Association of timing and agent for VTE prophylaxis in patients with severe traumatic brain injury on VTE, mortality, neurosurgical intervention, and discharge disposition

Patrick L Johnson; Shukri H A Dualeh; Ayobami Ward; Raymond A Jean; Staci Aubry; Alistair Chapman; William Curtiss; Jacob Joseph; John W Scott; Mark R Hemmila

doi:10.1097/TA.0000000000004383

Association of timing and agent for VTE prophylaxis in patients with severe traumatic brain injury on VTE, mortality, neurosurgical intervention, and discharge disposition

J Trauma Acute Care Surg. 2024 May 15. doi: 10.1097/TA.0000000000004383. Online ahead of print.

Authors

Patrick L Johnson, Shukri H A Dualeh, Ayobami Ward¹, Raymond A Jean, Staci Aubry, Alistair Chapman², William Curtiss³, Jacob Joseph¹, John W Scott, Mark R Hemmila

Affiliations

¹ Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI.
² Department of Surgery, Corewell Health Butterworth Hospital, Grand Rapids, MI.
³ Department of Surgery, Trinity Health Ann Arbor Hospital, Ypsilanti, MI.

PMID: 38745357
DOI: 10.1097/TA.0000000000004383

Abstract

Background: Trauma patients are at increased risk for venous thromboembolism events (VTE). The decision of when to initiate VTE chemoprophylaxis (VTEP) and with what agent remains controversial in patients with severe traumatic brain injury (TBI).

Methods: This comparative effectiveness study evaluated the impact of timing and agent for VTEP on outcomes for patients with severe TBI (AIS Head = 3,4, or 5). Data was collected at 35 Level 1 and 2 trauma centers from January 1, 2017 to June 1, 2022. Patients were placed into analysis cohorts: No VTEP, low-molecular weight heparin (LMWH) ≤ 48 hours, LMWH>48 hours, Heparin≤48 hours, Heparin>48 hours. Propensity score matching accounting for patient factors and injury characteristics was used with logistic regression modeling to evaluate in-hospital mortality, VTE events, and discharge disposition. Neurosurgical intervention after initiation of VTEP was used to evaluate extension of intracranial hemorrhage.

Results: Of 12,879 patients, 32% had no VTEP, 36% LMWH, and 32% Heparin. Overall mortality was 8.3% and lowest among patients receiving LMWH≤48 hours (4.1%). VTE rates were lower with use of LMWH (1.6 vs 4.5%, OR 2.98, 95% CI 1.40-6.34, p = 0.005) without increasing mortality or neurosurgical interventions. VTE rates were lower with early prophylaxis (2.0 vs 3.5%, OR 1.76, 95% CI 1.15-2.71, p = 0.01) without increasing mortality (p = 1.0). Early VTEP was associated with more non-fatal intracranial operations (p < 0.001). However, patients undergoing neurosurgical intervention after VTEP initiation had no difference in rates of mortality, withdrawal of care, or unfavorable discharge disposition (p = 0.7, p = 0.1, p = 0.5).

Conclusions: In patients with severe TBI, LMWH usage was associated with lower VTE incidence without increasing mortality or neurosurgical interventions. Initiation of VTEP≤48 hours decreased VTE incidence and increased non-fatal neurosurgical interventions without affecting mortality. LMWH is the preferred VTEP agent for severe TBI, and initiation ≤48 hours should be considered in relation to these risks and benefits.

Level of evidence: Therapeutic/Care Management, Level III.