Velmahos G C, Nigro J, Tatevossian R, Murray J A, Cornwell E E, Belzberg H, Asensio J A, Berne T V, Demetriades D
Department of Surgery, Los Angeles County + University of Southern California Medical Center, 90033-4525, USA.
J Am Coll Surg. 1998 Nov;187(5):529-33. doi: 10.1016/s1072-7515(98)00223-3.
Deep venous thrombosis (DVT) in severely injured patients is a life-threatening complication. Effective and safe thromboprophylaxis is highly desirable to prevent DVT. Low-dose heparin (LDH) and sequential compression device (SCDs) are the most frequently used methods. Inappropriate use of these methods because of the nature or site of critical injuries (eg, brain lesion, solid visceral or retroperitoneal hematoma, extremity fractures) may lead to failure of DVT prophylaxis.
A prospective study was performed to evaluate the efficacy of a policy of aggressive use of LDH and SCDs in patients who are at very high risk for DVT. From January 1996 to August 1997, 200 critically injured patients were followed by weekly Doppler examinations to detect DVT at the proximal lower extremities. Only 3 patients did not receive any thromboprophylaxis. SCDs were applied in 97.5% and LDH was administered to 46% of the patients; 45% had both.
DVT was found in 26 patients (13%). The majority (58%) developed DVT within the first 2 weeks, but new cases were found as late as 12 weeks after admission. The incidence of DVT was the same among patients who had SCDs only or a combination of LDH and SCDs. Mechanism of injury, type and number of operations, site of injury, Injury Severity Score, and the incidence of femoral lines were not different between patients with and without DVT. Differences were found in the severity of injury to the chest and the extremities and the need for high-level respiratory support. Patients with DVT had prolonged ICU and hospital stays (on average, 34 and 49 days, respectively) and a high mortality rate (31%).
The incidence of DVT remains high among severely injured patients despite aggressive thromboprophylaxis. A combination of LDH and an SCD showed no advantage over SCD alone in decreasing DVT rates. Risk factors in this group of patients who are already at very high risk are hard to detect; Doppler examinations are justified for surveillance in all critically injured patients. Current methods of thromboprophylaxis seem to offer limited efficacy, and the search for more effective methods should continue.
严重创伤患者的深静脉血栓形成（DVT）是一种危及生命的并发症。非常需要有效且安全的血栓预防措施来预防DVT。低剂量肝素（LDH）和序贯加压装置（SCDs）是最常用的方法。由于严重损伤的性质或部位（如脑损伤、实体脏器或腹膜后血肿、四肢骨折）而不适当使用这些方法可能导致DVT预防失败。
进行了一项前瞻性研究，以评估在DVT极高风险患者中积极使用LDH和SCDs策略的疗效。从1996年1月至1997年8月，对200例严重创伤患者每周进行多普勒检查，以检测下肢近端的DVT。只有3例患者未接受任何血栓预防措施。97.5%的患者应用了SCDs，46%的患者给予了LDH；45%的患者两者都用了。
26例患者（13%）发现有DVT。大多数（58%）在最初2周内发生DVT，但入院后12周时仍发现有新病例。仅使用SCDs或LDH与SCDs联合使用的患者中DVT的发生率相同。有或无DVT的患者在损伤机制、手术类型和数量、损伤部位、损伤严重程度评分以及股静脉置管发生率方面无差异。在胸部和四肢的损伤严重程度以及对高水平呼吸支持的需求方面发现了差异。发生DVT的患者在重症监护病房（ICU）和住院时间延长（平均分别为34天和49天），死亡率高（31%）。
尽管采取了积极的血栓预防措施，但严重创伤患者中DVT的发生率仍然很高。LDH与SCD联合使用在降低DVT发生率方面并不比单独使用SCD更具优势。在这组已经处于极高风险的患者中，危险因素难以检测；对所有严重创伤患者进行多普勒检查以进行监测是合理的。目前的血栓预防方法似乎疗效有限，应继续寻找更有效的方法。
