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CHICAGO – Performing rapid thromboelastography on admission can help trauma surgeons determine which patients are at greatest risk of developing pulmonary embolism, judging by results of a study of more than 8,000 patients.
The incidence of pulmonary embolism (PE), although still below 0.5%, has more than doubled in recent years, according to a recent report using data from the National Trauma Data Bank (Ann. Surg. 2011 Aug. 24 [E-pub ahead of print]).
"Despite this increasing knowledge of risk factors, despite increasing chemoprophylaxis – we’re getting more aggressive with head injuries in starting enoxaparin and heparin, and more aggressive with our spine and solid organ injuries – despite all this, the incidence of PE is increasing," Dr. Bryan A. Cotton said at the annual meeting of the American Association for the Surgery of Trauma.
To learn whether rapid thromboelastography (r-TEG), using a maximum amplitude (mA) greater than 65 mm, could identify patients at risk of developing PE during their hospital stay, Dr. Cotton and his colleagues at the University of Texas Health Science Center in Houston evaluated the use of r-TEG upon admission to the trauma bay for 8,330 total trauma patients over an 18-month period.
"Recent data from multiple institutions have shown an increase in vascular complications following these states if the mA values and certain other portions of TEG values are elevated," Dr. Cotton said. Besides PE and venous thromboembolism (VTE), complications including stroke and postoperative MI have been shown to increase with postoperative and postinjury r-TEG values, he added.
In the Houston study, r-TEG was obtained on 2,070 consecutive trauma patients. Of those, 2.5% went on to develop PE. These patients tended to be older and were more likely to be white and more severely injured than the other patients, and to have only blunt injuries.
"We found the admission mA, which is the highest amplitude of the clot, was associated with risk of developing PE during hospital stay," Dr. Cotton said.
The median time to development of PE was 6 days (duration, 2-31 days), he noted. The investigators also analyzed other factors, and when controlling for male sex, Injury Severity Score, and age, they found that an individual with an mA greater than 65 mm at the time of admission had a 3.5-fold greater odds of developing PE during the hospital stay, Dr. Cotton said. When they raised the threshold to an mA of 72 mm or higher, the risk profile increased sixfold, he said.
"An mA of 65 [mm] or greater is just as good as traditionally noted high-risk factors," Dr. Cotton said. "These include pelvic factures and lower extremity spine and head injuries. When mA is greater than 72 [mm], it exceeds or equals the odds ratio for very-high-risk factors such as prolonged ventilation and venous injuries."
Dr. Preston Miller of Wake Forest University in Winston-Salem, N.C., said that the study "answers some questions and creates a lot of questions as to what we’re doing in respect to PE and VTE prophylaxis in our patients." He asked whether the study accounted for intrinsic or genetic hypercoagulable states in the PE population.
"On TEG, maximal amplitude is mostly reflective of platelet activity; the elevated mA associated with pulmonary embolism may argue that platelet dysfunction is a problem," said Dr. Miller. "Does this argue for a potential role for antiplatelet agents for potential PE and thromboembolism prophylaxis in trauma patients?"
Dr. Cotton acknowledged that further studies are needed to determine whether anticoagulation protocols should be more aggressive. However, at his institution, these patients now get 30 mg of enoxaparin or 5,000 cc of heparin on admission unless they have traumatic brain injury. The investigators said the next step is to develop an algorithm and a guideline based on initiating aspirin along with enoxaparin.
Dr. Steven R. Shackford, who practices in San Diego, offered a likely explanation for the rising incidence of PE in trauma patients: "We have CT now, and instead of getting a pulmonary angiogram, we can now get a CT scan, which is much easier to get," he said.
Dr. Cotton disclosed that although the study received no direct funding, he has done work for Haemonetics Corp., which markets automated blood-processing systems.
