected. Data were analyzed via descriptive statistics, analysis of variance, and linear regression models. Results: Of 96 patients included, 14.6% did not receive VTE PPX (G1), 7.3% initiated therapy within 0 to 24 hours (G2), 14.6% after 24 to 48 hours (G3), and 63.5% after 48 hours (G4). VTE occurred in 0% of G1 and G2, 28.6% of G3, and 8.2% of G4 patients ( P = .038). Of 9 VTE cases, 8 received medical and 1 received trauma PPX dosing ( P = .44). There were 3 major bleeds ( P = .79) and 19 minor bleeds ( P = .042). Of 14 fatalities, 42.9% were in G1, 0% in G2, 14.2% in G3, and 42.9% in G4 ( P = .009). Conclusion: The majority of patients received delayed PPX, with no correlation between VTE incidence and PPX regimen. There was a significant difference in VTE incidence stratified by time to PPX. Further studies are required to determine optimal timing of PPX. Higher mortality rate was correlated with the lack of PPX. Increased minor bleeds occurred with earlier PPX initiation.

Late Venous Thromboembolism Prophylaxis after Craniotomy in Acute Traumatic Brain Injury

2015 ◽  
Vol 81 (2) ◽  
pp. 207-211 ◽  
Author(s):  
Mitchell J. Daley ◽  
Sadia Ali ◽  
Carlos V. R. Brown
Keyword(s):  
Traumatic Brain Injury ◽  
Venous Thromboembolism ◽  
Brain Injury ◽  
Trauma Patients ◽  
Thromboembolism Prophylaxis ◽  
Treatment Groups ◽  
Vein Thrombosis ◽  
Significant Difference ◽  
Pharmacologic Prophylaxis ◽  
Level I

The objective of this study is to compare rates of venous thromboembolism (VTE) in patients who receive enoxaparin prophylaxis compared with no enoxaparin prophylaxis after craniotomy for traumatic brain injury (TBI). This retrospective cohort evaluated all trauma patients admitted to a Level I trauma center from January 2006 to December 2011 who received craniotomy after acute TBI. Patients were excluded if developed VTE before administration of enoxaparin or they died within the first 72 hours of hospital admission. A total of 271 patients were included (enoxaparin prophylaxis, n = 45; no enoxaparin prophylaxis, n = 225). The median time until enoxaparin initiation was 11 ± 1 days. There was no significant difference in the proportion of patients who developed a VTE when using enoxaparin prophylaxis compared with no enoxaparin prophylaxis (2 vs 4%; P = 0.65). Rates of deep vein thrombosis (2 vs 3%; P = 0.87) and pulmonary embolism (0 vs 1%; P = 0.99) were similar between treatment groups, respectively. Late enoxaparin prophylaxis did not demonstrate a protective effect for VTE. Given the overall low event rate, the administration of pharmacologic prophylaxis against VTE late in the treatment course may not be routinely warranted after craniotomy for acute TBI. Further investigation with early administration of enoxaparin is needed.

scholarly journals Venous thromboembolism prophylaxis in patients with traumatic brain injury: a systematic review

F1000Research ◽  
2013 ◽  
Vol 2 ◽  
pp. 132 ◽  
Author(s):  
Yohalakshmi Chelladurai ◽  
Kent A Stevens ◽  
Elliott R Haut ◽  
Daniel J Brotman ◽  
Ritu Sharma ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Venous Thromboembolism ◽  
Brain Injury ◽  
Optimal Timing ◽  
Controlled Trials ◽  
Low Grade ◽  
Thromboembolism Prophylaxis ◽  
Randomized Controlled ◽  
Timing Of Initiation ◽  
Deep Vein

