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HOUSTON – Nearly 30% of trauma patients who were identified upon admission as being high risk for venous thromboembolism using a validated risk assessment tool went on to develop the thrombotic condition during their ICU stay, a study has shown.
Importantly, the deep vein thromboses in most of these patients were asymptomatic and might have gone undetected with potentially life-threatening consequences but for periodic ultrasound screening, Dr. Chad Thorson reported at the annual congress of the Society of Critical Care Medicine.
"Routine venous thromboembolism screening in the trauma population has been widely debated, and there currently is no protocol for it," according to Dr. Thorson of the Ryder Trauma Center at the University of Miami. Although the principal diagnostic screening tool – venous duplex ultrasound (VDU) – is not considered cost effective for screening all trauma patients, the investigators sought to determine whether prescreening trauma patients using the risk assessment profile (RAP) would yield a cohort of high- risk patients in whom increased vigilance and VDU screening are warranted (J. Trauma 1997;42:100-3).
Toward this end, all patients admitted to the Ryder Center’s level 1 trauma intensive care unit from November 2009 through January 2012 were prospectively screened with RAP, which stratifies an individual’s venous thromboembolism (VTE) risk based on underlying conditions, iatrogenic factors, injury-related factors, and age, within 24 hours of admission.
"Patients with [RAP] scores of 10 or higher received bilateral lower-extremity venous duplex ultrasounds at the time of admission and then weekly throughout their ICU stay," Dr. Thorson said, noting that logistic regression was performed on risk factors to identify independent predictors of VTE development. Among the risk factors considered were RAP score, RAP score higher than 20, femoral central venous catheterization for more than 24 hours, operative intervention duration longer than 2 hours, lower-extremity fracture, pelvic fracture, and spinal cord injury with paraplegia.
Of 534 trauma ICU admissions during the study period, 106 patients (mean age, 47 years) were identified as high risk based on their RAP score. Blunt trauma was the primary mechanism of injury in 79% of the population, and the mean injury severity score of the predominantly male (74%) high-risk population was 30, said Dr. Thorson.
Routine VDU screening identified 30 VTEs, including 20 that were asymptomatic and 10 that were symptomatic, despite the patients having received thromboprophylaxis (heparin 5,000 U every 8 hours or dalteparin 5,000 U daily), Dr. Thorson reported. Four of the symptomatic events were pulmonary emboli, and of the asymptomatic VTEs, six were identified on admission, seven were identified within the first week of admission, and four were identified within 2 weeks of admission, he said.
A comparison of those who did and did not develop VTEs showed significant differences in the number of risk factors, overall RAP score, and RAP score greater than 20, Dr. Thorson reported. Specifically, those in the non-VTE group averaged five risk factors compared with seven in the VTE group, and the respective median RAP scores were 14 and 19, he said. In addition, 6 patients in the non-VTE and 11 in the VTE group had RAP scores higher than 20. In the stepwise logistic regression analysis, RAP score and a combination of pelvic fracture and prolonged operative intervention were independent predictors of VTE development, he said.
Prescreening trauma patients with RAP is useful for identifying patients at increased risk of VTE who may be candidates for increased surveillance, according to Dr. Thorson. "There is plenty of debate with regard to the utility and cost effectiveness of routine screening, as well as the benefit of identifying asymptomatic deep vein thromboses," Dr. Thorson said in an interview.
"Ideally, we hope to find a decrease in the rate of pulmonary embolism as a result of screening, as this consequence can be devastating."
An important implication of the screening protocol, however, is identifying that DVT/VTE should not be included on the Centers for Medicare and Medicaid Services’ list of preventable complications (defined as errors in medical care that are clearly identifiable and preventable, and thus may no longer be eligible for reimbursement).
"A decision to no longer pay for [VTE] treatment could have devastating effects on many urban trauma centers," Dr. Thorson stressed.
The prescreening study was supported by grants from the Office of Naval Research and the U.S. Army Medical Research and Materiel Command. Dr. Thorson reported that he had no relevant financial disclosures.