Venous thromboembolism (VTE) is a common, morbid, costly, and oftentimes fatal complication of hospitalization or trauma/surgery. Yet, proven and effective thromboprophylaxis strategies are often underutilized which has fostered regulatory initiatives to improve VTE prevention efforts. For example, current Joint Commission performance measures endorse VTE risk assessment for all patients at the time of admission. Yet, our current ability to tailor thromboprophylaxis strategies to individualized patient specific risk is limited.
Consequently, we approach VTE prevention with a “pack mentality,” initiating the same strategy for all patients who fall within broad risk groups. The concept of more tailored and personalized approaches such as individualized risk assessment methods including clinical features, genetics, results of biomarkers, and/or coagulation parameters such as rapid thromboelastography (TEG) as studied by Dr Cotton, is intriguing and could have the potential to allow for the targeting of the most aggressive prevention efforts to those at the highest risk while obviating the need for thromboprophylaxis in identified low risk patients. Yet, these tailored approaches would add complexity and may increase the cost to patient care without improving outcomes.
Only through validation of tools such as the TEG along with the completion of prospective comparative effectiveness clinical studies will we be able to determine their utility. In the meantime, as it relates to VTE prevention, clinicians should continue to ensure that VTE risk is broadly performed on all hospital admissions and that proven thromboprophylaxis strategies are delivered to those groups identified at being at increased risk.
ROBERT PENDLETON, M.D., is associate professor of medicine in the general internal medicine division at the University of Utah in Salt Lake City. He reported having no disclosures.
Venous thromboembolism (VTE) is a common, morbid, costly, and oftentimes fatal complication of hospitalization or trauma/surgery. Yet, proven and effective thromboprophylaxis strategies are often underutilized which has fostered regulatory initiatives to improve VTE prevention efforts. For example, current Joint Commission performance measures endorse VTE risk assessment for all patients at the time of admission. Yet, our current ability to tailor thromboprophylaxis strategies to individualized patient specific risk is limited.
Consequently, we approach VTE prevention with a “pack mentality,” initiating the same strategy for all patients who fall within broad risk groups. The concept of more tailored and personalized approaches such as individualized risk assessment methods including clinical features, genetics, results of biomarkers, and/or coagulation parameters such as rapid thromboelastography (TEG) as studied by Dr Cotton, is intriguing and could have the potential to allow for the targeting of the most aggressive prevention efforts to those at the highest risk while obviating the need for thromboprophylaxis in identified low risk patients. Yet, these tailored approaches would add complexity and may increase the cost to patient care without improving outcomes.
Only through validation of tools such as the TEG along with the completion of prospective comparative effectiveness clinical studies will we be able to determine their utility. In the meantime, as it relates to VTE prevention, clinicians should continue to ensure that VTE risk is broadly performed on all hospital admissions and that proven thromboprophylaxis strategies are delivered to those groups identified at being at increased risk.
ROBERT PENDLETON, M.D., is associate professor of medicine in the general internal medicine division at the University of Utah in Salt Lake City. He reported having no disclosures.
Venous thromboembolism (VTE) is a common, morbid, costly, and oftentimes fatal complication of hospitalization or trauma/surgery. Yet, proven and effective thromboprophylaxis strategies are often underutilized which has fostered regulatory initiatives to improve VTE prevention efforts. For example, current Joint Commission performance measures endorse VTE risk assessment for all patients at the time of admission. Yet, our current ability to tailor thromboprophylaxis strategies to individualized patient specific risk is limited.
Consequently, we approach VTE prevention with a “pack mentality,” initiating the same strategy for all patients who fall within broad risk groups. The concept of more tailored and personalized approaches such as individualized risk assessment methods including clinical features, genetics, results of biomarkers, and/or coagulation parameters such as rapid thromboelastography (TEG) as studied by Dr Cotton, is intriguing and could have the potential to allow for the targeting of the most aggressive prevention efforts to those at the highest risk while obviating the need for thromboprophylaxis in identified low risk patients. Yet, these tailored approaches would add complexity and may increase the cost to patient care without improving outcomes.