Objective: There is considerable practice variation and clinical uncertainty about the choice of prophylaxis for preventing venous thromboembolism in patients with traumatic brain injury. We performed a systematic review to assess both the effectiveness and safety of pharmacologic and mechanical prophylaxis, and the optimal time to initiate pharmacologic prophylaxis in hospitalized patients with traumatic brain injury.Data sources and study selection: MEDLINE®, EMBASE®, SCOPUS, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library were searched in July 2012 to identify randomized controlled trials and observational studies reporting on the effectiveness or safety of venous thromboembolism prevention in traumatic brain injury patients.Data extraction: Paired reviewers extracted detailed information from included articles on standardized forms and assessed the risk of bias in each article.Data synthesis: Twelve studies (2 randomized controlled trials and 10 cohort studies) evaluated the effectiveness and safety of venous thromboembolism prophylaxis in patients with traumatic brain injury. Five of the included studies assessed the optimal timing of initiation of pharmacological prophylaxis. Low grade evidence supports the effectiveness of enoxaparin over control in reducing deep vein thrombosis. Low grade evidence also supports the safety of unfractionated heparin over control in reducing mortality in patients with traumatic brain injury. Evidence was insufficient for remaining comparisons and outcomes including the optimal timing of initiation of pharmacoprophylaxis.Conclusion: There is some evidence that pharmacoprophylaxis improves deep vein thromboses and mortality outcomes in patients hospitalized with traumatic brain injury. Additional studies are required to strengthen this evidence base.

scholarly journals Retrospective Study of Venous Thromboembolism Prophylaxis Dosing of Heparin in Adult Patients receiving Continuous Renal Replacement Therapy

2021 ◽  
Vol 6 (2) ◽  
Keyword(s):  
Venous Thromboembolism ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Safety Outcome ◽  
Venous Thromboembolism Prophylaxis ◽  
Efficacy Outcome ◽  
Significant Difference ◽  
Dosing Intervals

Background: Appropriate chemical and/or mechanical venous thromboembolism prophylaxis is a high priority for clinicians. Unfortunately, there is little evidence-based guidance for clinical decision making for patients requiring both renal replacement therapy and VTE prophylaxis. The package insert for unfractionated heparin recommends 5000 units subcutaneously every 8 to 12 hours for VTE prophylaxis. Objective: The purpose of this study was to assess the two recommended dosing intervals and determine if there is a difference in terms of incidence of clotting or bleeding events. Methods: 159 patients were admitted to the UNC Health Care system between March 2014 and November 2019 and retrospectively screened for incidence of both the primary composite efficacy outcome (symptomatic or asymptomatic vascular event (VTE [DVT and PE]), ischemic event (stroke, TIA, or myocardial infarction), or death related to coagulopathy), the individual components of the composite outcome and the primary safety outcome. The results of the outcomes were then compared and analyzed using Fischer’s Exact test. Results: The two tailed p-values of the primary composite efficacy outcome (0.3517), the primary safety outcome (0.1571) and each of the composite outcomes (0.1556, 1.0000, 0.2297, respectively) showed no statistically significant difference. Conclusion: Results of this study show that there is no statistical difference between the dosing intervals of prophylactic UFH of every 8 to 12 hours, in terms of the incidence of VTE and major bleed events, for patients requiring CRRT. Suggesting that either interval is both efficacious and safe for the use of VTE prophylaxis.

Low-Dose Aspirin is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Knee Arthroplasty: A Retrospective Cohort Study

2020 ◽  
Author(s):  
Alex Tang ◽  
Stephen G. Zak ◽  
Daniel Waren ◽  
Richard Iorio ◽  
James D. Slover ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Venous Thromboembolism ◽  
Knee Arthroplasty ◽  
Total Joint Replacement ◽  
Joint Infection ◽  
Revision Total Knee Arthroplasty ◽  
Bleeding Complications ◽  
Vte Prophylaxis ◽  
Significant Difference ◽  
Total Knee

