Progression of Intracranial Hemorrhage After Chemical Prophylaxis Using Low-Molecular-Weight Heparin in Patients With Traumatic Brain Injury

Introduction Chemical prophylaxis using low-molecular-weight heparin (LMWH) is considered a standard of care for venous thromboembolism in trauma patients. Our center performs a head computed tomography (CT) scan 24 hours after initiation with prophylactic LMWH in the setting of a known traumatic brain injury (TBI). The purpose was to determine the overall incidence of ICH progression after chemoprophylaxis in patients with a TBI. Methods This retrospective study was performed at a Level I trauma center, from 1/1/2014 to 12/31/2017. Study patients were drawn from the institution’s trauma registry based on Abbreviated Injury Score codes. Results 778 patients met all inclusion criteria after initial chart review. The proportion of patients with an observed radiographic progression of intracranial hemorrhage after LMWH was 5.8%. 3.1% of patients had a change in clinical management. Observed radiographic progression after LMWH prophylaxis and the presence of SDH on initial CT, the bilateral absence of pupillary response in the emergency department, and a diagnosis of dementia were found to have statistically significant correlation with bleed progression after LMWH was initiated. Conclusion Over a 4-year period, the use of CT to evaluate for radiographic progression of traumatic intracranial hemorrhage 24 hours after receiving LMWH resulted in a change in clinical management for 3.1% of patients. The odds of intracranial hemorrhage progression were approximately 6.5× greater in patients with subdural hemorrhage on initial CT, 3.1× greater in patients with lack of bilateral pupillary response in ED, and 4.2× greater in patients who had been diagnosed with dementia.

Chemical Versus Mechanical and Chemical Venous Thromboembolism Prophylaxis in Neurocritically Ill Patients: A Cohort Study

Background: Patients admitted with neurocritical illness are presumed to be at high risk for venothromboembolism (VTE). The administration of chemical and/or mechanical VTE prophylaxis is a common practice in critically ill patients. Recent data did not show a significant difference in the incidence of VTE between chemical compared to chemical and mechanical VTE prophylaxis in critically ill patients with limited data in neurocritically ill population. The objective of this study is to investigate the incidence of VTE between chemical alone compared to chemical and mechanical VTE prophylaxis in neurocritically ill patients. This was a retrospective cohort study at a tertiary teaching hospital. Data were obtained from electronic medical records for all patients admitted with neurocritical illness from 1/1/2016 to 1/12/2020. Patients were excluded if they did not receive VTE prophylaxis during admission or were younger than 18 YO. Major outcomes were symptomatic VTE based on clinical and radiological findings, intensive care unit (ICU) length of stay (LOS), and hospital LOS. Minor outcomes included severe or life-threatening bleeding based on GUSTO criteria, and mortality at 28-days. Results: Two hundred and twelve patients were included in this study. Patients did not have any significant differences in their baseline characteristics. The incidence of VTE was not different between chemical only compared to chemical and mechanical VTE prophylaxis groups (19/166 (11.3%) vs 7/46 (15.2%); P=0.49. No difference between groups in their ICU LOS 6 [3 – 16.2] vs 6.5 [3 – 19]; P=0.52, nor their mortality (18/166 (10.7%) vs 3/46 (6.5%); P=0.38, respectively. Less bleeding events were seen in the chemical prophylaxis group compared to the combined VTE prophylaxis group (19/166 (11.3%) vs 12/46 (26.1%); P= 0.013. Conclusion: Our findings observed no difference between the administration of chemical prophylaxis alone compared to combined VTE prophylaxis in neurocritically ill patients. More data are needed to confirm this finding with more robust methodology.