Trauma patients are at high risk for VTE, and in the absence of bleeding contraindications, all should be receiving pharmacologic prophylaxis with LDUH/LMWH. Therefore, a risk assessment program for VTE doesn't make much sense: Everyone "rules in" for VTE prophylaxis with medication unless a contraindication exists, according to Dr. Franklin A. Michota.
This observational study used a risk assessment program to identify patients for whom surveillance venous duplex ultrasound might be indicated on top of pharmacologic prophylaxis. Currently, VDU surveillance is not recommended in trauma patients, according to the recently published ninth American College of Chest Physicians' guidelines on antithrombotic therapy and the prevention of thrombosis (Chest 2012;141[suppl.]:e227S-77S). In fact, the ACCP specifically recommends that surveillance not be performed (grade 2C evidence). The rationale is well outlined in the guidelines. It is not clear that using VDU to detect and treat asymptomatic DVT reduces the risk of pulmonary embolism or fatal pulmonary embolism, and some studies have demonstrated that pulmonary embolism can occur even when VDU is negative.
As reported in the ACCP chapter on the prevention of VTE in surgery patients, a large retrospective study from a single center found that over a 6-year period ending in 2000, the frequency of surveillance VDU decreased from 32% to 3.4%, yet there was no increase in the incidence of pulmonary embolism. Also it is well known that surveillance VDU can lead to false-positive findings (asymptomatic distal clot that does not pose a risk for symptoms or embolization), and the risk of treating the false positives with full anticoagulation in the trauma surgery population may increase adverse outcomes.
This new study identified 30 VTEs in 106 high-risk trauma patients with surveillance VDU. However, the investigators reported that 10 of the events were symptomatic, so the VDU was not a screening tool; it was a diagnostic test for signs and symptoms, and therefore, those 10 symptomatic events need to be removed. That leaves you with 20 VTEs in 106 high-risk trauma patients (18.8%). So the real question is, Where were these clots located? If they were distal asymptomatic events, then they may all be false positives. If they were all proximal DVTs, then perhaps this study deserves more credit.
But we should also look at the intensity of VTE prophylaxis provided in this study cohort. The ACCP also recommends mechanical compression on top of pharmacologic prophylaxis in high-risk trauma patients. Was that done here? Perhaps the 20 VTEs were due to inadequate prophylaxis.
Dr. Michota is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic. He reported having no relevant financial disclosures.
Trauma patients are at high risk for VTE, and in the absence of bleeding contraindications, all should be receiving pharmacologic prophylaxis with LDUH/LMWH. Therefore, a risk assessment program for VTE doesn't make much sense: Everyone "rules in" for VTE prophylaxis with medication unless a contraindication exists, according to Dr. Franklin A. Michota.
This observational study used a risk assessment program to identify patients for whom surveillance venous duplex ultrasound might be indicated on top of pharmacologic prophylaxis. Currently, VDU surveillance is not recommended in trauma patients, according to the recently published ninth American College of Chest Physicians' guidelines on antithrombotic therapy and the prevention of thrombosis (Chest 2012;141[suppl.]:e227S-77S). In fact, the ACCP specifically recommends that surveillance not be performed (grade 2C evidence). The rationale is well outlined in the guidelines. It is not clear that using VDU to detect and treat asymptomatic DVT reduces the risk of pulmonary embolism or fatal pulmonary embolism, and some studies have demonstrated that pulmonary embolism can occur even when VDU is negative.
As reported in the ACCP chapter on the prevention of VTE in surgery patients, a large retrospective study from a single center found that over a 6-year period ending in 2000, the frequency of surveillance VDU decreased from 32% to 3.4%, yet there was no increase in the incidence of pulmonary embolism. Also it is well known that surveillance VDU can lead to false-positive findings (asymptomatic distal clot that does not pose a risk for symptoms or embolization), and the risk of treating the false positives with full anticoagulation in the trauma surgery population may increase adverse outcomes.