AbstractVenous thromboembolism (VTE) events are rare, but serious complications of total joint replacement affect patients and health care systems due to the morbidity, mortality, and associated cost of its complications. There is currently no established universal standard of care for prophylaxis against VTE in patients undergoing revision total knee arthroplasty (rTKA). The aim of this study was to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or sufficient in preventing VTE in patients undergoing rTKAs versus 325-mg ASA BID. In 2017, our institution adopted a new protocol for VTE prophylaxis for arthroplasty patients. Patients initially received 325-mg ASA BID for 1 month and then changed to a lower dose of 81-mg BID. A retrospective review from 2011 to 2019 was conducted identifying 1,438 consecutive rTKA patients and 90-day postoperative outcomes including VTE, gastrointestinal, and wound bleeding complications, acute periprosthetic joint infection, and mortality. In the 74 months prior to protocol implementation, 1,003 rTKAs were performed and nine VTE cases were diagnosed (0.90%). After 26 months of the protocol change, 435 rTKAs were performed with one VTE case identified (0.23%). There was no significant difference in rates or odds in postoperative pulmonary embolism (PE; p = 0.27), DVT (p = 0.35), and total VTE rates (p = 0.16) among patients using either protocol. There were also no differences in bleeding complications (p = 0.15) or infection rate (p = 0.36). No mortalities were observed. In the conclusion, 81-mg ASA BID is noninferior to 325-mg ASA BID in maintaining low rates of VTE and may be safe for use in patients undergoing rTKA.

Increased Enoxaparin Dosing for Venous Thromboembolism Prophylaxis in General Trauma Patients

2016 ◽  
Vol 51 (4) ◽  
pp. 323-331 ◽  
Author(s):  
Cheri K. Walker ◽  
Elizabeth A. Sandmann ◽  
Taylor J. Horyna ◽  
Mark A. Gales
Keyword(s):  
Venous Thromboembolism ◽  
Trauma Patient ◽  
Patient Population ◽  
Standard Dose ◽  
Bleeding Complications ◽  
Trauma Patients ◽  
Dosing Regimen ◽  
Thromboembolism Prophylaxis ◽  
General Trauma ◽  
Vte Prophylaxis

Objective: To review the evidence regarding increased enoxaparin dosing for venous thromboembolism (VTE) prophylaxis in the general trauma patient population. Data Sources: A search of MEDLINE databases (1946 to October 2016) was conducted using the search terms enoxaparin, thromboembolism prophylaxis, venous thromboembolism, trauma, anti-factor Xa, and weight-based dosing. Additional references were identified from a review of literature citations. Study Selection and Data Extraction: Search results were limited to English-language studies conducted in humans. Trials that included only obese patients or nontrauma patients were excluded. Data Synthesis: A total of 7 trials (958 patients) explored the use of increased dosing of enoxaparin for VTE prophylaxis in trauma patients. Patients were divided by enoxaparin dosing strategies: standard dosing of 30 mg twice daily (BID; n = 509), higher initial dosing regimen (n = 216), or dosing based on anti-FXa level adjustments (n = 233). The majority of the 42 total VTE events (64.3%) occurred in the standard dosing regimen. Within each group, VTE was reported in 5.3% of patients in the standard dosing group, 3.2% in the higher initial dosing group, and 4% in the anti-FXa adjustment group. Initial subtherapeutic anti-FXa levels occurred in 33% to 92% of standard dose patients and 9% to 39% of higher initial dose patients. The average weight-based dose required to achieve a therapeutic level ranged between 0.43 and 0.54 mg/kg/dose BID. The overall rate of bleeding was low, with 3 incidents (0.37%) reported. Conclusion: Standard-dose enoxaparin prophylaxis may not be optimal for the general trauma patient population. Weight-based enoxaparin dosing (0.5 mg/kg/dose BID) is an option in trauma patients considered to be at a lower risk of bleeding complications.

scholarly journals P133 Types and timing Of venous thromboembolism Prophylaxis for Traumatic Brain Injury (TOP TBI) Study

