Hypercoagulability and other risk factors in trauma intensive care unit patients with venous thromboembolism

Robert M. Van Haren, Evan J. Valle, Chad M. Thorson, Jassin M. Jouria, Alexander M. Busko, Gerardo A. Guarch, Nicholas Namias, Alan Livingstone, Kenneth G Proctor

Research output: Contribution to journalArticle

42 Citations (Scopus)

Abstract

BACKGROUND: Thromboelastography (TEG) on hospital admission can identify hypercoagulable trauma patients at risk for venous thromboembolism (VTE), but the value of TEGs obtained after multiple interventions, including tranexamic acid (TXA), has not been defined. We test the following hypotheses. (1) TEG on intensive care unit (ICU) admission can help stratify patients screened with Greenfield's risk assessment profile (RAP) for VTE. (2) TXA is a VTE risk factor, and its effect on fibrinolysis can be identified with TEG. METHODS: Trauma patients who survived to the ICU with RAP ≥ 10 received serial venous duplex ultrasound examinations and blood samples for coagulation analysis at admission to the ICU and weekly thereafter. RESULTS: Six hundred seventy-eight patients were screened and 121 were enrolled; 76% blunt injury, Injury Severity Score (ISS) 27, 13% mortality. Thromboprophylaxis was administered to 90% of the patients and was started a median of 2 days after hospital admission. VTE was detected in 28% (n = 34) of the patients (27 deep vein thrombosis and 7 pulmonary emboli) and occurred a median 10 days after admission. Twenty-nine percent (n = 10) of VTE occurred within 2 days of admission. Most variables were similar between those with and without VTE, but the VTE group received more operations (3 (2) vs. 2 (2), p = 0.044), had increased ICU days (25 (34) days vs. 15 (18) days, p = 0.004), and was more likely to have abdominal injury with Abbreviated Injury Scale (AIS) score > 2 (59% vs. 39%, p = 0.050). Upon ICU admission, standard coagulation markers were within normal limits, while TEG demonstrated hypercoagulability, but neither was associated with VTE. Repeat TEG one week after admission (n = 58) remained hypercoagulable but transitioned to a different pattern with increased clot strength. TXA was associated with reduced fibrinolysis on initial TEG (p < 0.05) but was not associated with VTE. CONCLUSION: Trauma ICU patients with RAP ≥ 10 are hypercoagulable at admission to ICU and remain so during recovery. They have a ≥ 25% rate of VTE, despite thromboprophylaxis. TXA is associated with reduced fibrinolysis but does not increase VTE rates. Neither TEG nor standard coagulation markers (measured on ICU admission) stratify high-risk patients who develop VTE from those who do not. LEVEL OF EVIDENCE: Prognostic study, level III.

Original languageEnglish
Pages (from-to)443-449
Number of pages7
JournalJournal of Trauma and Acute Care Surgery
Volume76
Issue number2
DOIs
StatePublished - Feb 1 2014

Fingerprint

Thrombophilia
Venous Thromboembolism
Intensive Care Units
Thrombelastography
Wounds and Injuries
Tranexamic Acid
Fibrinolysis
Abbreviated Injury Scale
Abdominal Injuries
Nonpenetrating Wounds
Injury Severity Score
Blood Coagulation
Embolism
Venous Thrombosis

Keywords

  • Thromboelastography
  • tranexamic acid
  • venous duplex ultrasound

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery

Cite this

Hypercoagulability and other risk factors in trauma intensive care unit patients with venous thromboembolism. / Van Haren, Robert M.; Valle, Evan J.; Thorson, Chad M.; Jouria, Jassin M.; Busko, Alexander M.; Guarch, Gerardo A.; Namias, Nicholas; Livingstone, Alan; Proctor, Kenneth G.

In: Journal of Trauma and Acute Care Surgery, Vol. 76, No. 2, 01.02.2014, p. 443-449.

