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Can we ever stop worrying about venous thromboembolism after trauma?

Laura N Godat, Leslie Kobayashi, David C Chang, Raul Coimbra
Journal of Trauma and Acute Care Surgery 2015, 78 (3): 475-80; discussion 480-1

BACKGROUND: Trauma patients are known to be at increased risk for venous thromboembolism (VTE); this risk may change over time following injury. Determining the period in which patients are at increased risk of developing VTE may have an impact on prophylaxis, cost, and quality of care.

METHODS: The California Office of Statewide Health Planning and Development hospital discharge database was searched between 1995 and 2010 for patients admitted with traumatic pelvic fractures, vertebral fractures, and spinal cord injuries. Those patients were then searched for VTE any time after injury. Cox proportional hazards analyses were used to assess the timing and risk of VTE events after injury.

RESULTS: A total of 267,743 trauma patients met the injury criteria; of those, 10,633 or 3.97% developed VTE. The occurrence of VTE was a significant predictor of mortality (hazard ratio [HR], 1.18; p < 0.001). Compared with patients with pelvic fractures, patients with vertebral fractures were less likely to develop VTE (HR, 0.85; p = 0.002). However, patients with spinal cord injury were more likely to develop VTE (HR, 3.17; p < 0.001); this remained true when in combination with a pelvic fracture (HR, 2.17; p = 0.001). Patients with cervical or thoracic spinal cord injuries were significantly more likely to develop VTE (HR of 1.49 [p = 0.037] and 1.87 [p = 0.001], respectively), compared with those with lumbar injury.In the first 3 months after injury, the incidence of VTE is 10.3%. This rate dropped to 0.5% by 6 months after injury, subsequently falling to 0.2% at 1 year and 0.14% at 18 months and remaining low at 0.12% at 2 years.

CONCLUSION: The highest risk of VTE is during the first 3 months after injury; between 12 months and 15 months, the rate returns to that of the general population at 0.1% to 0.2%. These results may guide management strategies such as duration of VTE prophylaxis and removal of inferior vena cava filters, which may have an impact on quality of care.

LEVEL OF EVIDENCE: Epidemiologic study, level IV.

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