Timing and Type of Venous Thromboembolic Prophylaxis in Isolated Severe Liver Injury Managed Non-Operatively
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ORIGINAL SCIENTIFIC REPORT
Timing and Type of Venous Thromboembolic Prophylaxis in Isolated Severe Liver Injury Managed Non-Operatively Dominik A. Jakob1 • Elizabeth R. Benjamin1 • Panagiotis Liasidis1 • Demetrios Demetriades1
Accepted: 11 October 2020 Ó Socie´te´ Internationale de Chirurgie 2020
Abstract Background The optimal timing and type of pharmacological venous thromboembolic prophylaxis (VTEp) after severe liver injury selected for nonoperative management (NOM) are controversial. The aim of this study was to assess the effect of timing and type of VTEp in severe liver injuries selected for NOM. Methods ACS-TQIP database study (2013–17) including patients with blunt isolated severe liver injuries (AIS C 3), selected for NOM, who received VTEp with either unfractionated heparin (UH) or low-molecular-weight heparin (LMWH). Patients who underwent laparotomy or angiointervention within 24 h or prior to the initiation of VTEp were excluded. The study population was stratified according to the timing of VTEp B 48 h (EP) and [ 48 h (LP) groups. Univariate and multivariate analyses were used to identify differences between the groups. Results A total of 4074 patients was included in the study. 2004 (49.2%) received EP and 2070 (50.8%) LP. Patients with more severe injuries were more likely to receive LP than an EP [ISS 24 (19–29) vs 22 (17–27), p \ 0.001]. On multivariate analysis (correcting for age, gender, comorbidities, blood pressure, GCS, ISS, type of VTEp), LP was identified as an independent risk factor for thromboembolic events (OR 1.52, p = 0.032) and mortality (OR 2.49, p = 0.031). LMWH was independently associated with lower mortality (OR 0.36, p = 0.007), compared to UH. EP did not increase the risk of laparotomy or angiointervention after starting VTEp, compared to LP (p = 0.992). Conclusion Early VTEp (B 48 h) is safe and independently associated with fewer thromboembolic events and a lower mortality after isolated severe liver injuries managed nonoperatively. LMWH was independently associated with improved outcomes when compared with UH.
Introduction
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00268-020-05831-5) contains supplementary material, which is available to authorized users. & Elizabeth R. Benjamin [email protected] 1
Division of Trauma and Critical Care, Department of Surgery, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles, CA 90033, USA
Trauma patients are at high risk for venous thromboembolic events [1–3]. Pharmacologic venous thromboembolism prophylaxis (VTEp) is effective in reducing the risk of thromboembolic events, and early initiation has been proven superior in several types of injury [4–8]. Blunt hepatic trauma is managed nonoperatively in the majority of hemodynamically stable patients. Due to concerns of secondary bleeding the initiation of VTEp is often delayed. The optimal timing of pharmacological prophylaxis remains controversial.
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World J Surg
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