Research output: Contribution to journalArticle

Van Haren, Robert M. ; Valle, Evan J. ; Thorson, Chad M. ; Jouria, Jassin M. ; Busko, Alexander M. ; Guarch, Gerardo A. ; Namias, Nicholas ; Livingstone, Alan ; Proctor, Kenneth G. / Hypercoagulability and other risk factors in trauma intensive care unit patients with venous thromboembolism. In: Journal of Trauma and Acute Care Surgery. 2014 ; Vol. 76, No. 2. pp. 443-449.
@article{e6f227be287f40cea70eb3c98c3f687a,
title = "Hypercoagulability and other risk factors in trauma intensive care unit patients with venous thromboembolism",
abstract = "BACKGROUND: Thromboelastography (TEG) on hospital admission can identify hypercoagulable trauma patients at risk for venous thromboembolism (VTE), but the value of TEGs obtained after multiple interventions, including tranexamic acid (TXA), has not been defined. We test the following hypotheses. (1) TEG on intensive care unit (ICU) admission can help stratify patients screened with Greenfield's risk assessment profile (RAP) for VTE. (2) TXA is a VTE risk factor, and its effect on fibrinolysis can be identified with TEG. METHODS: Trauma patients who survived to the ICU with RAP ≥ 10 received serial venous duplex ultrasound examinations and blood samples for coagulation analysis at admission to the ICU and weekly thereafter. RESULTS: Six hundred seventy-eight patients were screened and 121 were enrolled; 76{\%} blunt injury, Injury Severity Score (ISS) 27, 13{\%} mortality. Thromboprophylaxis was administered to 90{\%} of the patients and was started a median of 2 days after hospital admission. VTE was detected in 28{\%} (n = 34) of the patients (27 deep vein thrombosis and 7 pulmonary emboli) and occurred a median 10 days after admission. Twenty-nine percent (n = 10) of VTE occurred within 2 days of admission. Most variables were similar between those with and without VTE, but the VTE group received more operations (3 (2) vs. 2 (2), p = 0.044), had increased ICU days (25 (34) days vs. 15 (18) days, p = 0.004), and was more likely to have abdominal injury with Abbreviated Injury Scale (AIS) score > 2 (59{\%} vs. 39{\%}, p = 0.050). Upon ICU admission, standard coagulation markers were within normal limits, while TEG demonstrated hypercoagulability, but neither was associated with VTE. Repeat TEG one week after admission (n = 58) remained hypercoagulable but transitioned to a different pattern with increased clot strength. TXA was associated with reduced fibrinolysis on initial TEG (p < 0.05) but was not associated with VTE. CONCLUSION: Trauma ICU patients with RAP ≥ 10 are hypercoagulable at admission to ICU and remain so during recovery. They have a ≥ 25{\%} rate of VTE, despite thromboprophylaxis. TXA is associated with reduced fibrinolysis but does not increase VTE rates. Neither TEG nor standard coagulation markers (measured on ICU admission) stratify high-risk patients who develop VTE from those who do not. LEVEL OF EVIDENCE: Prognostic study, level III.",
keywords = "Thromboelastography, tranexamic acid, venous duplex ultrasound",
author = "{Van Haren}, {Robert M.} and Valle, {Evan J.} and Thorson, {Chad M.} and Jouria, {Jassin M.} and Busko, {Alexander M.} and Guarch, {Gerardo A.} and Nicholas Namias and Alan Livingstone and Proctor, {Kenneth G}",
year = "2014",
month = "2",
day = "1",
doi = "10.1097/TA.0b013e3182a9d11d",
language = "English",
volume = "76",
pages = "443--449",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
publisher = "Lippincott Williams and Wilkins",
number = "2",

}

TY - JOUR

T1 - Hypercoagulability and other risk factors in trauma intensive care unit patients with venous thromboembolism

AU - Van Haren, Robert M.

AU - Valle, Evan J.

AU - Thorson, Chad M.

AU - Jouria, Jassin M.

AU - Busko, Alexander M.

AU - Guarch, Gerardo A.

