Citation

Van Gent JM, Calvo RY, Zander AL, Olson EJ, Sise CB, Sise MJ, Shackford SR. J. Trauma Acute Care Surg. 2017; 83(6): 1154-1160.

Affiliation

Trauma Service, Scripps Mercy Hospital, San Diego, California.

Copyright

(Copyright © 2017, Lippincott Williams and Wilkins)

DOI

10.1097/TA.0000000000001652

PMID

28697017

Abstract

BACKGROUND: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is typically reported as a composite measure of the quality of trauma center care. Given recent data suggesting post-injury DVT and PE are distinct clinical processes, a better understanding may result from analyzing them as independent, competing events. Using competing risks analysis, we evaluated our hypothesis that the risk factors and timing of post-injury DVT and PE are different.

METHODS: We examined all adult trauma patients admitted to our Level I trauma center from 07/2006 to 12/2011 who received at least one surveillance duplex ultrasound of the lower extremities and who were at high risk or greater for DVT. Outcomes included DVT and PE events, and time-to-event from admission. We used competing risks analysis to evaluate risk factors for DVT while accounting for PE as a competing event, and vice versa.

RESULTS: Of 2,370 patients, 265 (11.2%) had at least one VTE event: 235 DVT Only, 19 PE Only, 11 DVT and PE. Within two days of admission, 38% of DVT cases had occurred compared to 26% of PE. Competing risks modeling of DVT as primary event identified older age, severe injury (ISS≥15), mechanical ventilation >4 days, active cancer, history of DVT or PE, major venous repair, male sex, prophylactic enoxaparin and prophylactic heparin as associated risk factors. Modeling of PE as the primary event showed younger age, non-severe injury (ISS<15), central line placement, and prophylactic heparin as relevant factors.

CONCLUSIONS: The risk factors for PE and DVT after injury were different, suggesting that they are clinically distinct events that merit independent consideration. Many DVT events occurred early despite prophylaxis, bringing into question the preventability of post-injury DVT. We recommend trauma center quality reporting program measures be revised to account for DVT and PE as unique events. LEVEL OF EVIDENCE: Level III, epidemiologic.

Language: en