Department of Surgery, Cedars-Sinai Medical Center, USA.
Injury. 2013 Jan;44(1):80-5. doi: 10.1016/j.injury.2011.10.006. Epub 2011 Nov 1.
Standard venous thromboembolism (VTE) prevention for critically ill trauma patients includes sequential compression devices and chemical prophylaxis. When contraindications to anticoagulation are present, prophylactic inferior vena cava filters (IVCF) may be used to prevent pulmonary emboli (PE) in high-risk patients, but specific indications are lacking. We sought to identify independent predictors of VTE in critically-ill trauma patients who cannot receive chemical prophylaxis in order to identify a subset of patients who may benefit from aggressive screening and/or prophylactic IVCF placement.
All trauma patients in the surgical ICU from 2008 to 2009 were prospectively followed. Patients with an ICU length of stay ≥2 days who had contraindications to prophylactic anticoagulation were included. Screening duplex exams were obtained within 48 h of admission and then weekly. CT-angiography for PE was obtained if clinically indicated. Patients were excluded if they did not receive a duplex or if they had a post-injury VTE prior to ICU admission. Data regarding VTE rates (lower extremity [LE] DVT or PE), demographics, past medical history (PMH), injuries, and surgeries were collected. Univariate and multivariable analyses were performed to identify independent predictors of VTE with a p<0.05.
411 trauma patients with a mean age of 48 (SD 22) years and 8 (SD 9) ICU days were included. 72% were male and the mean ISS was 22 (SD 13). 30 (7.3%) patients developed VTE: 28 (6.8%) with LEDVT and 2 (0.5%) with PE. Risk factors for VTE with a p<0.2 on univariate analysis included: PMH of DVT, injury severity score (ISS), extremity fractures (Fx), and a pelvis or LE extremity Fx repair. After logistic regression, only PMH of DVT (OR=22.6) and any extremity Fx (OR=2.4) remained as independent predictors.
VTE occur in 7% of critically injured trauma patients who cannot receive chemical prophylaxis. Aggressive screening and/or prophylactic IVCF placement may be considered in patients with a PMH of DVT or extremity fractures when anticoagulation is prohibited.
对于危重症创伤患者，标准的静脉血栓栓塞症（VTE）预防包括序贯压迫装置和化学预防。当存在抗凝禁忌证时，可使用预防性下腔静脉滤器（IVCF）预防高危患者的肺栓塞（PE），但缺乏具体的适应证。我们旨在确定不能接受化学预防的危重症创伤患者中 VTE 的独立预测因素，以便确定可能受益于积极筛查和/或预防性 IVCF 放置的亚组患者。
对 2008 年至 2009 年期间外科重症监护病房的所有创伤患者进行前瞻性随访。纳入 ICU 住院时间≥2 天且存在预防性抗凝禁忌证的患者。患者入院后 48 小时内进行筛查性双功超声检查，然后每周进行一次。如果临床需要，进行 CT 肺动脉造影以排除 PE。如果患者未进行双功超声检查或在 ICU 入院前已有创伤后 VTE，则将其排除在外。收集 VTE 发生率（下肢 [LE] DVT 或 PE）、人口统计学资料、既往病史（PMH）、损伤和手术相关的数据。采用单变量和多变量分析确定 VTE 的独立预测因素，p<0.05。
共纳入 411 例创伤患者，平均年龄为 48（SD 22）岁，ICU 住院时间为 8（SD 9）天。72%为男性，ISS 平均为 22（SD 13）分。30（7.3%）例患者发生 VTE：28（6.8%）例为 LEDVT，2（0.5%）例为 PE。单变量分析中 p<0.2 的 VTE 危险因素包括：PMH 有 DVT、损伤严重程度评分（ISS）、肢体骨折（Fx）和骨盆或 LE 肢体 Fx 修复。经过逻辑回归分析，只有 PMH 有 DVT（OR=22.6）和任何肢体 Fx（OR=2.4）是独立的预测因素。
不能接受化学预防的危重症创伤患者中，VTE 的发生率为 7%。当抗凝禁忌时，对于 PMH 有 DVT 或肢体骨折的患者，可考虑进行积极的筛查和/或预防性 IVCF 放置。
