创伤患者的“高风险”深静脉血栓筛查方案：是否实用？
The "high-risk" deep venous thrombosis screening protocol for trauma patients: Is it practical?
作者信息
Dietch Zachary C, Petroze Robin T, Thames Matthew, Willis Rhett, Sawyer Robert G, Williams Michael D
出版信息
J Trauma Acute Care Surg. 2015 Dec;79(6):970-5; discussion 975. doi: 10.1097/TA.0000000000000855.
BACKGROUND
Many centers advocate aggressive lower extremity deep venous thrombosis (DVT) screening using ultrasound (LUS) for patients meeting high-risk criteria. We hypothesized that a high-risk screening protocol is impractical and costly to implement.
METHODS
The University of Virginia's trauma database was queried to identify 6,656 patients admitted between 2009 and 2013. Patient characteristics and outcomes were recorded. Multivariate analyses were performed on patients who underwent LUS to assess the association between patient characteristics and the development of DVT. A predictive model for DVT was applied to the entire population to determine performance and resources required for implementation.
RESULTS
Overall, 2,350 (35.3%) of admitted patients underwent LUS. A total of 146 patients (6.2%) developed DVT. Patients who underwent LUS were significantly older (54.5 years vs. 50.4 years, p < 0.0001), had higher Injury Severity Scores (ISSs) (13.5 vs. 8.6, p < 0.0001), and had longer admissions to the intensive care unit (5.6 days vs. 0.9 days, p < 0.0001). Backward selection multivariable logistic regression identified intensive care unit length of stay, transfusion of blood products, spinal cord injury, and pelvic fracture to be associated with DVT (c statistic, 0.76). The model was applied to the entire population to evaluate probability of DVT (c statistic, 0.87). Predictive performance and costs were determined using a cost per LUS of $228. The most sensitive threshold for screening would detect 53% of DVTs, require screening of 26% of all trauma patients, and cost nearly $600,000 to implement during the study period.
CONCLUSION
Although a predictive model identified high-risk criteria for the development of DVT at our institution, the model demonstrated poor sensitivity and positive predictive value. These results suggest that implementing a high-risk screening protocol in trauma patients would require a costly and burdensome commitment of resources and that high-risk DVT screening protocols may not be practical or cost-effective for trauma patients.
LEVEL OF EVIDENCE
Therapeutic/care management study, level IV.
背景
许多中心主张对符合高风险标准的患者采用超声（LUS）进行积极的下肢深静脉血栓形成（DVT）筛查。我们推测高风险筛查方案实施起来不切实际且成本高昂。
方法
查询弗吉尼亚大学的创伤数据库，以识别2009年至2013年间入院的6656例患者。记录患者特征和结局。对接受LUS检查的患者进行多变量分析，以评估患者特征与DVT发生之间的关联。将DVT预测模型应用于整个人口，以确定实施所需的性能和资源。
结果
总体而言，2350例（35.3%）入院患者接受了LUS检查。共有146例患者（6.2%）发生了DVT。接受LUS检查的患者年龄明显更大（54.5岁对50.4岁，p<0.0001），损伤严重程度评分（ISS）更高（13.5对8.6，p<0.0001），在重症监护病房的住院时间更长（5.6天对0.9天，p<0.0001）。向后选择多变量逻辑回归确定重症监护病房住院时间、输血、脊髓损伤和骨盆骨折与DVT相关（c统计量，0.76）。该模型应用于整个人口以评估DVT的概率（c统计量，0.87）。使用每次LUS检查成本228美元来确定预测性能和成本。筛查的最敏感阈值将检测到53%的DVT，需要对所有创伤患者的26%进行筛查，在研究期间实施成本接近60万美元。
结论
尽管预测模型确定了我们机构DVT发生的高风险标准，但该模型显示出较差的敏感性和阳性预测值。这些结果表明，在创伤患者中实施高风险筛查方案需要投入高昂且繁重的资源，并且高风险DVT筛查方案对于创伤患者可能不切实际或不具有成本效益。证据水平：治疗/护理管理研究，IV级。
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