From the Department of Surgery (A.J.K.-H., S.M.S., D.R.C., A.P.R., D.S., N.N.S., S.E.S., C.M.T.), and Department of Orthopedic Surgery (M.S.K.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts.
J Trauma Acute Care Surg. 2024 Jul 1;97(1):96-104. doi: 10.1097/TA.0000000000004331. Epub 2024 Mar 29.
There are no clear recommendations for the perioperative timing and initiation of venous thromboembolism pharmacologic prophylaxis (VTEp) among polytrauma patients undergoing high-risk bleeding orthopedic operative intervention, leading to variations in VTEp administration. Our study examined the association between the timing of VTEp and VTE complications in polytrauma patients undergoing high-risk operative orthopedic interventions nationwide.
We performed a retrospective cohort study of trauma patients 18 years or older who underwent high-risk bleeding operative orthopedic interventions for pelvic, hip, and femur fractures within 24 hours of admission at American College of Surgeons-verified trauma centers using the 2019-2020 American College of Surgeons Trauma Quality Improvement Program databank. We excluded patients with a competing risk of nonorthopedic surgical bleeding. We assessed operative orthopedic polytrauma patients who received VTEp within 12 hours of orthopedic surgical intervention compared with VTEp received beyond 12 hours of intervention. The primary outcome assessed was overall VTE events. Secondary outcomes were orthopedic reinterventions within 72 hours after primary orthopedic surgery, deep venous thromboembolism, and pulmonary embolism rates.
The study included 2,229 patients who underwent high-risk orthopedic operative intervention. The median time to VTEp initiation was 30 hours (interquartile range, 18-44 hours). After adjustment for baseline patient, injury, and hospital characteristics, VTEp initiated more than 12 hours from primary orthopedic surgery was associated with increased odds of VTE (adjusted odds ratio, 2.02; 95% confidence interval, 1.08-3.77). Earlier initiation of prophylaxis was not associated with an increased risk for surgical reintervention (hazard ratio, 0.90; 95% confidence interval, 0.62-1.34).
Administering VTEp within 24 hours of admission and within 12 hours of major orthopedic surgery involving the femur, pelvis, or hip demonstrated an associated decreased risk of in-hospital VTE without an accompanying elevated risk of bleeding-related orthopedic reintervention. Clinicians should reconsider delays in initiating or withholding perioperative VTEp for stable polytrauma patients needing major orthopedic intervention.
Therapeutic/Care Management; Level III.
对于接受高风险出血骨科手术干预的多发伤患者，围手术期静脉血栓栓塞症（VTEp）预防的时机和启动尚无明确建议，这导致 VTEp 的管理存在差异。我们的研究调查了全国范围内接受高风险骨科手术干预的多发伤患者中 VTEp 时机与 VTE 并发症之间的关联。
我们对在接受美国外科医师学会认证的创伤中心入院后 24 小时内接受高风险出血性骨科手术干预的骨盆、臀部和股骨骨折的 18 岁或以上创伤患者进行了回顾性队列研究，使用 2019-2020 年美国外科医师学会创伤质量改进计划数据库。我们排除了有非骨科手术出血竞争风险的患者。我们评估了在骨科手术干预后 12 小时内接受 VTEp 与在干预后 12 小时以上接受 VTEp 的骨科多发伤患者。主要评估指标为总体 VTE 事件。次要结局指标为术后 72 小时内的骨科再干预、深静脉血栓形成和肺栓塞发生率。
这项研究纳入了 2229 名接受高风险骨科手术干预的患者。VTEp 启动的中位时间为 30 小时（四分位距，18-44 小时）。在调整基线患者、损伤和医院特征后，与主要骨科手术后 12 小时以上开始 VTEp 相比，VTEp 开始时间超过 12 小时与 VTE 风险增加相关（调整后的优势比，2.02；95%置信区间，1.08-3.77）。更早开始预防措施与手术再干预的风险增加无关（风险比，0.90；95%置信区间，0.62-1.34）。
在入院后 24 小时内以及涉及股骨、骨盆或臀部的主要骨科手术后 12 小时内给予 VTEp，可降低住院期间 VTE 的风险，同时不会增加与出血相关的骨科再干预的风险。对于需要接受重大骨科干预的稳定多发伤患者，临床医生应重新考虑延迟开始或停止围手术期 VTEp 的做法。
治疗/护理管理；III 级。