243 Thromboprophylaxis In Elective Arthroplasty Patients: Assessing DVT Rates

Introduction Deep vein thrombosis (DVT) in elective hip and knee arthroplasty range from 1-25%. The NICE Guidelines for Venous Thromboembolism (VTE) advise offering chemical prophylaxis with anti-embolism stockings (AES) as VTE prophylaxis. The aim of this study was to assess the role of anti-embolism stockings, by analysing the rates of DVT in patients who had chemical VTE prophylaxis in combination with anti-embolism stockings compared to patients who had chemical prophylaxis alone. Method Retrospective data analysis of patients who underwent elective primary hip or knee replacements from April 2018 to April 2019. Patient records were reviewed for each patient to identify any subsequent DVT diagnosis. Results 759 patients were identified. 595 patients had combined chemical VTE prophylaxis and AES. 164 patients did not have AES. 12 patients who received the combined therapy presented to A+E with suspected DVT, which was confirmed in two patients. Of the patients who did not receive AES, there were no cases of DVT. Conclusions There was no increase in DVT rates in patients who were not offered anti-embolic stockings. Taking into account the risks associated with AES and the costs incurred, the routine prescription of stockings must be carefully reviewed by orthopaedic departments.

The Incidence and Location of Deep Vein Thrombosis in Lower Extremity Fracture Patients Receiving Sequential Chemical Prophylaxis

To investigate the incidence and location of deep vein thrombosis (DVT) in patients with lower extremity fractures receiving pharmacological thromboprophylaxis with LMWH followed by rivaroxaban. All patients aged ≥18 years with lower extremity fractures were included in the study. Duplex ultrasonography (DUS) was performed in the lower extremities before and after surgery for DVT evaluation. According to the location, the DVT was divided into proximal, distal, and mixed thromboses. According to fracture location, patients were classified as having fractures proximal, around, and distal to the knee. All patients received sequential chemical prophylaxis. A total of 404 patients with a mean age of 44.2 ± 13.8 years were included. The incidence of DVT postoperatively was higher than that preoperatively and at 1 month postoperatively. Patients with fractures proximal and around the knee had higher DVT incidences detected on DUS postoperatively and at 1 month postoperatively. Most DVTs were located in the distal vein. DVT incidence and severity were the highest immediately after surgery. DVT incidence in fractures around and proximal to the knee increased after surgery and at 1 month postoperatively. Although with chemical thromboprophylaxis, distal DVT was the most variable during the early stage.

To Assess the Appropriateness of the Venous Thromboembolism (VTE) Prophylaxis Agent Used Based on the VTE Risk Stratification in Hospitalised Acutely Ill Medical Patients

