Background: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality following traumatic injury. Trauma patients are at an increased risk for VTE secondary to dysregulation of the coagulation system, reduced mobility, and the type of traumatic injury. Low molecular weight heparin (LMWH) is the drug of choice for VTE prophylaxis in this population because of its increased bioavailability, longer half-life, and predictable pharmacokinetics. Subcutaneous heparin is alternatively recommended for patients with a creatinine clearance less than 30 mL/min or with end stage renal disease on hemodialysis. Timely initiation of appropriate VTE prophylaxis is crucial to preventing fatal complications in trauma patients. VTE prophylaxis must be initiated early and continue throughout the admission without missing doses for orthopedic and most other surgical procedures. Limited guidance has been established and VTE prophylaxis strategies generally rely on institutional protocol and surgeon’s discretion. Given the challenges of balancing bleed risk and VTE prevention, there is a need for a standardized protocol guided VTE prophylaxis in trauma patients. The purpose of this study was to determine the impact of implementing a VTE prophylaxis protocol in trauma patients admitted to the intensive care unit.
Methods: This was an observational, pre-post study completed at Piedmont Columbus Regional Midtown in Columbus, GA during two independent time periods. The primary objective of this study was to determine rate of compliance with evidence based VTE prophylaxis in the pre-implementation group compared to the post-implementation group, including appropriate dose of VTE prophylaxis, time to administration of VTE prophylaxis, and time to perioperative re-initiation of VTE prophylaxis. The secondary objectives were incidence of VTE, incidence of major bleeding, number of initial anti-Xa levels in goal for patients who received LMWH, and days needed to achieve goal anti-Xa level for patients who received LMWH. The primary outcome was analyzed using Chi-square test and the secondary outcomes were analyzed using either Chi-square test or Fisher's exact test. Patients were excluded if their length of stay was less than 24 hours, they were pregnant, had coagulopathy on admission, clinical signs of ongoing hemorrhage, had an indication for therapeutic anticoagulation on admission, or traumatic brain injury meeting high-risk Modified Berne-Norwood Criteria.
Results: For the primary objective of protocol compliance for VTE prophylaxis, 25% of patients in the pre-group met compliance with the protocol versus 41% in the post-group. For secondary objectives, three patients in the pre-group had a VTE occurrence whereas none did in the post-group. Six patients in the pre-group had an incidence of major bleeding, compared to none in the post-group. Only 10 patients in the pre-group had anti-Xa level monitoring obtained and 13 patients in the post group. Of which, 40% had an initial anti-Xa at goal in the pre-group versus 54% in the post-group. The days needed to achieve anti-Xa goal was also not significantly different after implementation of the protocol.
Conclusion: Implementation of a standardized VTE prophylaxis protocol improved appropriate selection of dose and time to initiation without increasing frequency of bleeding.
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