BJS Open ◽  
2021 ◽  
Vol 5 (Supplement_1) ◽  
Author(s):  
Soham Bandyopadhyay ◽  
Robin Borchert ◽  
Angelos G Kolias ◽  
Aswin Chari ◽  
Daniel M Fountain ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Venous Thromboembolism ◽  
Brain Injury ◽  
Intracranial Haemorrhage ◽  
Research Network ◽  
Thromboembolism Prophylaxis ◽  
High Quality ◽  
Venous Thromboembolism Prophylaxis ◽  
The Uk ◽  
Pharmacological Thromboprophylaxis

Abstract Background Patients with traumatic brain injury are at significant risk for both developing venous thromboembolisms and haemorrhagic progression. Pharmacological thromboprophylaxis and mechanical thromboprophylaxis may be able to minimise the incidence of venous thromboembolisms. Problematically, pharmacological thromboprophylaxis also has the potential to augment clinically significant intracranial haemorrhage expansion. Compounding this issue is that the evidence for mechanical thromboprophylaxis is not based on neurotrauma populations, and there is insufficient evidence to guide clinicians on the optimum agent, dose, and timing of pharmacological thromboprophylaxis. Based on the need for high quality evidence, we propose the Types and timing Of venous thromboembolism Prophylaxis for Traumatic Brain Injury (TOP TBI) Study. Aim To collect high quality and relevant data regarding thromboprophylaxis practice and associated outcomes - including rates of venous thromboembolisms, intracranial haemorrhage expansion and mortality – for TBI patients in the UK and Ireland in order to optimise management for these patients. Methods We will adopt a multicentre, prospective, observational cohort design. All neurosurgical units: in the UK and Ireland will be eligible to participate. Patient eligibility will be determined according to pre-specified criteria. Eligible cases will be prospectively recruited over two months and followed-up in 6 months. Based on epidemiological investigations and data from the Trauma Audit and Research Network, we expect to recruit between 1000 to 2000 patients. Anonymised data will be collected locally and submitted to a secure web-based central database. Outcome measures These include all-cause mortality, venous thromboembolism events, haemorrhagic progression, re-admission, surgical intervention, length of stay in admitting unit, neurological status, and Extended Glasgow Outcome Scale during follow-up. Conclusion TOP TBI is an important step in the ongoing efforts to optimise the outcomes of patients who have suffered a traumatic brain injury. It is hoped that the results will give insight into contemporary practice in the UK and Ireland and inform future studies.

Early Chemoprophylaxis Against Venous Thromboembolism in Patients With Traumatic Brain Injury

2021 ◽  
pp. 000313482098317
Author(s):  
Lisbi Rivas ◽  
Michael Vella ◽  
Tammy Ju ◽  
Joseph S. Fernandez-Moure ◽  
Andrew Sparks ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Venous Thromboembolism ◽  
Brain Injury ◽  
Organ Injury ◽  
Blunt Injury ◽  
Vte Prophylaxis ◽  
Time To Initiation ◽  
Early Cohort ◽  
Head Computed Tomography

Introduction Timing to start of chemoprophylaxis for venous thromboembolism (VTE) in patients with traumatic brain injury (TBI) remains controversial. We hypothesize that early administration is not associated with increased intracranial hemorrhage. Methods A retrospective study of adult patients with TBI following blunt injury was performed. Patients with penetrating brain injury, any moderate/severe organ injury other than the brain, need for craniotomy/craniectomy, death within 24 hours of admission, or progression of bleed on 6 hour follow-up head computed tomography scan were excluded. Patients were divided into early (≤24 hours) and late (>24 hours) cohorts based on time to initiation of chemoprophylaxis. Progression of bleed was the primary outcome. Results 264 patients were enrolled, 40% of whom were in the early cohort. The average time to VTE prophylaxis initiation was 17 hours and 47 hours in the early and late groups, respectively ( P < .0001). There was no difference in progression of bleed (5.6% vs. 7%, P = .67), craniectomy/-craniotomy rate (1.9% vs. 2.5%, P = .81), or VTE rate (0% vs. 2.5%, P = .1). Conclusion Early chemoprophylaxis is not associated with progression of hemorrhage or need for neurosurgical intervention in patients with TBI and a stable head CT 7 hours following injury.

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