This new study identified 30 VTEs in 106 high-risk trauma patients with surveillance VDU. However, the investigators reported that 10 of the events were symptomatic, so the VDU was not a screening tool; it was a diagnostic test for signs and symptoms, and therefore, those 10 symptomatic events need to be removed. That leaves you with 20 VTEs in 106 high-risk trauma patients (18.8%). So the real question is, Where were these clots located? If they were distal asymptomatic events, then they may all be false positives. If they were all proximal DVTs, then perhaps this study deserves more credit.
But we should also look at the intensity of VTE prophylaxis provided in this study cohort. The ACCP also recommends mechanical compression on top of pharmacologic prophylaxis in high-risk trauma patients. Was that done here? Perhaps the 20 VTEs were due to inadequate prophylaxis.
Dr. Michota is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic. He reported having no relevant financial disclosures.
Trauma patients are at high risk for VTE, and in the absence of bleeding contraindications, all should be receiving pharmacologic prophylaxis with LDUH/LMWH. Therefore, a risk assessment program for VTE doesn't make much sense: Everyone "rules in" for VTE prophylaxis with medication unless a contraindication exists, according to Dr. Franklin A. Michota.
This observational study used a risk assessment program to identify patients for whom surveillance venous duplex ultrasound might be indicated on top of pharmacologic prophylaxis. Currently, VDU surveillance is not recommended in trauma patients, according to the recently published ninth American College of Chest Physicians' guidelines on antithrombotic therapy and the prevention of thrombosis (Chest 2012;141[suppl.]:e227S-77S). In fact, the ACCP specifically recommends that surveillance not be performed (grade 2C evidence). The rationale is well outlined in the guidelines. It is not clear that using VDU to detect and treat asymptomatic DVT reduces the risk of pulmonary embolism or fatal pulmonary embolism, and some studies have demonstrated that pulmonary embolism can occur even when VDU is negative.
As reported in the ACCP chapter on the prevention of VTE in surgery patients, a large retrospective study from a single center found that over a 6-year period ending in 2000, the frequency of surveillance VDU decreased from 32% to 3.4%, yet there was no increase in the incidence of pulmonary embolism. Also it is well known that surveillance VDU can lead to false-positive findings (asymptomatic distal clot that does not pose a risk for symptoms or embolization), and the risk of treating the false positives with full anticoagulation in the trauma surgery population may increase adverse outcomes.
This new study identified 30 VTEs in 106 high-risk trauma patients with surveillance VDU. However, the investigators reported that 10 of the events were symptomatic, so the VDU was not a screening tool; it was a diagnostic test for signs and symptoms, and therefore, those 10 symptomatic events need to be removed. That leaves you with 20 VTEs in 106 high-risk trauma patients (18.8%). So the real question is, Where were these clots located? If they were distal asymptomatic events, then they may all be false positives. If they were all proximal DVTs, then perhaps this study deserves more credit.
But we should also look at the intensity of VTE prophylaxis provided in this study cohort. The ACCP also recommends mechanical compression on top of pharmacologic prophylaxis in high-risk trauma patients. Was that done here? Perhaps the 20 VTEs were due to inadequate prophylaxis.
Dr. Michota is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic. He reported having no relevant financial disclosures.
HOUSTON – Nearly 30% of trauma patients who were identified upon admission as being high risk for venous thromboembolism using a validated risk assessment tool went on to develop the thrombotic condition during their ICU stay, a study has shown.
Importantly, the deep vein thromboses in most of these patients were asymptomatic and might have gone undetected with potentially life-threatening consequences but for periodic ultrasound screening, Dr. Chad Thorson reported at the annual congress of the Society of Critical Care Medicine.
"Routine venous thromboembolism screening in the trauma population has been widely debated, and there currently is no protocol for it," according to Dr. Thorson of the Ryder Trauma Center at the University of Miami. Although the principal diagnostic screening tool – venous duplex ultrasound (VDU) – is not considered cost effective for screening all trauma patients, the investigators sought to determine whether prescreening trauma patients using the risk assessment profile (RAP) would yield a cohort of high- risk patients in whom increased vigilance and VDU screening are warranted (J. Trauma 1997;42:100-3).
