BACKGROUND: Venous thromboembolic (VTE) disease has a high incidence following trauma, but debate remains regarding optimal prophylaxis. Thrombelastography (TEG) has been suggested to be optimal in guiding prophylaxis. Thus, we designed a phase II randomized controlled trial to test the hypothesis that TEG-guided prophylaxis with escalating low-molecular weight heparin (LMWH), followed by antiplatelet therapy would reduce VTE incidence. METHODS:Surgical intensive care unit trauma patients (n = 50) were randomized to receive 5,000 IU of LMWH daily (control) or to TEG-guided prophylaxis, up to 5,000 IU twice daily with the addition of aspirin, and were followed up for 5 days. In vitro studies were also conducted in which apheresis platelets were added to blood from healthy volunteers (n = 10). RESULTS: Control (n = 25) and TEG-guided prophylaxis (n = 25) groups were similar in age, body mass index, Injury Severity Score, and male sex. Fibrinogen levels and platelet counts did not differ, and increased LMWH did not affect clot strength between the control and study groups. The correlation of clot strength (G value) with fibrinogen was stronger on Days 1 and 2 but was superseded by platelet count on Days 3, 4, and 5. There was also a trend in increased platelet contribution to clot strength in patients receiving increased LMWH. In vitro studies demonstrated apheresis platelets significantly increased clot strength (7.19 ± 0.35 to 10.34 ± 0.29), as well as thrombus generation (713.86 ± 12.19 to 814.42 ± 7.97) and fibrin production (274.03 ± 15.82 to 427.95 ± 16.58). CONCLUSION: Increased LMWH seemed to increase platelet contribution to clot strength early in the study but failed to affect the overall rise clot strength. Over time, platelet count had the strongest correlation with clot strength, and in vitro studies demonstrated that increased platelet counts increase fibrin production and thrombus generation. In sum, these data suggest an important role for antiplatelet therapy in VTE prophylaxis following trauma, particularly after 48 hours. LEVEL OF EVIDENCE: Therapeutic study, level III.
RCT Entities:
BACKGROUND:Venous thromboembolic (VTE) disease has a high incidence following trauma, but debate remains regarding optimal prophylaxis. Thrombelastography (TEG) has been suggested to be optimal in guiding prophylaxis. Thus, we designed a phase II randomized controlled trial to test the hypothesis that TEG-guided prophylaxis with escalating low-molecular weight heparin (LMWH), followed by antiplatelet therapy would reduce VTE incidence. METHODS: Surgical intensive care unit traumapatients (n = 50) were randomized to receive 5,000 IU of LMWH daily (control) or to TEG-guided prophylaxis, up to 5,000 IU twice daily with the addition of aspirin, and were followed up for 5 days. In vitro studies were also conducted in which apheresis platelets were added to blood from healthy volunteers (n = 10). RESULTS: Control (n = 25) and TEG-guided prophylaxis (n = 25) groups were similar in age, body mass index, Injury Severity Score, and male sex. Fibrinogen levels and platelet counts did not differ, and increased LMWH did not affect clot strength between the control and study groups. The correlation of clot strength (G value) with fibrinogen was stronger on Days 1 and 2 but was superseded by platelet count on Days 3, 4, and 5. There was also a trend in increased platelet contribution to clot strength in patients receiving increased LMWH. In vitro studies demonstrated apheresis platelets significantly increased clot strength (7.19 ± 0.35 to 10.34 ± 0.29), as well as thrombus generation (713.86 ± 12.19 to 814.42 ± 7.97) and fibrin production (274.03 ± 15.82 to 427.95 ± 16.58). CONCLUSION: Increased LMWH seemed to increase platelet contribution to clot strength early in the study but failed to affect the overall rise clot strength. Over time, platelet count had the strongest correlation with clot strength, and in vitro studies demonstrated that increased platelet counts increase fibrin production and thrombus generation. In sum, these data suggest an important role for antiplatelet therapy in VTE prophylaxis following trauma, particularly after 48 hours. LEVEL OF EVIDENCE: Therapeutic study, level III.