Only through validation of tools such as the TEG along with the completion of prospective comparative effectiveness clinical studies will we be able to determine their utility. In the meantime, as it relates to VTE prevention, clinicians should continue to ensure that VTE risk is broadly performed on all hospital admissions and that proven thromboprophylaxis strategies are delivered to those groups identified at being at increased risk.
ROBERT PENDLETON, M.D., is associate professor of medicine in the general internal medicine division at the University of Utah in Salt Lake City. He reported having no disclosures.
CHICAGO – Performing rapid thromboelastography on admission can help trauma surgeons determine which patients are at greatest risk of developing pulmonary embolism, judging by results of a study of more than 8,000 patients.
The incidence of pulmonary embolism (PE), although still below 0.5%, has more than doubled in recent years, according to a recent report using data from the National Trauma Data Bank (Ann. Surg. 2011 Aug. 24 [E-pub ahead of print]).
"Despite this increasing knowledge of risk factors, despite increasing chemoprophylaxis – we’re getting more aggressive with head injuries in starting enoxaparin and heparin, and more aggressive with our spine and solid organ injuries – despite all this, the incidence of PE is increasing," Dr. Bryan A. Cotton said at the annual meeting of the American Association for the Surgery of Trauma.
To learn whether rapid thromboelastography (r-TEG), using a maximum amplitude (mA) greater than 65 mm, could identify patients at risk of developing PE during their hospital stay, Dr. Cotton and his colleagues at the University of Texas Health Science Center in Houston evaluated the use of r-TEG upon admission to the trauma bay for 8,330 total trauma patients over an 18-month period.
"Recent data from multiple institutions have shown an increase in vascular complications following these states if the mA values and certain other portions of TEG values are elevated," Dr. Cotton said. Besides PE and venous thromboembolism (VTE), complications including stroke and postoperative MI have been shown to increase with postoperative and postinjury r-TEG values, he added.
In the Houston study, r-TEG was obtained on 2,070 consecutive trauma patients. Of those, 2.5% went on to develop PE. These patients tended to be older and were more likely to be white and more severely injured than the other patients, and to have only blunt injuries.
"We found the admission mA, which is the highest amplitude of the clot, was associated with risk of developing PE during hospital stay," Dr. Cotton said.
The median time to development of PE was 6 days (duration, 2-31 days), he noted. The investigators also analyzed other factors, and when controlling for male sex, Injury Severity Score, and age, they found that an individual with an mA greater than 65 mm at the time of admission had a 3.5-fold greater odds of developing PE during the hospital stay, Dr. Cotton said. When they raised the threshold to an mA of 72 mm or higher, the risk profile increased sixfold, he said.
"An mA of 65 [mm] or greater is just as good as traditionally noted high-risk factors," Dr. Cotton said. "These include pelvic factures and lower extremity spine and head injuries. When mA is greater than 72 [mm], it exceeds or equals the odds ratio for very-high-risk factors such as prolonged ventilation and venous injuries."
Dr. Preston Miller of Wake Forest University in Winston-Salem, N.C., said that the study "answers some questions and creates a lot of questions as to what we’re doing in respect to PE and VTE prophylaxis in our patients." He asked whether the study accounted for intrinsic or genetic hypercoagulable states in the PE population.
"On TEG, maximal amplitude is mostly reflective of platelet activity; the elevated mA associated with pulmonary embolism may argue that platelet dysfunction is a problem," said Dr. Miller. "Does this argue for a potential role for antiplatelet agents for potential PE and thromboembolism prophylaxis in trauma patients?"
Dr. Cotton acknowledged that further studies are needed to determine whether anticoagulation protocols should be more aggressive. However, at his institution, these patients now get 30 mg of enoxaparin or 5,000 cc of heparin on admission unless they have traumatic brain injury. The investigators said the next step is to develop an algorithm and a guideline based on initiating aspirin along with enoxaparin.
Dr. Steven R. Shackford, who practices in San Diego, offered a likely explanation for the rising incidence of PE in trauma patients: "We have CT now, and instead of getting a pulmonary angiogram, we can now get a CT scan, which is much easier to get," he said.