Toward this end, all patients admitted to the Ryder Center’s level 1 trauma intensive care unit from November 2009 through January 2012 were prospectively screened with RAP, which stratifies an individual’s venous thromboembolism (VTE) risk based on underlying conditions, iatrogenic factors, injury-related factors, and age, within 24 hours of admission.
"Patients with [RAP] scores of 10 or higher received bilateral lower-extremity venous duplex ultrasounds at the time of admission and then weekly throughout their ICU stay," Dr. Thorson said, noting that logistic regression was performed on risk factors to identify independent predictors of VTE development. Among the risk factors considered were RAP score, RAP score higher than 20, femoral central venous catheterization for more than 24 hours, operative intervention duration longer than 2 hours, lower-extremity fracture, pelvic fracture, and spinal cord injury with paraplegia.
Of 534 trauma ICU admissions during the study period, 106 patients (mean age, 47 years) were identified as high risk based on their RAP score. Blunt trauma was the primary mechanism of injury in 79% of the population, and the mean injury severity score of the predominantly male (74%) high-risk population was 30, said Dr. Thorson.
Routine VDU screening identified 30 VTEs, including 20 that were asymptomatic and 10 that were symptomatic, despite the patients having received thromboprophylaxis (heparin 5,000 U every 8 hours or dalteparin 5,000 U daily), Dr. Thorson reported. Four of the symptomatic events were pulmonary emboli, and of the asymptomatic VTEs, six were identified on admission, seven were identified within the first week of admission, and four were identified within 2 weeks of admission, he said.
A comparison of those who did and did not develop VTEs showed significant differences in the number of risk factors, overall RAP score, and RAP score greater than 20, Dr. Thorson reported. Specifically, those in the non-VTE group averaged five risk factors compared with seven in the VTE group, and the respective median RAP scores were 14 and 19, he said. In addition, 6 patients in the non-VTE and 11 in the VTE group had RAP scores higher than 20. In the stepwise logistic regression analysis, RAP score and a combination of pelvic fracture and prolonged operative intervention were independent predictors of VTE development, he said.
Prescreening trauma patients with RAP is useful for identifying patients at increased risk of VTE who may be candidates for increased surveillance, according to Dr. Thorson. "There is plenty of debate with regard to the utility and cost effectiveness of routine screening, as well as the benefit of identifying asymptomatic deep vein thromboses," Dr. Thorson said in an interview.
"Ideally, we hope to find a decrease in the rate of pulmonary embolism as a result of screening, as this consequence can be devastating."
An important implication of the screening protocol, however, is identifying that DVT/VTE should not be included on the Centers for Medicare and Medicaid Services’ list of preventable complications (defined as errors in medical care that are clearly identifiable and preventable, and thus may no longer be eligible for reimbursement).
"A decision to no longer pay for [VTE] treatment could have devastating effects on many urban trauma centers," Dr. Thorson stressed.
The prescreening study was supported by grants from the Office of Naval Research and the U.S. Army Medical Research and Materiel Command. Dr. Thorson reported that he had no relevant financial disclosures.
HOUSTON – Nearly 30% of trauma patients who were identified upon admission as being high risk for venous thromboembolism using a validated risk assessment tool went on to develop the thrombotic condition during their ICU stay, a study has shown.
Importantly, the deep vein thromboses in most of these patients were asymptomatic and might have gone undetected with potentially life-threatening consequences but for periodic ultrasound screening, Dr. Chad Thorson reported at the annual congress of the Society of Critical Care Medicine.
"Routine venous thromboembolism screening in the trauma population has been widely debated, and there currently is no protocol for it," according to Dr. Thorson of the Ryder Trauma Center at the University of Miami. Although the principal diagnostic screening tool – venous duplex ultrasound (VDU) – is not considered cost effective for screening all trauma patients, the investigators sought to determine whether prescreening trauma patients using the risk assessment profile (RAP) would yield a cohort of high- risk patients in whom increased vigilance and VDU screening are warranted (J. Trauma 1997;42:100-3).