Authors: Matthew E Kutcher; Brittney J Redick; Ryan C McCreery; Ian M Crane; Molly D Greenberg; Leslie M Cachola; Mary F Nelson; Mitchell Jay Cohen Journal: J Trauma Acute Care Surg Date: 2012-07 Impact factor: 3.313
Authors: G C Velmahos; J Nigro; R Tatevossian; J A Murray; E E Cornwell; H Belzberg; J A Asensio; T V Berne; D Demetriades Journal: J Am Coll Surg Date: 1998-11 Impact factor: 6.113
Authors: Charles A Pierce; Elliott R Haut; Shahrzad Kardooni; David C Chang; David T Efron; Adil Haider; Peter J Pronovost; Edward E Cornwell Journal: J Trauma Date: 2008-04
Authors: Sunil X Anand; Michael C Kim; Mazullah Kamran; Samin K Sharma; Annapoorna S Kini; Jawed Fareed; Debra A Hoppensteadt; Frank Carbon; Erdal Cavusoglu; David Varon; Juan F Viles-Gonzalez; Juan J Badimon; Jonathan D Marmur Journal: Am J Cardiol Date: 2007-06-13 Impact factor: 2.778
Authors: Jeffrey N Harr; Ernest E Moore; Jeffrey Johnson; Theresa L Chin; Max V Wohlauer; Ronald Maier; Joseph Cuschieri; Jason Sperry; Anirban Banerjee; Christopher C Silliman; Angela Sauaia Journal: Crit Care Med Date: 2013-02 Impact factor: 7.598
Authors: Lucy Z Kornblith; Matthew E Kutcher; Brittney J Redick; Carolyn S Calfee; Ryan F Vilardi; Mitchell Jay Cohen Journal: J Trauma Acute Care Surg Date: 2014-02 Impact factor: 3.313
Authors: Belinda H McCully; Christopher R Connelly; Kelly A Fair; John B Holcomb; Erin E Fox; Charles E Wade; Eileen M Bulger; Martin A Schreiber Journal: J Am Coll Surg Date: 2017-03-16 Impact factor: 6.113
Authors: J N Harr; E E Moore; T L Chin; M P Chapman; A Ghasabyan; J R Stringham; A Banerjee; C C Silliman Journal: Eur J Trauma Emerg Surg Date: 2014-04-04 Impact factor: 3.693
Authors: Brandon C Chapman; Ernest E Moore; Carlton Barnett; Robert T Stovall; Walter L Biffl; Clay C Burlew; Denis D Bensard; Gregory J Jurkovich; Fredric M Pieracci Journal: Am J Surg Date: 2013-10-07 Impact factor: 2.565
Authors: Mitchell R Dyer; Wyeth Alexander; Adnan Hassoune; Qiwei Chen; Tomasz Brzoska; Jurgis Alvikas; Yingjie Liu; Shannon Haldeman; Will Plautz; Patricia Loughran; Hui Li; Brian Boone; Yoel Sadovsky; Prithu Sundd; Brian S Zuckerbraun; Matthew D Neal Journal: J Thromb Haemost Date: 2019-07-28 Impact factor: 5.824
Authors: M J George; J Burchfield; B MacFarlane; Y-W W Wang; J C Cardenas; N J White; B S Gill; C E Wade Journal: Transfus Med Date: 2017-09-15 Impact factor: 2.019
Authors: Jeffrey N Harr; Ernest E Moore; Theresa L Chin; Arsen Ghasabyan; Eduardo Gonzalez; Max V Wohlauer; Angela Sauaia; Anirban Banerjee; Christopher C Silliman Journal: Shock Date: 2014-01 Impact factor: 3.454
Authors: Peter J Lawson; Hunter B Moore; Ernest E Moore; Mark E Gerich; Gregory R Stettler; Anirban Banerjee; Richard D Schulick; Trevor L Nydam Journal: J Surg Res Date: 2018-06-08 Impact factor: 2.192