Initiation Of Chemoprophylaxis Research Articles

Immediate vs. delayed venous thromboembolism prophylaxis following spine surgery: increased rate of unplanned reoperation for postoperative hematoma with immediate prophylaxis

BACKGROUND CONTEXTThere is significant variability in postoperative chemoprophylaxis protocols amongst spine providers due to perceived risks and benefits, but limited data on the topic. At our institution, both orthopaedic spine and neurosurgery departments utilize unfractionated subcutaneous heparin in identical dosages and frequency, with the only difference being time to initiation postoperatively. PURPOSETo evaluate the rate of symptomatic venous thromboembolism (VTEs) and unplanned reoperation for hematoma based on timing of chemoprophylaxis initiation. STUDY DESIGN/SETTINGSingle institution retrospective cohort study. PATIENT SAMPLEPatients undergoing elective spine surgery, excluding patients undergoing surgery in the setting of trauma, malignancy, or infection OUTCOME MEASURESOutcome measures included the diagnosis of a venous thromboembolism within 90 days of surgery and unplanned reoperation for a hematoma METHODSPatients undergoing elective spine surgery from 2017 to 2021 were grouped based on chemoprophylaxis protocol. In the “immediate” group, patients received subcutaneous heparin 5000 units every 8 hours starting immediately after surgery, and in the “delayed” group, patients received chemoprophylaxis starting postoperative day (POD)-2 for any decompressions and/or fusions involving a spinal cord level (i.e., L2 and above) and POD-1 for those involving only levels below the spinal cord (i.e., L3 to pelvis). A cox proportional hazards model was created to assess independent predictors of venous thromboembolic events, while a logistic regression was utilized for unplanned reoperations for hematoma. RESULTSOf 8,704 patients, a total of 98 (1.13%) VTE events occurred, of which 43 (0.49%) were pulmonary embolism. Fifty-four patients (0.62%) had unplanned reoperations for postoperative hematomas. On cox proportional hazards model analysis, immediate chemoprophylaxis was not protective of a venous thromboembolism (Hazard Ratio: 1.18, p=.436), but, it was a significant independent predictor for unplanned reoperation for hematoma on multivariable logistic regression modeling (Odds Ratio: 3.29, p<.001). CONCLUSIONSBoth chemoprophylaxis protocols in our study resulted in low rates of VTE and postoperative hematoma. However, our findings suggest that the delayed chemoprophylaxis protocol may mitigate postoperative hematoma formation without increasing the risk for a thrombotic event.

‘Door-to-prophylaxis’ as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury

ObjectiveVenous thromboembolism (VTE) risk reduction strategies include early initiation of chemoprophylaxis, reducing missed doses, weight-based dosing and dose adjustment using anti-Xa levels. We hypothesized that time to initiation of chemoprophylaxis...

A Dangerous Relationship: A Case of Imported Plasmodium falciparum and Salmonella Typhi Coinfection.

Malaria is a parasitic disease transmitted by the bite of female Anopheles mosquitoes. Although domestic malaria case notification in our country is not seen in World Health Organization records, cases originating from abroad are detected. Travelers to countries where malaria is endemic can become infected with the parasite. In our country, an average of 200-250 cases of malaria originating from abroad are reported every year. Approximately 75% of malaria cases of foreign origin detected in our country are P. falciparum malaria. Malaria and salmonellosis are infections especially seen in developing countries. Although malaria-Salmonella coinfection is rare, early diagnosis and treatment are important in terms of its high mortality rate. Preliminary information and initiation of chemoprophylaxis in travels to regions where the disease is endemic remain important in transmission. In this presentation, a case was examined following a business trip to Africa without any chemoprophylaxis, who applied to a local hospital upon symptoms and was diagnosed with P. falciparum and Salmonella Typhi coinfection but given incomplete treatment. After returning to our country, the patient applying to us with complaints of high fever, chills, nausea, diarrhea and abdominal pain and was discharged with ful recovery. Keywords: Coinfection, malaria, Plasmodium falciparum, Salmonella Typhi.

A collaborative multidisciplinary trauma program improvement team improves VTE chemoprophylaxis guideline compliance in non-operative stable TBI.