AU - Namias, Nicholas

AU - Livingstone, Alan

AU - Proctor, Kenneth G

PY - 2014/2/1

Y1 - 2014/2/1

N2 - BACKGROUND: Thromboelastography (TEG) on hospital admission can identify hypercoagulable trauma patients at risk for venous thromboembolism (VTE), but the value of TEGs obtained after multiple interventions, including tranexamic acid (TXA), has not been defined. We test the following hypotheses. (1) TEG on intensive care unit (ICU) admission can help stratify patients screened with Greenfield's risk assessment profile (RAP) for VTE. (2) TXA is a VTE risk factor, and its effect on fibrinolysis can be identified with TEG. METHODS: Trauma patients who survived to the ICU with RAP ≥ 10 received serial venous duplex ultrasound examinations and blood samples for coagulation analysis at admission to the ICU and weekly thereafter. RESULTS: Six hundred seventy-eight patients were screened and 121 were enrolled; 76% blunt injury, Injury Severity Score (ISS) 27, 13% mortality. Thromboprophylaxis was administered to 90% of the patients and was started a median of 2 days after hospital admission. VTE was detected in 28% (n = 34) of the patients (27 deep vein thrombosis and 7 pulmonary emboli) and occurred a median 10 days after admission. Twenty-nine percent (n = 10) of VTE occurred within 2 days of admission. Most variables were similar between those with and without VTE, but the VTE group received more operations (3 (2) vs. 2 (2), p = 0.044), had increased ICU days (25 (34) days vs. 15 (18) days, p = 0.004), and was more likely to have abdominal injury with Abbreviated Injury Scale (AIS) score > 2 (59% vs. 39%, p = 0.050). Upon ICU admission, standard coagulation markers were within normal limits, while TEG demonstrated hypercoagulability, but neither was associated with VTE. Repeat TEG one week after admission (n = 58) remained hypercoagulable but transitioned to a different pattern with increased clot strength. TXA was associated with reduced fibrinolysis on initial TEG (p < 0.05) but was not associated with VTE. CONCLUSION: Trauma ICU patients with RAP ≥ 10 are hypercoagulable at admission to ICU and remain so during recovery. They have a ≥ 25% rate of VTE, despite thromboprophylaxis. TXA is associated with reduced fibrinolysis but does not increase VTE rates. Neither TEG nor standard coagulation markers (measured on ICU admission) stratify high-risk patients who develop VTE from those who do not. LEVEL OF EVIDENCE: Prognostic study, level III.

AB - BACKGROUND: Thromboelastography (TEG) on hospital admission can identify hypercoagulable trauma patients at risk for venous thromboembolism (VTE), but the value of TEGs obtained after multiple interventions, including tranexamic acid (TXA), has not been defined. We test the following hypotheses. (1) TEG on intensive care unit (ICU) admission can help stratify patients screened with Greenfield's risk assessment profile (RAP) for VTE. (2) TXA is a VTE risk factor, and its effect on fibrinolysis can be identified with TEG. METHODS: Trauma patients who survived to the ICU with RAP ≥ 10 received serial venous duplex ultrasound examinations and blood samples for coagulation analysis at admission to the ICU and weekly thereafter. RESULTS: Six hundred seventy-eight patients were screened and 121 were enrolled; 76% blunt injury, Injury Severity Score (ISS) 27, 13% mortality. Thromboprophylaxis was administered to 90% of the patients and was started a median of 2 days after hospital admission. VTE was detected in 28% (n = 34) of the patients (27 deep vein thrombosis and 7 pulmonary emboli) and occurred a median 10 days after admission. Twenty-nine percent (n = 10) of VTE occurred within 2 days of admission. Most variables were similar between those with and without VTE, but the VTE group received more operations (3 (2) vs. 2 (2), p = 0.044), had increased ICU days (25 (34) days vs. 15 (18) days, p = 0.004), and was more likely to have abdominal injury with Abbreviated Injury Scale (AIS) score > 2 (59% vs. 39%, p = 0.050). Upon ICU admission, standard coagulation markers were within normal limits, while TEG demonstrated hypercoagulability, but neither was associated with VTE. Repeat TEG one week after admission (n = 58) remained hypercoagulable but transitioned to a different pattern with increased clot strength. TXA was associated with reduced fibrinolysis on initial TEG (p < 0.05) but was not associated with VTE. CONCLUSION: Trauma ICU patients with RAP ≥ 10 are hypercoagulable at admission to ICU and remain so during recovery. They have a ≥ 25% rate of VTE, despite thromboprophylaxis. TXA is associated with reduced fibrinolysis but does not increase VTE rates. Neither TEG nor standard coagulation markers (measured on ICU admission) stratify high-risk patients who develop VTE from those who do not. LEVEL OF EVIDENCE: Prognostic study, level III.

KW - Thromboelastography

KW - tranexamic acid

KW - venous duplex ultrasound

UR - http://www.scopus.com/inward/record.url?scp=84894076778&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84894076778&partnerID=8YFLogxK

U2 - 10.1097/TA.0b013e3182a9d11d

DO - 10.1097/TA.0b013e3182a9d11d

M3 - Article

C2 - 24398771

AN - SCOPUS:84894076778

VL - 76

SP - 443

EP - 449

JO - Journal of Trauma and Acute Care Surgery

JF - Journal of Trauma and Acute Care Surgery

SN - 2163-0755

IS - 2

ER -