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Thromboprophylasis in Trauma Pts

Thomas J Moore MD
Richard Thomas MD
Atlanta Trauma Symposium
April 26, 2013

No Conflicts

Introduction

Introduction

Venous thromboembolic (VTE)


disease is associated with significant
morbidity and mortality
Acute PE is responsible for more than
150,000 deaths per year
Symptomatic PE: 2-10% of pelvic fx
pts, fatal 0.5%-2%
Most preventable cause (3rd most
frequent cause) of in-hospital
mortality among trauma patients
Increased risk of developing VTE in
patients undergoing major
orthopedic procedures involving:

Pelvis
Hip
Knee
Multiple trauma involving lower
extremity fractures
Spinal cord injury

Tornetta JAAOS 2012

Pathogenesis of VTE disease

Virchows Triad
Endothelial injury
Venous stasis
Hypercoagulable state
Endothelial injury alone can induce thrombosis
Examples:
Kinking of veins during total hip and
knee surgery
Use of a tourniquet
Limb positioning during surgery
Poor mobility after surgery leads to stasis,
which leads to platelet adhesion to
endothelium
Mechanism by which hypercoagulable state
leads to clot formation is poorly understood

Risk Factors
Inherited thrombophilia
Bed rest or immobility for
more than 5 days
Malignancy
Estrogen or hormone
replacement therapy
History of MI or stroke
Obesity
History of smoking
Prior VTE

Increased risk of VTE Associated with Inherited


Thrombophilia

The balance between procoagulant


and anticoagulant systems
disturbed by overactive
coagulopathic factors or
underactive antithrombotic factors
~ 15% of pts <45 yrs with idiopathic
DVTs have deficiency of protein C,
protein S or antithrombin III
Recommend LMWH in
asymptomatic pts with known
heritary thrombophilia with major
trauma
? Routine testing for pts with
clinically significant DVT with
trauma unless family history or
recurrent DVTs

Factor V Leiden mutation


Heterozygous..7X
Homozygous.80X
Prothrombin G20210A..2.8%
Antithrombin III deficiency..5-20X
Protein C deficiency2-10X
Protein S deficiency.2-10X
Hyperhomocysteinemia.2.5X
Elevated factor VII..5X
Elevated factor XI..........2.2X
Grabowski JAAOS 2013

Thromboembolic Prophylaxis

99% : VTE prophylaxis necessary

VTE Prophylaxis in Orthopaedic


Trauma Patients
The American College of
Chest Physicians (ACCP) and
American Academy of
Orthopedic Surgeons (AAOS)
have designed
comprehensive
Thromboprophylasis
guidelines
Little recommendations for
trauma patients and more
specifically orthopaedic
trauma patients

American College of Chest Physicians Evidencebased Guidelines for Venous Thromboembolic


Prophylaxis: the Guideline Wars Are Over
ACCP Guidelines (2012) and the AAOS Guidelines (2011) provide safety
and efficacy recommendations for VTE prophylaxis
For pts undergoing major orthopaedic surgery: dual prophylaxis with an
antithrombotic agent and an intermittent pneumatic compression device
(IPCD) during hospital stay and Thromboprophylasis for up to 35 days as
outpatient (up from 10-14 days)
In pts undergoing major orthopaedic surgery and with risk of bleeding:
an IPCD or no prophylaxis rather than pharmacologic treatment
In pts undergoing major orthopaedic surgery with contraindications to
to both pharmacologic and IPCD prophylasis: no IVC filter
Moderate-quality evidence to support the use of low-dose ASA for VTE
prophylasis compared to no prophylasis
Lieberman JAAOS 2012

HIERARCHY OF EVIDENCE
Basic
Science

Clinical
Relevance

Economic

Level 1 Randomized Trials


Level 2 Prospective Cohort Studies
Level 3. Case Control Studies
Level 4.
Retrospective Case Series
Level 5
Expert Opinion

Metaanalysis

Less Bias

Meta-analysis
1. Enoxaprin vs new agents (fondaparinux, dabigatran,
apixaban, rivaoxabin) : relative equivalence in DVT and PE
prophylasis but difference in bleeding complications and cost
Ann Vasc Surg 2913
2. LMWH vs other anticoagulents (unfractionated heparin, Vit K
antagonists, Factor Xa inhibitors, direct thrombin inhibitors):
additional benefits with LMWH with less harm Pharmotherapy
2012
3. Pharmacologic agents plus IPCD vs IPCD alone: no difference in
DVT or PE rates Pharmacotherapy 2013

Pharmacologic Prophylaxis
Rivaroxaban (Xarelto)
First oral selective Xa inhibitor
Approved for DVT prophylaxis in patients undergoing
total knee and hip arthroplasty surgery
Taken once daily
Relatively low cost
No monitoring needed
Shown to reduce the risk of VTEs after total knee and
hip surgery
May be associated with increased wound bleeding
complications
Jameson JBJS 2012

304 patients with hip and pelvic fractures randomized to


SCDs or no treatment
Followed by Doppler, duplex scans, and VQ scans
11% incidence of VTE in control group
0.4% incidence of VTE in experimental group
In patients with hip fracture:
12% incidence in control group vs. 4% in experimental group

No difference in patients with a pelvis fracture

Indications, Complications, and Management


of IVC Filters: the Experience of 952 Pts in a
Level 1 Trauma Center
Only 8.5% filters removed,
despite the use of removeable
filters
74 clinically significant venous
thrombotic events occurred post
filter placement, including 25 PEs
The use IVC filters for
prophylasis for VTE in trauma pts
results in suboptimal outcomes
due to high rates of venous
thromboembolism and potential
complications

Sarosiek JAMA 2013

Conclusions

Legal and Economic Considerations


1.

2.

3.

Geographic variability in use of


IVC filters: higher use in states
with significantly higher paid
malpractice claims per 100K
and significantly higher liability
insurance premiums (Meltzer
Surgery 2013)
2nd highest malpractice payout
for fatal PE without prophylasis
in 2009 Mag Mutual
Pay for Performance criteria in
pilot study hip fxs in California:
$ surgical fee penalty for
absence of DVT Prophylasis

Inpatient Enoxaparin and Outpatient ASA


Chemoprophylaxis Regimen after THR and TKR
500 pts
Inpatient enoxaparin (ave
2.75days) followed by
outpatient ASA (28 days)
VTE rate 0.6% (1 DVT, 2 PE)
Bleeding (requiring Tx) 1.8%
Compared favorably with
control group Rxed with 14
days enoxaparin followed
by 14 days ASA

Hamilton, Bradbury, Roberson J Arthroplasty 2012

Recommendations for
Thromboprophylasis in Major Trauma
1. Peri-operative: pharmacologic (Lovenox) with IPCD
2. Outpatient Rx: ASA 325mg daily for 28 days
3. If significant risk of bleeding (ie liver contusion, epidural
head bleed) no pharmacologic antithrombotic Rx, IPCD if
possible
4. No indication for IVC filter placement for prophylaxis
5. No indication for radiographic imaging to r/o DVT at
discharge from initial hospitization