DVT Prophylaxis in the Trauma Patient

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DVT Prophylaxis in the Trauma Patient

• Christopher E. Mutty, MD
• Wake Forest University
• 1/19/08

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DVT Prophylaxis in the Trauma Patient

• Large topic / little time.
• Focus on
• Basic science (sub-101).
• Incidence.
• VTE risk factors.
• Treatment options.
• Recommendations.
• New directions.

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DVT Basic Science
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DVT Basic Science
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DVT Basic Science
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DVT Basic Science
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DVT Basic Science
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DVT Basic Science
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DVT Basic Science
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DVT Trauma Incidence
A Prospective Study of Venous Thromboembolism
after Major Trauma William H. Geerts, Karen I.
Code, Richard M. Jay, Erluo Chen, and John Paul
Szalai
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DVT Trauma Incidence
A Prospective Study of Venous Thromboembolism
after Major Trauma William H. Geerts, Karen I.
Code, Richard M. Jay, Erluo Chen, and John Paul
Szalai

• Canadian level 1 trauma center.
• 349 patients admitted to trauma unit
• ISS gt 8.
• No pharmacologic or mechanical prophylaxis.
• DVT diagnosed by venography.
• PE diagnosed by VQ scan (or at autopsy).

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DVT Trauma Incidence
A Prospective Study of Venous Thromboembolism
after Major Trauma William H. Geerts, Karen I.
Code, Richard M. Jay, Erluo Chen, and John Paul
Szalai

• 201/349 (58) patients diagnosed with DVT.
• 63/349 (18) patients diagnosed with proximal
  DVT.
• Only 3 patients had clinical characteristics of
  DVT prior to diagnosis by venography.
• 39 patients had clinically suspected PE.
• PE confirmed in 7 patients, fatal in three
  cases.

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DVT Trauma Incidence

• In at risk populations (which includes
  orthopaedic trauma patients)
• DVT rates reported at 10-20.
• PE rates reported at 1-2.
• Mortality in patients with PE 20-50.
• These rates are reported in studies which
  include patients receiving some type of
  prophylaxis!

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DVT Trauma Risk Factors
Venous thromboembolism after trauma Trauma Knuds
on, M Margaret Ikossi, Danagra G Department of
Surgery, University of California, San Francisco,
San Francisco Injury Center for Research and
Prevention, San Francisco, California, USA
Volume 10(6), December 2004, pp 539-548
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DVT Trauma Risk Factors
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DVT Prophylaxis - Pharmacologic

• Vitamin K antagonists
• Warfarin
• Antithrombin agonists
• Unfractionated heparin
• Low molecular weight heparin
• Factor Xa inhibitors
• Fondaparinux
• Direct thrombin antagonists
• Hirudin, argatroban, ximelgatran, etc.
• Anti-platelet agents
• Aspirin, dipyrimadole, clopidogrel, etc.

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DVT Prophylaxis - Pharmacologic
Extrinsic pathway
Intrinsic pathway
Antithrombin III
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DVT Prophylaxis - Mechanical

• Pneumatic Compression Devices
• Foot pumps, sequential compression devices
  (SCDs).
• Vena Cava filters

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Vena Cava Filters
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Vena Cava Filters

• IVC filters are relatively safe and appear to
  be effective in reducing the incidence of PE.
• The literature on the use of prophylactic IVC
  filters in trauma patients is conflicting.

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Vena Cava Filters
Cochrane Database of Systematic Reviews.
(3)CD006212, 2007.
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Vena Cava Filters

• Limited generalisability prevents any
  conclusions to be drawn from the PREPIC trial in
  that permanent filters were used and the study
  lacked statistical power to detect a reduction
  in PE over shorter and more clinically
  significant time periods.

Cochrane Database of Systematic Reviews.
(3)CD006212, 2007.
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DVT Prophylaxis - Recommendations
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DVT Prophylaxis - Recommendations

• 62 page article?!
• Lists 794 references!

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DVT Prophylaxis - Recommendations

• Chest???
• Who are these guys?
• What do they really know about orthopaedics?

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DVT Prophylaxis - Recommendations
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DVT Prophylaxis - Recommendations
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DVT Prophylaxis - Recommendations

• Orthopaedic surgery sections of recommendations
  were formally reviewed by 16 external experts,
  10 of whom were orthopaedic surgeons (including
  several well known orthopaedic traumatologists).
• Recommendations reviewed and supported by the
  AAOS.

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DVT Prophylaxis - Recommendations

• 1.4.4 Aspirin
• Recommend against aspirin alone as prophylaxis
  for any patient group. (Grade 1A).
• 1.4.3 Mechanical Prophylaxis
• To be used primarily in patients who are at high
  risk of bleeding (Grade 1C), or as an adjunct to
  anticoagulant-based prophylaxis (Grade 2A).