Introduction: An estimated 16% of acutely ill medical patients are at risk of developing venous thromboembolism (VTE) in the absence of appropriate VTE prophylaxis. Hence, the appropriate use of risk stratification models such as Padua Prediction Score(PPS) and prophylactic agents is paramount to mitigate the risk of VTE among hospitalized patients. Despite the existence of VTE prophylaxis guidelines published by the American Society of Hematology(ASH), the risk stratification models and VTE prophylactic agents are often either over- or under-utilized by the clinicians. Objective: To determine the characteristics of VTE prophylaxis orders in a community hospital and the rate of PPS utilization by the clinicians in assessing the VTE risk. The secondary outcome is the appropriateness of the prophylactic agent prescribed based on the patients' risk stratification. Method: We conducted a retrospective chart review of 480 hospitalized medical patients for the month of September 2018. We assessed the adherence of our clinicians to the use of PPS and the VTE prophylaxis agents used per the ASH 2018 VTE Guidelines. Inclusion criteria: ≥18-year-old patients admitted to medical service. Exclusion criteria: admission to non-medical services or ICU, on-going anticoagulation therapy, and pregnancy. Statistical analysis was performed to compare the use of VTE prophylactic agents between teaching and non-teaching services. A survey consisting of 9 questions was distributed to 15 resident physicians to assess their understanding of the VTE prophylaxis for hospitalized medical patients per the ASH 2018 recommendations. Results: Based on our inclusion criteria, a total of 333 patients were eligible for data analysis. Only 3.3%(11/333 patients) had a PPS documented. We re-calculated the PPS for the missing data, 222 patients had a PPS of <4 and 111 patients had a PPS of ≥4. Out of 333 patients, 243 of the patients received chemical prophylaxis either alone or in combination with a mechanical agent, 66 of the patients received mechanical prophylaxis, and 24 of the patients received no VTE prophylaxis (Fig.1). No VTE or bleeding events were recorded in any of our patients. Majority of the patients, 70.37% were prescribed unfractionated heparin(UFH), 23.04% received low molecular weight heparin(LMWH), 6.5% received a combined VTE prophylaxis (Fig.1). Notably, 71.62% (159/222) low-risk for VTE (PPS <4) patients were prescribed chemical VTE prophylactic agents either alone or in combination with the mechanical agents (Fig.2). The extra expense incurred secondary to unnecessary chemical prophylaxis for low-risk patients was calculated about $18/patient (based on an average length of stay of 5 days and cost of UFH dosed thrice daily for a total of 15 vials/patient). In our study, expenditure on these 159 patients amounts to $2862/month, and a calculated approximate annual expenditure of $34,000/year. Based on Fisher's exact test there was a statistically significant difference between the teaching and non-teaching services in prescribing VTE prophylactic agents [p=0.026] among patients with PPS<4. The non-teaching service clinicians were less likely to prescribe pharmacologic VTE prophylaxis compared to teaching clinicians [60.75% vs. 72.17%] (Fig.3). Nonetheless, there was no statistical significance between the two services in the use of VTE prophylactic agent in patients with PPS ≥4 [p=0.38]. Our resident survey revealed that 60% of the residents used their clinical judgment for initiating VTE prophylaxis and did not utilize PPS. 80% of them were aware of the ASH panel 2018 guidelines about LMWH being the VTE prophylaxis agent of choice. Conclusion: Our study revealed that PPS remained underused among the clinicians in our community hospital before prescribing VTE prophylactic agent. The selection of appropriate VTE prophylactic agent remained underscored among our clinicians. It was notable that UFH continued to be the most commonly prescribed VTE prophylactic agent among hospitalized medical patients in our hospital. As a result, we are determined to educate, improve, and raise awareness on the use of PPS and prophylactic agent among our clinicians in accordance with the ASH 2018 VTE guidelines. Disclosures No relevant conflicts of interest to declare.

A cross sectional study to measure prevalence of DVT in subacute and chronic spinal cord injury patients without any chemical prophylaxis

<p class="abstract"><strong>Background:</strong> Prevalence of DVT in patients with sub-acute and chronic SCI has only been reported in a limited number of studies. Knowing the incidence of thromboembolic events in the sub-acute and chronic rehabilitation phase is important to estimate disease risk and facilitate evidence based prevention. We sought to determine the prevalence of DVT in patients of subacute and chronic phases post spinal cord injury without any chemical prophylaxis.</p><p class="abstract"><strong>Methods:</strong> Between June 2016 and April 2018, all cases of sub-acute and chronic spinal cord injury, undergoing rehabilitation at our centre were studied. Patients with pre-existing coagulopathy/hypercoagulable state/ bleeding diathesis or on medications for these conditions, tobacco smokers, chronic alcoholics and obese individuals were excluded from the study. All patients enrolled in the study were given mechanical DVT prophylaxis and followed institutional rehabilitation protocol. They were evaluated at 3 months, 6 months and 9 months by clinical examination and CDFI for any evidence of DVT.<strong></strong></p><p class="abstract"><strong>Results:</strong> Out of 60 patients studied, 04 patients developed DVT (3 in ASIA grade A and 1 in ASIA grade B patient). 75% (3 cases) of the cases were detected in the first 3 months and only one case was detected between 3-6 moths post Spinal cord injury. The prevalence of DVT in our study, in subacute and chronic cases of spinal cord injury was 6.67%.</p><p><strong>Conclusions:</strong> Our study is in concurrence with the existing literature about the low prevalence of DVT in Southeast Asian population which doesn’t warrant DVT chemoprophylaxis in subacute and chronic SCI cases.</p>

Venous Thromboprophylaxis in Spine Surgery

Study Design: Review article. Objective: A review of the literature on postoperative initiation of thrombophylactic agents following spine surgery. Methods: A review of the literature and synthesis of the data to provide an update on venous thromboprophylaxis following spine surgery. Results: Postoperative regimens of venous thromboprophylaxis measures following spine surgery remain a controversial issue. Recommendations regarding mechanical versus chemical prophylaxis vary greatly among institutions. Conclusion: Postoperative spine surgery initiation of thromboprophylaxis remains controversial regarding optimal timing and agent selection. The benefits of deep vein thrombosis/pulmonary embolism prophylaxis must be weighed against the possible postoperative complications associated with spine surgery.