Dr. Cotton disclosed that although the study received no direct funding, he has done work for Haemonetics Corp., which markets automated blood-processing systems.
CHICAGO – Performing rapid thromboelastography on admission can help trauma surgeons determine which patients are at greatest risk of developing pulmonary embolism, judging by results of a study of more than 8,000 patients.
The incidence of pulmonary embolism (PE), although still below 0.5%, has more than doubled in recent years, according to a recent report using data from the National Trauma Data Bank (Ann. Surg. 2011 Aug. 24 [E-pub ahead of print]).
"Despite this increasing knowledge of risk factors, despite increasing chemoprophylaxis – we’re getting more aggressive with head injuries in starting enoxaparin and heparin, and more aggressive with our spine and solid organ injuries – despite all this, the incidence of PE is increasing," Dr. Bryan A. Cotton said at the annual meeting of the American Association for the Surgery of Trauma.
To learn whether rapid thromboelastography (r-TEG), using a maximum amplitude (mA) greater than 65 mm, could identify patients at risk of developing PE during their hospital stay, Dr. Cotton and his colleagues at the University of Texas Health Science Center in Houston evaluated the use of r-TEG upon admission to the trauma bay for 8,330 total trauma patients over an 18-month period.
"Recent data from multiple institutions have shown an increase in vascular complications following these states if the mA values and certain other portions of TEG values are elevated," Dr. Cotton said. Besides PE and venous thromboembolism (VTE), complications including stroke and postoperative MI have been shown to increase with postoperative and postinjury r-TEG values, he added.
In the Houston study, r-TEG was obtained on 2,070 consecutive trauma patients. Of those, 2.5% went on to develop PE. These patients tended to be older and were more likely to be white and more severely injured than the other patients, and to have only blunt injuries.
"We found the admission mA, which is the highest amplitude of the clot, was associated with risk of developing PE during hospital stay," Dr. Cotton said.
The median time to development of PE was 6 days (duration, 2-31 days), he noted. The investigators also analyzed other factors, and when controlling for male sex, Injury Severity Score, and age, they found that an individual with an mA greater than 65 mm at the time of admission had a 3.5-fold greater odds of developing PE during the hospital stay, Dr. Cotton said. When they raised the threshold to an mA of 72 mm or higher, the risk profile increased sixfold, he said.
"An mA of 65 [mm] or greater is just as good as traditionally noted high-risk factors," Dr. Cotton said. "These include pelvic factures and lower extremity spine and head injuries. When mA is greater than 72 [mm], it exceeds or equals the odds ratio for very-high-risk factors such as prolonged ventilation and venous injuries."
Dr. Preston Miller of Wake Forest University in Winston-Salem, N.C., said that the study "answers some questions and creates a lot of questions as to what we’re doing in respect to PE and VTE prophylaxis in our patients." He asked whether the study accounted for intrinsic or genetic hypercoagulable states in the PE population.
"On TEG, maximal amplitude is mostly reflective of platelet activity; the elevated mA associated with pulmonary embolism may argue that platelet dysfunction is a problem," said Dr. Miller. "Does this argue for a potential role for antiplatelet agents for potential PE and thromboembolism prophylaxis in trauma patients?"
Dr. Cotton acknowledged that further studies are needed to determine whether anticoagulation protocols should be more aggressive. However, at his institution, these patients now get 30 mg of enoxaparin or 5,000 cc of heparin on admission unless they have traumatic brain injury. The investigators said the next step is to develop an algorithm and a guideline based on initiating aspirin along with enoxaparin.
Dr. Steven R. Shackford, who practices in San Diego, offered a likely explanation for the rising incidence of PE in trauma patients: "We have CT now, and instead of getting a pulmonary angiogram, we can now get a CT scan, which is much easier to get," he said.
Dr. Cotton disclosed that although the study received no direct funding, he has done work for Haemonetics Corp., which markets automated blood-processing systems.
FROM THE ANNUAL MEETING OF THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA