接受常规双功能超声筛查的有静脉血栓栓塞风险的创伤患者发生肺栓塞的几率更低：一项前瞻性随机试验。
Trauma patients at risk for venous thromboembolism who undergo routine duplex ultrasound screening experience fewer pulmonary emboli: A prospective randomized trial.
机构信息
From the Division of Trauma Services and Surgical Critical Care (A.B.K., D.S.M., S.M.), Department of Medicine (S.C.W., S.M.S.), Intermountain Medical Center, Murray; Department of Medicine (S.C.W., S.M.S.), University of Utah School of Medicine, Salt Lake City; Department of Emergency Medicine (J.R.B.), Intermountain Medical Center, Murray; Medical Informatics (J.F.L.), Intermountain Medical Center; and Office of Research (D.S.C.), Intermountain Medical Center, Murray, Utah.
出版信息
J Trauma Acute Care Surg. 2021 May 1;90(5):787-796. doi: 10.1097/TA.0000000000003104.
BACKGROUND
Although guidelines are established for the prevention and management of venous thromboembolism (VTE) in trauma, no consensus exists regarding protocols for the diagnostic approach. We hypothesized that at-risk trauma patients who undergo duplex ultrasound (DUS) surveillance for lower extremity deep venous thrombosis (DVT) will have a lower rate of symptomatic or fatal pulmonary embolism (PE) than those who do not undergo routine surveillance.
METHODS
Prospective, randomized trial between March 2017 and September 2019 of trauma patients admitted to a single, level 1 trauma center, with a risk assessment profile score of ≥5. Patients were randomized to receive either bilateral lower extremity DUS surveillance on days 1, 3, and 7 and weekly during hospitalization ultrasound group (US) or no surveillance no ultrasound group (NoUS). Rates of in-hospital and 90-day DVT and PE were reported as was DVT propagation and all-cause mortality. Standard care for the prevention and management of VTE per established institutional protocols was provided to all patients.
RESULTS
A total of 3,236 trauma service admissions were screened, and 1,989 moderate- and high-risk patients were randomized (US, 995; NoUS, 994). The mean ± SD age was 62 ± 20.1 years, Injury Severity Score was 14 ± 9.7, risk assessment profile was 7.1 ± 2.4, and 97% suffered blunt trauma. There was no difference in demographics or VTE risk factors between the groups. There were significantly fewer in-hospital PE in the US group than the NoUS group (1 [0.1%] vs. 9 [0.9%], p = 0.01). The US group experienced more in-hospital below-knee DVTs (124 [12.5%] vs. 8 [0.8%], p < 0.001) and above-knee DVTs (19 [1.9%] vs. 8 [0.8%], p = 0.05). There was no difference in 90-day PE or DVT, or overall mortality.
CONCLUSION
The implementation of a selective routine DUS protocol was associated with significantly fewer in-hospital PE. More DVTs were identified with routine screening; however, surveillance bias appears to exist primarily with distal DVT. Larger trials are needed to further characterize the relationship between routine DUS screening and VTE outcomes in the high-risk trauma population.
LEVEL OF EVIDENCE
Therapeutic/care management, level II.
背景
尽管已经制定了预防和管理创伤后静脉血栓栓塞症（VTE）的指南，但对于诊断方法的方案仍未达成共识。我们假设，接受下肢深静脉血栓形成（DVT）的双功超声（DUS）监测的高危创伤患者，其症状性或致命性肺栓塞（PE）发生率将低于未接受常规监测的患者。
方法
这是一项于 2017 年 3 月至 2019 年 9 月期间，在一家单一的 1 级创伤中心进行的前瞻性、随机试验，纳入了风险评估评分≥5 的创伤患者。患者被随机分为接受双侧下肢 DUS 监测组（DUS 组）或不接受常规监测组（NoUS 组）。DUS 组在入院第 1、3 和 7 天以及住院期间每周进行双侧下肢 DUS 监测，而 NoUS 组则不进行监测。报告了住院期间和 90 天的 DVT 和 PE 发生率，以及 DVT 传播和全因死亡率。所有患者均按照既定的机构方案接受预防和管理 VTE 的标准护理。
结果
共筛选了 3236 例创伤服务入院患者，其中 1989 例中-高危患者被随机分为 DUS 组（995 例）和 NoUS 组（994 例）。平均年龄±标准差为 62±20.1 岁，损伤严重程度评分（ISS）为 14±9.7，风险评估评分（RAPS）为 7.1±2.4，97%的患者为钝性创伤。两组之间在人口统计学或 VTE 危险因素方面无差异。DUS 组的住院期间 PE 发生率明显低于 NoUS 组（1[0.1%] vs. 9[0.9%]，p=0.01）。DUS 组的住院期间膝下 DVT 发生率更高（124[12.5%] vs. 8[0.8%]，p<0.001）和膝上 DVT 发生率更高（19[1.9%] vs. 8[0.8%]，p=0.05）。两组之间 90 天 PE 或 DVT 发生率或总死亡率无差异。
结论
实施选择性常规 DUS 方案与住院期间 PE 发生率显著降低有关。常规筛查发现了更多的 DVT；然而，监测偏倚似乎主要存在于远端 DVT。需要更大规模的试验来进一步描述高危创伤人群中常规 DUS 筛查与 VTE 结果之间的关系。
证据水平
治疗/护理管理，II 级。
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