Department of Orthopaedic Surgery, The Johns Hopkins University, 601N Caroline St 5th floor, Baltimore, MD 21205, United States.
Department of Neurology, The Johns Hopkins University, Baltimore, MD, United States.
Injury. 2022 Apr;53(4):1449-1454. doi: 10.1016/j.injury.2022.01.045. Epub 2022 Feb 5.
It is unclear which pharmacological agents, and at what dosage and timing, are most effective for venous thromboembolism (VTE) prophylaxis in patients with pelvic/acetabular fractures.
We searched the Cochrane Database of Systematic Reviews, Embase, Web of Science, EBSCO, and PubMed on October 3, 2020, for English-language studies of VTE prophylaxis in patients with pelvic/acetabular fractures. We applied no date limits. We included studies that compared efficacy of pharmacological agents for VTE prophylaxis, timing of administration of such agents, and/or dosage of such agents. We recorded interventions, sample sizes, and VTE incidence, including deep vein thrombosis (DVT) and pulmonary embolism.
Two studies (3604 patients) compared pharmacological agents, reporting that patients who received direct oral anticoagulants (DOACs) were less likely to develop DVT than those who received low molecular weight heparin (LMWH) (p < 0.01). Compared with unfractionated heparin (UH), LMWH was associated with lower odds of VTE (odds ratio [OR] = 0.37, 95% confidence interval [CI]: 0.22-0.63) and death (OR = 0.27, 95% CI: 0.10-0.72). Three studies (3107 patients) compared timing of VTE prophylaxis, reporting that late prophylaxis was associated with higher odds of VTE (OR = 1.9, 95% CI: 1.2-3.2) and death (OR = 4.0, 95% CI: 1.5-11) and higher rates of symptomatic DVT (9.2% vs. 2.5%, p = 0.03; and 22% vs. 3.1%, p = 0.01). One study (31 patients) investigated dosage of VTE prophylaxis, reporting that a higher proportion of patients with acetabular fractures were underdosed (23% of patients below range of anti-Factor Xa [aFXa] had acetabular fractures vs. 4.8% of patients within adequate range of aFXa, p<0.01).
Early VTE chemoprophylaxis (within 24 or 48 h after injury) was better than late administration in terms of VTE and death. Many patients with acetabular fractures are underdosed with LMWH, with inadequate aFXa levels. Compared with UH, LMWH was associated with lower odds of VTE and death. DOACs were associated with lower risk of DVT compared with LMWH.
III, systematic review of retrospective cohort studies.
对于骨盆/髋臼骨折患者，哪种药理学药物、剂量和时间最有效预防静脉血栓栓塞（VTE）尚不清楚。
我们于 2020 年 10 月 3 日在 Cochrane 系统评价数据库、Embase、Web of Science、EBSCO 和 PubMed 上检索了有关骨盆/髋臼骨折患者 VTE 预防的英语研究，未设定日期限制。我们纳入了比较药理学药物预防 VTE 效果、药物使用时间和/或剂量的研究。我们记录了干预措施、样本量和 VTE 发生率，包括深静脉血栓形成（DVT）和肺栓塞。
两项研究（3604 例患者）比较了药物，结果表明，接受直接口服抗凝剂（DOAC）的患者发生 DVT 的可能性低于接受低分子肝素（LMWH）的患者（p<0.01）。与未分级肝素（UFH）相比，LMWH 与较低的 VTE 发生率（比值比 [OR] = 0.37，95%置信区间 [CI]：0.22-0.63）和死亡率（OR = 0.27，95%CI：0.10-0.72）相关。三项研究（3107 例患者）比较了 VTE 预防的时间，结果表明，晚期预防与更高的 VTE 发生率（OR = 1.9，95%CI：1.2-3.2）和死亡率（OR = 4.0，95%CI：1.5-11）以及更高的症状性 DVT 发生率（9.2%比 2.5%，p=0.03；22%比 3.1%，p=0.01）相关。一项研究（31 例患者）调查了 VTE 预防的剂量，结果表明，髋臼骨折患者中，更多患者的剂量不足（接受抗因子 Xa[aFXa]治疗的患者中，23%的髋臼骨折患者低于 aFXa 范围，而在适当的 aFXa 范围内的患者为 4.8%，p<0.01）。
与晚期给药相比，早期（损伤后 24 或 48 小时内）VTE 化学预防在 VTE 和死亡方面效果更好。许多髋臼骨折患者接受 LMWH 治疗剂量不足，aFXa 水平不足。与 UFH 相比，LMWH 与较低的 VTE 和死亡率相关。与 LMWH 相比，DOAC 与较低的 DVT 风险相关。
III，回顾性队列研究的系统评价。
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