Early Pharmacologic Venous Thromboembolism (VTE) prophylaxis is NOT indicated in Traumatic Brain Injury Nefertiti A. Brown, MD Morbidity & Mortality Conference SUNY Downstate Medical Center Department of Surgery March 28, 2013
What you need to know NO Level I evidence exists to guide TBI caregivers for the use (or timing) of prophylactic anticoagulation Current standard of care?
Brain Trauma Foundation (2007)
The guidelines Brain Trauma Foundation (2007) Level III evidence - Graduated compression stockings or intermittent pneumatic compression (IPC) stockings are recommended, unless lower extremity injuries prevent their use. Use should be continued until patients are ambulatory. - Low molecular weight heparin (LMWH) or low dose unfractionated heparin should be used in combination with mechanical prophylaxis. However, there is an increased risk for expansion of intracranial hemorrhage. - There is insufficient evidence to support recommendations regarding the preferred agent, dose, or timing of pharmacologic prophylaxis for venous thromboembolism (VTE).
Balancing act Reduced risk of VTE VS. Increased risk of ICH expansion VALUE?
Preliminary report on the safety of heparin for deep venous thrombosis prophylaxis after severe head injury. Kim J, Gearhart MM, Zurick A, Zuccarello M, James L, Luchette FA. Design: Retrospective, n=64; [ <72h: early; >72h: late] Conclusion: Early vs. late use of VTE prophylaxis does not increase bleeding complications, but does not reduce the rate of VTE events.
Thromboembolic prophylaxis in blunt traumatic intracranial hemorrhage: a retrospective review. Depew AJ, Hu CK, Nguyen AC, Driessen N. Aim: Compare incidences of DVT/PE in patients w/ ICH receiving early (<72h from admission) vs. late (>72h from admission) & progression of ICH. Design: Retrospective chart review (n=124) Results: Equal TBI progression rates and nearly identical rates of VTE of 13% and 11%, respectively Conclusions: Early PTP may not increase bleeding progression in severe traumatic brain injury, but may not reduce the true incidence of VTE
Is early venous thromboembolism prophylaxis safe in trauma patients with intracranial hemorrhage? Koehler DM, Shipman J, Davidson MA, Guillamondegui O. No significant reduction in VTE, but patient s still bled ** There were no differences in injury severity score, age, and pelvic and/or long bone fractures.
Prophylactic anticoagulation to prevent venous thromboembolism in traumatic intracranial hemorrhage: a decision analysis Damon C Scales, Jay Riva-Cambrin, Dave Wells, Valerie Athaide, John T Granton, and Allan S Detsky Conclusion: There is no clear advantage to providing or withholding anticoagulant prophylaxis for DVT/PE prevention at 24 hours after traumatic brain injury associated with ICH.
The timing of anticoagulant is not going to reduce the risk of VTE. Is it safe to give in the setting of TBI at all?
Is low-molecular-weight heparin safe for venous thromboembolism prophylaxis in patients with traumatic brain injury? A Western Trauma Association multicenter study Kwiatt, Michael E. MD; Patel, Mitul S. MD; Ross, Steven E. MD; Lachant, Mary T. RN, MPA; MacNew, Heather G. MD; Ochsner, M. Gage MD; Norwood, Scott H. MD; Speier, LaDonna RN; Kozar, Rosemary MD; Gerber, Jonathan A. BS; Rowell, Susan MD; Krishnakumar, Sheetal; Livingston, David H. MD; Manis, George MD; Haan, James M. MD Risk factors for hemorrhage progression **LMWH in: <48 hrs: 22.2% hemorrhage progression >48hrs: 12.6% >7days: 14.9% Conclusion: Patients receiving LMWH are at higher risk for hemorrhage progression. Based on this, the safety of LMWH for VTE prophylaxis in patients with brain injury cannot be demonstrated.
Safety and efficacy of heparin or enoxaparin prophylaxis in blunt trauma patients with a head abbreviated injury severity score >2. Minshall CT, Eriksson EA, Leon SM, Doben AR, McKinzie BP, Fakhry SM The UFH group had a significantly higher rate of deep venous thrombosis and pulmonary embolus. Progression of ICH that occurred after the initiation of CP was significantly higher in the UFH-treated patients (59%) when compared with those treated with LMWH (40%). Two patients in the UFH group required craniotomy after the initiation of CP. Conclusion: LMWH is an effective method of CP in patients with TBI, providing a lower rate of venous thromboembolic and hemorrhagic complications when compared with UFH. 59% of patients bleed vs. 40%--which would you choose?
Are you kidding?!? NEITHER! (is taking the chance really worth it?)
Conclusions No reliable data can support a recommendation regarding when it is safe to begin pharmacological prophylaxis. No recommendations can be made regarding medication choice or optimal dosing regimen for patients with severe TBI, based on the current evidence. Patients receiving pharmacologic VTE prophylaxis are at higher risk for hemorrhage progression. Studies have been unable to demonstrate safety of pharmacologic VTE prophylaxis in patients with brain injury. It s questionable whether or not the timing (or administration) of VTE prophylaxis truly reduces the risk of thromboembolic events in TBI; however, the risk of using these medications may exceed their benefit. The lack of persuasive evidence to guide decisions about using anticoagulant prophylaxis in patients with traumatic intracranial hemorrhage implies that clinicians must make decisions based on
References 1. Guidelines for the Management of Severe Traumatic Brain Injury, 2 nd & 3 rd eds. (2007, 2010) 2. Kim J, Gearhart MM, Zurick A, Zuccarello M, James L, Luchette FA. Preliminary report on the safety of heparin for deep venous thrombosis prophylaxis after severe head injury. J Trauma. 2002 Jul;53(1):38-42 3. Depew AJ, Hu CK, Nguyen AC, Driessen N.Thromboembolic prophylaxis in blunt traumatic intracranial hemorrhage: a retrospective review. Am Surg. 2008 Oct;74(10):906-11. 4. Koehler DM, Shipman J, Davidson MA, Guillamondegui O. Is early venous thromboembolism prophylaxis safe in trauma patients with intracranial hemorrhage. J Trauma. 2011 Feb;70(2):324-9 5. Scales DC, Riva-Cambrin J, Wells D, Athaide V, Granton JT, Detsky AS. Prophylactic anticoagulation to prevent venous thromboembolism in traumatic intracranial hemorrhage: a decision analysis. Crit Care. 2010;14(2):R72 6. Kwiatt ME, Patel MS, Ross SE, Lachant MT, MacNew HG, Ochsner MG, Norwood SH, Speier L, Kozar R, Gerber JA, Rowell S, Krishnakumar S, Livingston DH, Manis G, Haan JM. Is lowmolecular-weight heparin safe for venous thromboembolism prophylaxis in patients with traumatic brain injury? A Western Trauma Association multicenter study. J Trauma Acute Care Surg. 2012 Sep;73(3):625-8. 7. Minshall CT, Eriksson EA, Leon SM, Doben AR, McKinzie BP, Fakhry SM. Safety and efficacy of heparin or enoxaparin prophylaxis in blunt trauma patients with a head abbreviated injury severity score >2. J Trauma. 2011 Aug;71(2):396-9;