Prevalence and Predictors of Deep Vein Thrombosis in Critically Ill Medical Patients Who Underwent Diagnostic Duplex Ultrasonography

Introduction: Deep vein thrombosis (DVT) is a recognized but preventable cause of morbidity and mortality in the medical intensive care unit (MICU). We examined the prevalence and risk factors for DVT in MICU patients who underwent diagnostic venous duplex ultrasonography (DUS) and the potential effect on clinical outcomes. Methods: This is a retrospective study examining prevalence of DVT in 678 consecutive patients admitted to a tertiary care level academic MICU from July 2014 to 2015. Patients who underwent diagnostic DUS were included. Potential conditions of interest were mechanical ventilation, hemodialysis, sepsis, Sequential Organ Failure Assessment (SOFA) scores, central venous catheters, prior DVT, and malignancy. Primary outcomes were pulmonary embolism, ICU length of stay, and mortality. Additionally, means of thromboprophylaxis was compared between the groups. Multivariable logistic regression analysis was utilized to determine predictors of DVT occurrence. Results: Of the 678 patients, 243 (36%) patients underwent DUS to evaluate for DVT. The prevalence of DVT was 16% (38) among tested patients, and a prior history of DVT was associated with DVT prevalence ( P < .01). Between cases and controls, there were no significant differences in central venous catheters, mechanical ventilation, hemodialysis, sepsis, SOFA scores, malignancy, and recent surgery. Patients receiving chemical prophylaxis had fewer DVTs compared to persons with no prophylaxis (14% vs 29%; P = .01) and persons with dual chemical and mechanical prophylaxis ( P = 0.1). Fourteen percent of patients tested had documented DVT while on chemoprophylaxis. There were no significant differences in ICU length of stay ( P = .35) or mortality ( P = .34). Conclusions: Despite the appropriate use of universal thromboprophylaxis, critically ill nonsurgical patients still demonstrated high rates of DVT. A history of DVT was the sole predictor for development of proximal DVT on DUS testing. Dual chemical and mechanical prophylaxis does not appear to be superior to single-chemical prophylaxis in DVT prevention in this population.

Chemical venous thromboembolism prophylaxis in neurosurgical patients: an updated systematic review and meta-analysis

OBJECTIVEVenous thromboembolism (VTE) is a common and potentially life-threatening complication. The risk of serious hemorrhagic complications when starting chemical prophylaxis for VTE prevention is a substantial concern for neurosurgeons. The objective of this study was to perform an updated systematic review and meta-analysis to determine if the rates of VTE and bleeding complications are different in patients undergoing chemoprophylaxis compared with placebo or mechanical prophylaxis alone following cranial or spinal procedures.METHODSIn February 2016 a systematic literature review was performed identifying 3944 articles from 4 different databases. A random-effects meta-analysis was performed after identifying the articles that met inclusion criteria.RESULTSNine articles that met the inclusion criteria were included. The quality of the studies was good, with all of them being classified as Level 2 evidence, with moderate Jadad scores. A meta-analysis comparing chemoprophylaxis with placebo in the prevention of deep venous thrombosis showed a significant benefit to chemical prophylaxis (OR 0.51, 95% CI 0.37–0.71; p < 0.0001). No significant increase in major intracranial hemorrhage (p = 0.60), major extracranial hemorrhage (p = 0.98), or minor bleeding complications (p = 0.60) was found.CONCLUSIONSBased on moderate-to-good quality of evidence, chemoprophylaxis is beneficial in preventing VTE, with no significant increase in either major or minor bleeding complications in patients undergoing cranial and spinal procedures. Further research is needed to determine whether this conclusion holds true for more specific subpopulations.