严重创伤性脑损伤的早期静脉血栓栓塞预防：EAST 多中心倾向评分加权研究。
Early VTE prophylaxis in severe traumatic brain injury: A propensity score weighted EAST multicenter study.
机构信息
From the Division of Trauma and Surgical Critical Care, Department of Surgery (A.M.R.), Drexel College of Medicine, Philadelphia; Department of Surgery (D.K., S.S.S.), Crozer Health, Upland; Department of Surgery (C.J., E.J.K.), University of Pennsylvania, Philadelphia PA, Pennsylvania; Department of Surgery (H.M.S., M.B.A.), Virginia Commonwealth University, Richmond, Virginia; Department of Surgery (L.L.P.), Penn Medicine Lancaster General Health, Lancaster; Department of Surgery (C.M.), Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania; Department of Surgery (I.S.), Surgical Intensive Care Unit, New York Medical College, Department of Surgery (A.J.), West Chester Medical Center, Valhalla, New York; Department of Surgery (V.S., A.M.), St. Joseph Mercy Ann Arbor, Ypsilanti, Michigan; Department of Surgery (E.T., M.R.), Loma Linda University Medical Center, Loma Linda, California; Department of Surgery (L.L., W.Z.), St. Mary's Medical Center, West Palm Beach; Florida Atlantic University (L.L., W.Z.), Boca Raton, Florida; Department of Surgery (A.K., M.H.), Trinity Health Oakland, Pontiac, Michigan; Department of Surgery (J.C., C.B.), Prisma Health Upstate, Greenville, South Carolina; Department of Surgery (T.E., A.M.), Cooper University Hospital, Camden New Jersey; Department of Surgery (M.K., S.D.), Ohio Health Grant Medical Center, Columbus; Department of Surgery (R.C.), Department of Research (S.S.), Promedica Toledo Hospital, Toledo Ohio; Department of Surgery (L.E.J., J.W.), Ascension St. Vincent Hospital, Indianapolis, Indiana; Department of Trauma and Acute Care Surgery (M.W., B.P.), Kettering Health Main Campus, Kettering Ohio; Department of Surgery (C.M., N.T.), Spartanburg Medical Center, Spartanburg South Carolina; Department of Surgery (T.H., T.D.), Memorial Healthcare System, Hollywood, Florida; Department of Surgery (S.M.), Conemaugh Memorial Medical Center, Johnstown, Pennsylvania; Department of Surgery (L.D.-S., A.R.), University Hospitals Cleveland Medical Center, Cleveland, Ohio; Department of Surgery (L.C.T., T.J.N.), Cook County Hospital, Chicago, Illinois; Department of Surgery (D.H., D.R.), Penrose Hospital, Colorado Springs, Colorado; Department of Surgery (D.C.C., C.F.), Maine Medical Center, Portland, Maine; Department of Surgery (M.M., C.D.), St. Anthony Hospital, Lakewood, Colorado; Department of Surgery (J.D., S.B.), University of California, San Francisco-Fresno, San Francisco, California; Department of Surgery (K.S.), Yale School of Medicine, New Haven, Connecticut; Department of Surgery (P.F.), INOVA Fairfax Health System, Fairfax, Virginia.
出版信息
J Trauma Acute Care Surg. 2023 Jul 1;95(1):94-104. doi: 10.1097/TA.0000000000003985. Epub 2023 Apr 5.
BACKGROUND
Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism events (VTE). We hypothesized that early chemical VTE prophylaxis initiation (≤24 hours of a stable head CT) in severe TBI would reduce VTE without increasing risk of intracranial hemorrhage expansion (ICHE).
METHODS
A retrospective review of adult patients 18 years or older with isolated severe TBI (Abbreviated Injury Scale score, ≥ 3) who were admitted to 24 Level I and Level II trauma centers from January 1, 2014 to December 31 2020 was conducted. Patients were divided into those who did not receive any VTE prophylaxis (NO VTEP), who received VTE prophylaxis ≤24 hours after stable head CT (VTEP ≤24) and who received VTE prophylaxis >24 hours after stable head CT (VTEP>24). Primary outcomes were VTE and ICHE. Covariate balancing propensity score weighting was utilized to balance demographic and clinical characteristics across three groups. Weighted univariate logistic regression models were estimated for VTE and ICHE with patient group as predictor of interest.
RESULTS
Of 3,936 patients, 1,784 met inclusion criteria. Incidences of VTE was significantly higher in the VTEP>24 group, with higher incidences of DVT in the group. Higher incidences of ICHE were observed in the VTEP≤24 and VTEP>24 groups. After propensity score weighting, there was a higher risk of VTE in patients in VTEP >24 compared with those in VTEP≤24 (odds ratio, 1.51; 95% confidence interval, 0.69-3.30; p = 0.307), however was not significant. Although, the No VTEP group had decreased odds of having ICHE compared with VTEP≤24 (odds ratio, 0.75; 95% confidence interval, 0.55-1.02, p = 0.070), the result was not statistically significant.
CONCLUSION
In this large multi-center analysis, there were no significant differences in VTE based on timing of initiation of VTE prophylaxis. Patients who never received VTE prophylaxis had decreased odds of ICHE. Further evaluation of VTE prophylaxis in larger randomized studies will be necessary for definitive conclusions.
LEVEL OF EVIDENCE
Therapeutic Care Management; Level III.
背景
颅脑创伤（TBI）患者发生静脉血栓栓塞症（VTE）的风险较高。我们假设，在严重 TBI 中早期进行化学 VTE 预防（≤头部 CT 稳定后 24 小时内），不会增加颅内出血扩大（ICH）的风险，同时可降低 VTE 的发生风险。
方法
对 2014 年 1 月 1 日至 2020 年 12 月 31 日期间在 24 个 1 级和 2 级创伤中心就诊的年龄≥18 岁的单纯性严重 TBI（损伤严重程度评分≥3）的成年患者进行了回顾性分析。将患者分为未接受任何 VTE 预防（NO VTEP）、头部 CT 稳定后≤24 小时接受 VTE 预防（VTEP≤24）和头部 CT 稳定后>24 小时接受 VTE 预防（VTEP>24）。主要结局为 VTE 和 ICHE。利用协变量平衡倾向评分加权法对三组患者的人口统计学和临床特征进行平衡。采用患者组为预测因子的加权单因素逻辑回归模型估计 VTE 和 ICHE。
结果
3936 例患者中，有 1784 例符合纳入标准。VTEP>24 组 VTE 发生率明显较高，DVT 发生率较高。VTEP≤24 组和 VTEP>24 组的 ICHE 发生率较高。在进行倾向评分加权后，与 VTEP≤24 组相比，VTEP>24 组患者发生 VTE 的风险更高（比值比，1.51；95%置信区间，0.69-3.30；p=0.307），但差异无统计学意义。然而，与 VTEP≤24 组相比，未接受 VTEP 预防的患者发生 ICHE 的可能性较低（比值比，0.75；95%置信区间，0.55-1.02，p=0.070），但差异无统计学意义。
结论
在这项大型多中心分析中，根据 VTE 预防开始时间，VTE 无显著差异。从未接受过 VTE 预防的患者发生 ICHE 的可能性降低。需要进一步开展更大规模的随机研究评估 VTE 预防的效果，以得出明确的结论。
证据等级
治疗性护理管理；III 级。
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