Abstract
Background
Venous thromboembolic (VTE) events are a major concern in trauma and intensive care, with the prothrombotic state caused by traumatic brain injury (TBI) increasing the risk in affected patients. We sought to identify critical demographic and clinical variables and determine their influence on subsequent VTE development in patients with TBI.
Methods
This was a cross-sectional study with data retrospectively collected from 818 patients with TBI admitted to a level I trauma center in 2015–2020 and placed on VTE prophylaxis.
Results
The overall VTE incidence was 9.1% (7.6% deep vein thrombosis, 3.2% pulmonary embolism, 1.7% both). The median time to diagnosis was 7 days (interquartile range 4–11) for deep vein thrombosis and 5 days (interquartile range 3–12) for pulmonary embolism. Compared with those who did not develop VTE, patients who developed VTE were younger (44 vs. 54 years, p = 0.02), had more severe injury (Glasgow Coma Scale 7.5 vs. 14, p = 0.002, Injury Severity Score 27 vs. 21, p < 0.001), were more likely to have experienced polytrauma (55.4% vs. 34.0%, p < 0.001), more often required neurosurgical intervention (45.9% vs. 30.5%, p = 0.007), more frequently missed ≥ 1 dose of VTE prophylaxis (39.2% vs. 28.4%, p = 0.04), and were more likely to have had a history of VTE (14.9% vs. 6.5%, p = 0.008). Univariate analysis demonstrated that 4–6 total missed doses predicted the highest VTE risk (odds ratio 4.08, 95% confidence interval 1.53–10.86, p = 0.005).
Conclusions
Our study highlights patient-specific factors that are associated with VTE development in a cohort of patients with TBI. Although many of these are unmodifiable patient characteristics, a threshold of four missed doses of chemoprophylaxis may be particularly important in this critical patient population because it can be controlled by the care team. Development of intrainstitutional protocols and tools within the electronic medical record to avoid missed doses, particularly among patients who require operative interventions, may result in decreasing the likelihood of future VTE formation.
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References
Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;331:1601–6.
Cook DJ, Crowther MA, Meade MO, Douketis J; VTE in the ICU Workshop Participants. Prevalence, incidence, and risk factors for venous thromboembolism in medical-surgical intensive care unit patients. J Crit Care. 2005;20:309–13.
O’Malley KF, Ross SE. Pulmonary embolism in major trauma patients. J Trauma. 1990;30:748–50.
Reitsma PH, Versteeg HH, Middeldorp S. Mechanistic view of risk factors for venous thromboembolism. Arterioscler Thromb Vasc Biol. 2012;32:563–8.
Reiff DA, Haricharan RN, Bullington NM, Griffin RL, McGwin G Jr, Rue LW 3rd. Traumatic brain injury is associated with the development of deep vein thrombosis independent of pharmacological prophylaxis. J Trauma. 2009;66:1436–40.
Praeger AJ, Westbrook AJ, Nichol AD, et al. Deep vein thrombosis and pulmonary embolus in patients with traumatic brain injury: a prospective observational study. Crit Care Resusc. 2012;14:10–3.
Laroche M, Kutcher ME, Huang MC, Cohen MJ, Manley GT. Coagulopathy after traumatic brain injury. Neurosurgery. 2012;70:1334–45.
Hammond FM, Meighen MJ. Venous thromboembolism in the patient with acute traumatic brain injury: screening, diagnosis, prophylaxis, and treatment issues. J Head Trauma Rehabil. 1998;13:36–50.
Scudday T, Brasel K, Webb T, et al. Safety and efficacy of prophylactic anticoagulation in patients with traumatic brain injury. J Am Coll Surg. 2011;213:148–53 (discussion 53–4).
Paydar S, Sabetian G, Khalili H, et al. Management of deep vein thrombosis (DVT) prophylaxis in trauma patients. Bull Emerg Trauma. 2016;4:1–7.
Phelan HA. Pharmacologic venous thromboembolism prophylaxis after traumatic brain injury: a critical literature review. J Neurotrauma. 2012;29:1821–8.
Louis SG, Sato M, Geraci T, et al. Correlation of missed doses of enoxaparin with increased incidence of deep vein thrombosis in trauma and general surgery patients. JAMA Surg. 2014;149:365–70.
Salottolo K, Offner P, Levy AS, Mains CW, Slone DS, Bar-Or D. Interrupted pharmocologic thromboprophylaxis increases venous thromboembolism in traumatic brain injury. J Trauma. 2011;70:19–24 (discussion 5–6).
Ali AB, Khawaja AM, Reilly A, et al. Venous thromboembolism risk and outcomes following decompressive craniectomy in severe traumatic brain injury: an analysis of the nationwide inpatient sample database. World Neurosurg. 2022;161:e531–45.
Karsy M, Azab MA, Harper J, et al. Evaluation of a D-Dimer protocol for detection of venous thromboembolism. World Neurosurg. 2020;133:e774–83.
Van Gent JM, Bandle J, Calvo RY, et al. Isolated traumatic brain injury and venous thromboembolism. J Trauma Acute Care Surg. 2014;77:238–42.
Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury. Neurosurgery. 2017;80:6–15.
Lichte P, Kobbe P, Almahmoud K, et al. Post-traumatic thrombo-embolic complications in polytrauma patients. Int Orthop. 2015;39:947–54.
Dengler BA, Mendez-Gomez P, Chavez A, et al. Safety of chemical DVT prophylaxis in severe traumatic brain injury with invasive monitoring devices. Neurocrit Care. 2016;25:215–23.
MacCallum KP, Kalata S, Darcy D, et al. Prolonged use of spinal precautions is associated with increased morbidity in the trauma patient. Injury. 2020;51:317–21.
Acknowledgements
We acknowledge Kristin Kraus, MSc, for her expert editing and review of this article.
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Conceptualization: SN, SM, JN, RG; Data curation: SN, KLC, SG, JH, JC; Formal analysis: KLC; Funding acquisition: SM, RG; Methodology: SN, KLC, RG; Project administration: SM, RG; Visualization: SN, KLC; Writing—original draft: SN, KLC, RG; Writing—review & editing: SN, KLC, JN, SM, RG. The final manuscript was approved by all authors.
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Cole, K.L., Nguyen, S., Gelhard, S. et al. Factors Associated with Venous Thromboembolism Development in Patients with Traumatic Brain Injury. Neurocrit Care 40, 568–576 (2024). https://doi.org/10.1007/s12028-023-01780-8
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DOI: https://doi.org/10.1007/s12028-023-01780-8