Delays in initiating venous thromboembolism (VTE) prophylaxis in patients suffering from traumatic brain injury (TBI) persist despite guidelines recommending early initiation. We hypothesized that the expansion of a Trauma Program Performance Improvement (PI) team will improve compliance of early (24-48 hours) initiation of VTE prophylaxis and will decrease VTE events in TBI patients. We performed a single-center retrospective review of all TBI patients admitted to a Level I trauma center before (2015-2016,) and after (2019-2020,) the expansion of the Trauma Performance Improvement and Patient Safety (PIPS) team and the creation of trauma process and outcome dashboards. Exclusion criteria included discharge or death within 48 hours of admission, expanding intracranial hemorrhage on CT scan, and a neurosurgical intervention (craniotomy, pressure monitor, or drains) prior to chemoprophylaxis initiation. A total of 1,112 patients met the inclusion criteria, of which 54% (n = 604) were admitted after Trauma PIPS expansion. Following the addition of a dedicated PIPS nurse in the trauma program and creation of process dashboards, the time from stable CT to VTE prophylaxis initiation decreased (52 hours to 35 hours; p < 0.001) and more patients received chemoprophylaxis at 24 hours to 48 hours (59% from 36%, p < 0.001) after stable head CT. There was no significant difference in time from first head CT to stable CT (9 vs. 9 hours; p = 0.15). The Contemporary group had a lower rate of VTE events (1% vs. 4%; p < 0.001) with no increase in bleeding events (2% vs. 2%; p = 0.97). On multivariable analysis, being in the Early cohort was an independent predictor of VTE events (adjusted odds ratio, 3.74; 95% confidence interval, 1.45-6.16). A collaborative multidisciplinary Trauma PIPS team improves guideline compliance. Initiation of VTE chemoprophylaxis within 24 hours to 48 hours of stable head CT is safe and effective. Therapeutic/Care Management; Level IV.

Early venous thromboembolism chemoprophylaxis in traumatic brain injury requiring neurosurgical intervention: Safe and effective

BackgroundTraumatic brain injury patients who require neurosurgical intervention are at the highest risk of worsening intracranial hemorrhage. This subgroup of patients has frequently been excluded from prior research regarding the timing of venous thromboembolism chemoprophylaxis. This study aims to assess the efficacy and safety of early venous thromboembolism chemoprophylaxis in patients with traumatic brain injuries requiring neurosurgical interventions. MethodsThis is a single-center retrospective review (2016–2020) of traumatic brain injury patients requiring neurosurgical intervention admitted to a level I trauma center. Interventions included intracranial pressure monitoring, subdural drain, external ventricular drain, craniotomy, and craniectomy. Exclusion criteria included neurosurgical intervention after chemoprophylaxis initiation, death within 5 days of admission, and absence of chemoprophylaxis. The total population was stratified into Early (≤72 hours of intervention) versus Late (>72 hours after intervention) chemoprophylaxis initiation. ResultsA total of 351 patients met the inclusion criteria, of whom 204 (58%) had early chemoprophylaxis initiation. Overall, there were no significant differences in baseline and admission characteristics between cohorts. The Early chemoprophylaxis cohort had a statistically significant lower venous thromboembolism rate (5% vs 13%, P < .001) with no increased risk of worsening intracranial hemorrhage (10% vs 13%, P = .44) or neurosurgical reintervention (8% vs 10%, P = .7). On subgroup analysis, a total of 169 patients required either a craniotomy or a craniectomy before chemoprophylaxis. The Early chemoprophylaxis cohort had statistically significant lower venous thromboembolism rates (2% vs 11%, P < .001) with no increase in intracranial hemorrhage (8% vs 11%, P = .6) or repeat neurosurgical intervention (8% vs 10%, P = .77). ConclusionVenous thromboembolism prophylaxis initiation within 72 hours of neurosurgical intervention is safe and effective. Further prospective research is warranted to validate the results of this study.

Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry

IntroductionOptimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads...