Toward this end, all patients admitted to the Ryder Center’s level 1 trauma intensive care unit from November 2009 through January 2012 were prospectively screened with RAP, which stratifies an individual’s venous thromboembolism (VTE) risk based on underlying conditions, iatrogenic factors, injury-related factors, and age, within 24 hours of admission.
"Patients with [RAP] scores of 10 or higher received bilateral lower-extremity venous duplex ultrasounds at the time of admission and then weekly throughout their ICU stay," Dr. Thorson said, noting that logistic regression was performed on risk factors to identify independent predictors of VTE development. Among the risk factors considered were RAP score, RAP score higher than 20, femoral central venous catheterization for more than 24 hours, operative intervention duration longer than 2 hours, lower-extremity fracture, pelvic fracture, and spinal cord injury with paraplegia.
Of 534 trauma ICU admissions during the study period, 106 patients (mean age, 47 years) were identified as high risk based on their RAP score. Blunt trauma was the primary mechanism of injury in 79% of the population, and the mean injury severity score of the predominantly male (74%) high-risk population was 30, said Dr. Thorson.
Routine VDU screening identified 30 VTEs, including 20 that were asymptomatic and 10 that were symptomatic, despite the patients having received thromboprophylaxis (heparin 5,000 U every 8 hours or dalteparin 5,000 U daily), Dr. Thorson reported. Four of the symptomatic events were pulmonary emboli, and of the asymptomatic VTEs, six were identified on admission, seven were identified within the first week of admission, and four were identified within 2 weeks of admission, he said.
A comparison of those who did and did not develop VTEs showed significant differences in the number of risk factors, overall RAP score, and RAP score greater than 20, Dr. Thorson reported. Specifically, those in the non-VTE group averaged five risk factors compared with seven in the VTE group, and the respective median RAP scores were 14 and 19, he said. In addition, 6 patients in the non-VTE and 11 in the VTE group had RAP scores higher than 20. In the stepwise logistic regression analysis, RAP score and a combination of pelvic fracture and prolonged operative intervention were independent predictors of VTE development, he said.
Prescreening trauma patients with RAP is useful for identifying patients at increased risk of VTE who may be candidates for increased surveillance, according to Dr. Thorson. "There is plenty of debate with regard to the utility and cost effectiveness of routine screening, as well as the benefit of identifying asymptomatic deep vein thromboses," Dr. Thorson said in an interview.
"Ideally, we hope to find a decrease in the rate of pulmonary embolism as a result of screening, as this consequence can be devastating."
An important implication of the screening protocol, however, is identifying that DVT/VTE should not be included on the Centers for Medicare and Medicaid Services’ list of preventable complications (defined as errors in medical care that are clearly identifiable and preventable, and thus may no longer be eligible for reimbursement).
"A decision to no longer pay for [VTE] treatment could have devastating effects on many urban trauma centers," Dr. Thorson stressed.
The prescreening study was supported by grants from the Office of Naval Research and the U.S. Army Medical Research and Materiel Command. Dr. Thorson reported that he had no relevant financial disclosures.
FROM THE ANNUAL CONGRESS OF THE SOCIETY OF CRITICAL CARE MEDICINE
Major Finding: Of 106 trauma patients identified through a prescreening protocol as being high risk for venous thromboembolism, 30 developed the condition during their ICU stay despite their receiving standard thromboprophylaxis.
Data Source: A prospective study in which 106 patients deemed to be at high risk of venous thromboembolism underwent venous duplex ultrasound at the time of admission and then weekly throughout their ICU stay.
Disclosures: The prescreening study was supported by grants from the Office of Naval Research and the U.S. Army Medical Research and Materiel Command. Dr. Thorson reported that he had no relevant financial disclosures.