Venous thromboembolism after trauma: A never event?

Objective: Rates of venous thromboembolism as high as 58 percent have been reported after trauma, but there is no widely accepted screening protocol. If Medicare adds venous thromboembolism to the list of "preventable complications," they will no longer reimburse for treatment, which could have devastating effects on many urban centers. We hypothesized that prescreening with a risk assessment profile followed by routine surveillance with venous duplex ultrasound that could identify asymptomatic venous thromboembolism in trauma patients.

Results: In prescreened high-risk patients, 20 asymptomatic deep vein thrombosis were detected with venous duplex ultrasound (19 percent). An additional ten venous thromboembolisms occurred, including six symptomatic deep vein thrombosis and four pulmonary emboli, resulting in an overall venous thromboembolism rate of 28 percent. The most common risk factors discriminating venous thromboembolism vs. no venous thromboembolism were femoral central venous catheter (23 versus 8 percent), operative intervention >2 hrs (77 versus 46 percent), complex lower extremity fracture (53  percent 32 percent), and pelvic fracture (70 percent versus 47 percent), respectively (all p < .05). Risk assessment profile scores were higher in patients with venous thromboembolism (19 +/- 6 vs. 14 +/- 4, p = .001). Risk assessment profile score (odds ratio 1.14) and the combination of pelvic fracture requiring operative intervention >2 hrs (odds ratio 5.75) were independent predictors for development of venous thromboembolism. The rates of venous thromboembolism for no chemical prophylaxis (33 percent), unfractionated heparin (29 percent), dalteparin (40 percent), or inferior vena cava filters (20 percent) were not statistically different (p = .764).

Conclusions: Medicare's inclusion of venous thromboembolism after trauma as a never event should be questioned. In trauma patients, high-risk assessment profile score and pelvic fracture with prolonged operative intervention are independent predictors for venous thromboembolism development, despite thromboprophylaxis. Although routine venous duplex ultrasound screening may not be cost-effective for all trauma patients, prescreening using risk assessment profile yielded a cohort of patients with a high prevalence of venous thromboembolism. In such high-risk patients, routine venous duplex ultrasound and/or more aggressive prophylactic regimens may be beneficial.

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