Ask the Experts - Venous Thromboembolism Prophylaxis and Diagnosis in...
Ask the Experts - Venous Thromboembolism Prophylaxis and Diagnosis in...
What is the current approach to venous thromboembolism prophylaxis and diagnosis in trauma patients?
Dr. A. Halpern
This topic may be one of the most controversial in the management of the postinjury patient. Fortunately, we have at least 2 good studies to guide us in venous thromboembolism prophylaxis and diagnosis. These studies are discussed below.
The first study, developed by the Eastern Association for the Surgery of Trauma (EAST), presents recommended practice management guidelines for venous thromboprophylaxis in trauma patients. A definition of the classes of data and levels of recommendation are seen in the Table.
Table. AHCPR Definition of Classes of Data and Levels of Recommendation
* AHCPR = Agency for Health Care Policy and Research
EAST based its information on a 1988 meta-analysis by Clagett and a study by Geerts and colleagues of low-dose heparin (LDH) and low-molecular-weight heparin (LMWH) after major trauma. As a level I recommendation for thromboprophylaxis in the trauma patient, there is little if any benefit for LDH, LMWH, or the arterial venous foot pump. As a level II recommendation for venous thromboprophylaxis, LMWH should be used. As a level III recommendation for venous thromboprophylaxis, LDH in combination with sequential compression devices (SCDs) should be used in trauma patients at high risk (ie, high-risk patients would include those with severe closed head injury [Glasgow Coma Score < 8], pelvis and long bone fractures, multiple long bone fractures, and spinal cord injury), where arteriovenous foot pumps could be used as a substitute for SCDs. However, the authors found scarce data in trauma patients to support combination prophylaxis.
The same EAST practice guidelines found that ultrasonography can be used to assess symptomatic trauma patients with suspected deep venous thrombosis (DVT) without confirmatory venography. There was insufficient data to support the use of impedance plethysmography in diagnostic imaging for DVT following trauma.
Velmahos and colleagues looked at the cost-effectiveness of the different methods of posttraumatic venous thromboprophylaxis. They found that LMWH and SCDs must show substantial improvements in measured outcomes in future studies to be more cost-effective than LDH.
Based on the above information, LMWH can be used for venous thromboprophylaxis in trauma patients with high-risk injuries; however, LDH is more cost-effective.
What is the current approach to venous thromboembolism prophylaxis and diagnosis in trauma patients?
Dr. A. Halpern
This topic may be one of the most controversial in the management of the postinjury patient. Fortunately, we have at least 2 good studies to guide us in venous thromboembolism prophylaxis and diagnosis. These studies are discussed below.
The first study, developed by the Eastern Association for the Surgery of Trauma (EAST), presents recommended practice management guidelines for venous thromboprophylaxis in trauma patients. A definition of the classes of data and levels of recommendation are seen in the Table.
Table. AHCPR Definition of Classes of Data and Levels of Recommendation
|
Classes of Data |
|
|
Class I |
Prospective, randomized, controlled trials |
|
Class II |
Clinical studies with prospectively collected data and large retrospective analyses based on reliable data |
|
Class III |
Retrospectively collected data and expert opinion |
|
Recommendation Level Level I |
It is usually based on class I data; however, strong class II evidence may form the basis for a level I recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, weak or contradictory class I data may not be able to support a level I recommendation. |
|
Level II |
It is usually supported by class II data or a preponderance of class III evidence. |
|
Level III |
It is generally supported by class III data. |
* AHCPR = Agency for Health Care Policy and Research
EAST based its information on a 1988 meta-analysis by Clagett and a study by Geerts and colleagues of low-dose heparin (LDH) and low-molecular-weight heparin (LMWH) after major trauma. As a level I recommendation for thromboprophylaxis in the trauma patient, there is little if any benefit for LDH, LMWH, or the arterial venous foot pump. As a level II recommendation for venous thromboprophylaxis, LMWH should be used. As a level III recommendation for venous thromboprophylaxis, LDH in combination with sequential compression devices (SCDs) should be used in trauma patients at high risk (ie, high-risk patients would include those with severe closed head injury [Glasgow Coma Score < 8], pelvis and long bone fractures, multiple long bone fractures, and spinal cord injury), where arteriovenous foot pumps could be used as a substitute for SCDs. However, the authors found scarce data in trauma patients to support combination prophylaxis.
The same EAST practice guidelines found that ultrasonography can be used to assess symptomatic trauma patients with suspected deep venous thrombosis (DVT) without confirmatory venography. There was insufficient data to support the use of impedance plethysmography in diagnostic imaging for DVT following trauma.
Velmahos and colleagues looked at the cost-effectiveness of the different methods of posttraumatic venous thromboprophylaxis. They found that LMWH and SCDs must show substantial improvements in measured outcomes in future studies to be more cost-effective than LDH.
Based on the above information, LMWH can be used for venous thromboprophylaxis in trauma patients with high-risk injuries; however, LDH is more cost-effective.