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DVT Prophylaxis - Recommendations

• 3.7 Isolated lower extremity injuries
• We suggest that clinicians not use
  thromboprophylaxis routinely in patients with
  isolated lower extremity injuries (Grade 2A).
• 3.4 Hip fracture surgery (HFS)
• Recommend the routine use of fondaparinux
  (Grade 1A), LMWH (Grade 1C), adjusted dose VKA
  with target INR 2.5 (Grade 2B), or LDUH (Grade
  1B).
• 3.5.3.2 Patients undergoing THA or HFS be given
  extended prophylaxis for up to 28-35 days after
  surgery (Grade 1A). Options for prophylaxis
  include fondaparinux, LMWH, VKA.

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DVT Prophylaxis - Recommendations

• 5.1 Trauma
• All trauma patients receive thromboprophylaxis,
  if possible (Grade 1A).
• Unless contraindicated, use LMWH starting as
  soon as it is considered safe to do so (Grade
  1A).
• Recommend against the use of vena cava filters
  as primary prophylaxis in trauma patients (Grade
  1C).
• Recommend continuation of prophylaxis through
  the completion of inpatient rehab (Grade 1C),
  and suggest continued prophylaxis after
  discharge with LMWH or VKA in patients with
  impaired mobility (Grade 2C).

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DVT Prophylaxis Recent Reports

• Stannard et al (JBJS 200688(2)261-266)
  conducted a prospective RCT of early foot pumps
  LMWH vs. LMWH alone in the trauma patient
  population.
• 224 patients.
• DVT prevalence 8.7 vs. 13.4 (no diff).
• Large / occlusive DVT 2.9 vs. 11.3 (p0.025).
• early mechanical prophylaxis with the addition
  of LMWH on a delayed basis is a very
  successful strategy for prophylaxis against VTE
  following serious musculoskeletal injury.

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DVT Prophylaxis New Strategies

• Direct Factor Xa inhibitors
• DX-9065a, Razaxaban
• Direct Thrombin Inhibitors
• Hirudin, Argatroban, Ximelagatran
• Continuous Passive Motion
• Arthroflow

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Thank You
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DVT Prophylaxis - References

• Whang PG. Lieberman JR. Low Molecular-Weight
  Heparin. JAAOS. 200210(5)299-302.
• Rogers FB et al. Practice Management Guidelines
  for the Prevention of Venous Thromboembolism in
  Trauma Patients The EAST Practice Management
  Guidelines Work Group. Journal of Trauma.
  200253(1)142-64.
• Turpie A et al. Fondaparinux. JAAOS.
  200412(6)371-75.
• Geerts WH et al. Prevention of Venous
  Thromboembolism The Seventh ACCP Conference on
  Antithrombotic and Thrombolytic Therapy.
  Chest2004126338-400.
• Knudson MM. Ikossi DG. Venous Thromboembolism
  After Trauma. Current Opinion in Critical Care.
  200410(6)539-548.
• Geerts WH et al. A Prospective Study of Venous
  Thromboembolism After Major Trauma. NEJM.
  19943311601-1606.
• Avorn J. Winkelmayer WC. Comparing the Costs,
  Risks, and Benefits of Competing Stategies for
  the Primary Prevention of Venous Thromboembolism.
  Circulation. 2004110(24), S425-32.
• Callahan JJ et al. Prophylaxis for Thromboembolic
  Disease Recommendations From the American
  College of Chest Physicians Are They
  Appropriate for Orthopaedic Surgery? Journal of
  Arthroplasty. 200520(3)273-274.
• Stannard JP et al. Prophylaxis Against Deep-Vein
  Thrombosis Following Trauma A Prospective,
  Randomized Comparison of Mechanical and
  Pharmacologic Prophylaxis. JBJS. 200688261-66.
• Cole PA. Bhandari M. Whats New in Orthopaedic
  Trauma. JBJS. 2006882545-61.

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DVT Basic Science
Structural conformation of antithrombin III
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DVT Trauma Incidence
Figure 1. The Frequency of Deep-Vein Thrombosis
among 349 Patients with One or More Major
Injuries. The white boxes indicate the
frequencies of deep-vein thrombosis among the 243
patients with injuries confined to a single
region of the body, and the black boxes indicate
the frequencies among the 106 patients with
injuries in two regions (87 patients) or three
regions (19 patients). (No patient had major
injuries in all four regions.) For example, the
incidence of deep-vein thrombosis was 39 percent
among patients with head injuries alone 50
percent among those with injuries of the head and
spine 69 percent among those with injuries of
the head and face, chest, or abdomen and 77
percent among those with head injuries and
orthopedic injuries of the lower extremities.
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DVT Trauma Risk Factors
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DVT Basic Science
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DVT Prophylaxis - Recommendations
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DVT Trauma Risk Factors
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Vena Cava Filters