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Prevention of Venous Thromboembolism After Injury
Evidence Reports/Technology Assessments, No. 22
Investigators: George C Velmahos, MD, PhD, Principal Investigator, Jack Kern, PhD, Linda Chan, PhD, Oder Danila, James A Murray, MD, and Paul Shekelle, MD.
Structured Abstract
Objectives:
This project's goals are to evaluate the existing literature, summarize the evidence, and perform meta-analysis and cost-effectiveness analysis on data relevant to prevention of venous thromboembolism after injury. Venous thromboembolism occurs frequently after trauma and causes significant mortality and long-term disability. At the same time, methods to prevent and diagnose it are highly controversial and physicians' practices vary widely. With this evidence report, we intend to examine these controversial areas by analyzing the existing scientific literature. An equally important objective is to identify areas in which evidence is lacking in order to direct future research.
Search Strategy:
Three databases were searched: MEDLINE (1966--99), EMBASE (1980--99), and the Cochrane Controlled Trials Register (1980--99). The following medical subject headings were used: Thrombophlebitis, Thrombosis, Thromboembolism, Pulmonary embolism, Wounds and injuries; the subheadings: pc (prevention and control), in (injuries); and the text words: prevent$, thromboprophyla$, prophylac$, trauma$, posttrauma$, post-trauma$.
Selection Criteria:
Studies were selected if they specifically reported on methods of venous thromboembolism prevention and screening in trauma patients. Studies including only nontrauma patients were rejected. A panel of technical experts assisted in identifying four key questions: 1) What is the best method of venous thromboembolism prophylaxis? 2) What groups of patients are at high risk of developing venous thromboembolism? 3) What is the best method of screening for venous thromboembolism? 4) What is the role of vena cava filters in preventing pulmonary embolism? Studies were selected if they addressed any of these four questions.
Data Collection and Analysis:
Screening of 4,093 relevant titles by two independent reviewers resulted in acceptance of 2,437 of them for abstract review; 227 of these were accepted for further review. Finally, 73 studies were analyzed. Meta-analysis and supplemental analyses were performed on the available data.
Main Results:
The reported incidence of deep venous thrombosis in trauma patients in the selected studies is 12 percent and varies from 3 percent to 23 percent according to study design, type of trauma population, and method of deep venous thrombosis prophylaxis and diagnosis. The reported incidence of pulmonary embolism in these studies is 1.5 percent and varies from 0.1 percent to 15 percent. Few randomized controlled trials provided data that could be combined for meta-analysis. From the limited data available, there is no evidence that mechanical prophylaxis or low-dose heparin is superior to no prophylaxis or to each other for prevention of deep venous thrombosis. The role of low-molecular-weight heparin in trauma patients is unclear because the few relevant studies are heterogeneous. Spinal fractures and spinal-cord injuries increase the risk of venous thromboembolism. No relevant data are available for drawing conclusions about the best method of screening for venous thromboembolism. Although vena cava filter placement in selected trauma patients may decrease the incidence of pulmonary embolism and fatal pulmonary embolism, the designs of the studies reporting these results do not allow definitive conclusions to be drawn.
Conclusions:
The evidence on prevention of venous thromboembolism after injury is scanty. Many practices are based on extrapolations from data on nontrauma patients. The risk of venous thromboembolism increases in the presence of spinal trauma with or without injury to the spinal cord. Currently, the most frequently used methods of venous thromboembolism prophylaxis do not offer a proven benefit over no prophylaxis. There is a pressing need for well-designed studies that will identify the best method of prevention of venous thromboembolism in trauma patients.
Contents
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.1 Contract No. 290-97-0001. Prepared by: Southern California Evidence-based Practice Center/RAND.
Suggested citation:
Velmahos GC, Kern J, Chan L, et al. Prevention of Venous Thromboembolism After Injury. Evidence Report/ Technology Assessment No. 22. (Prepared by Southern California Evidence-based Practice Center/RAND under Contract No. 290-97-0001.) AHRQ Publication No. 01-E004. Rockville, MD: Agency for Healthcare Research and Quality. November 2000.
On December 6, 1999, under Public Law 106-129, the Agency for Health Care Policy and Research (AHCPR) was reauthorized and renamed the Agency for Healthcare Research and Quality (AHRQ). The law authorizes AHRQ to continue its research on the cost, quality, and outcomes of health care, and expands its role to improve patient safety and address medical errors.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, test, treatment, or other clinical service.
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2101 East Jefferson Street, Rockville, MD 20852. www
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