1011 Chemical VTE Prophylaxis for Adults with Abdominal Trauma: A Systematic Review

Abstract Aim The increased incidence of VTE following blunt and penetrating abdominal trauma is well documented due to trauma induced coagulopathy and immobility. Whilst guidance often advocates early chemical thromboprophylaxis with low molecular weight heparin, clinical practice varies. This systematic review aims to evaluate evidence regarding VTE chemical prophylaxis in the adult trauma population (16+) presenting with blunt and penetrating abdominal trauma. Method A search of MEDLINE, EMBASE and PubMed databases was conducted, and additional references were identified from a review of literature citations. Search results were limited to English language and human studies. Co-existing severe head injuries defined as AIS&amp;gt;3 was excluded. Data was summarised in data extraction tables, along with level of evidence and bias scores for each study. Results A total of 9 retrospective trials exploring the timings of VTE chemoprophylaxis were included. All but 3 studies showed late VTE chemoprophylaxis initiation (&amp;gt;48hrs) was linked with a higher incidence of VTE, with significant results in 4 studies. Early VTE chemoprophylaxis was not associated with increased risk of NOM failure. Early VTE chemoprophylaxis was also not found to be associated with an increased risk in bleeding in most studies, with non-significant differences in blood transfusion requirements. Conclusions Research favours early initiation of VTE chemoprophylaxis in the abdominal trauma population, without significant risk of complications and supports results from other trauma populations. Further prospective studies are needed in the abdominal trauma population, as well as its sub-populations, to directly compare VTE agents and dosing regimens and provide higher quality evidence to support chemical thromboprophylaxis.

Revisiting Anticoagulation in Spine Surgery: Balancing Venous Thromboembolic Events and Epidural Hematoma.

Retrospective Cohort Study. Venous thromboembolic events (VTE) and post-operative epidural hematoma (EDH) are significant complications after spine surgery. Guidelines for chemoprophylaxis are controversial and variability amongst surgeons remains. The objective of this study was to establish the incidence of clinical VTE and EDH at our institution and evaluate the association of chemoprophylaxis with clinical VTE and EDH. We conducted a retrospective cohort study of patients undergoing spine surgery at a high-volume tertiary care center in Seattle, WA between January 2016 and December 2019. The Premier Health Care Database and Agency for Healthcare Research and Quality (AHRQ) patient indicators PSI-9 (Perioperative hemorrhage and hematoma) and PSI-12(Perioperative PE or DVT) were used to identify patients experiencing VTE and/or post-operative EDH. The primary outcome was the incidence of clinical VTE and EDH in post-operative spine patients. Secondary outcomes included the association of chemoprophylaxis with clinical VTE and EDH. From 2016 to 2019, 4587 patients underwent spine surgery, totaling 4764 hospital stays. The incidence of clinical VTE was .21% (10/4764) and the incidence of EDH was .10% (5/4764). Most hemorrhages occurred prior to the initiation of chemoprophylaxis. One patient with EDH received chemoprophylaxis prior to hemorrhage. The rate of post-operative clinical VTE and EDH in spine surgery is low. Despite early initiation of chemoprophylaxis after major spine surgery we did not appreciate a high rate of EDH. We attribute our low rate of clinical VTE to multimodal prophylaxis with SCDs, early mobilization and chemoprophylaxis on post-operative day 1.

EFFECTS OF SARS COVID-19 POSITIVITY STATUS ON VENOUS THROMBOSIS AND PULMONARY EMBOLISM RATES IN TRAUMA PATIENTS.

Introduction : COVID-19-induced coagulopathy (CIC) can increase the risk of thromboembolism without underlying clotting disorders, even when compared with other respiratory viruses. Trauma has a known association with hypercoagulability. Trauma patients with concurrent COVID-19 infection potentially have an even greater risk of thrombotic events. The purpose of this study was to evaluate venous thromboembolism (VTE) rates in trauma patients with COVID-19. Methods : This study reviewed all adult patients (≥18 years of age) admitted to the Trauma Service from April through November 2020 for a minimum of 48 hours. Patients were grouped based off COVID-19 status and compared for inpatient VTE chemoprophylaxis regimen, thrombotic complications defined as deep vein thrombosis, pulmonary embolism, myocardial infarction, and cerebrovascular accident, intensive care unit (ICU) length of stay, hospital length of stay, and mortality. Results : A total of 2,907 patients were reviewed and grouped into COVID-19-positive (n = 110) and COVID-19-negative (n = 2,797) groups. There was no difference in terms of receiving deep vein thrombosis chemoprophylaxis or type, but a longer time to initiation in the positive group ( P = 0.0012). VTE occurred in 5 (4.55%) positive and 60 (2.15%) negative patients without a significant difference between the groups, as well as no difference in type of VTE observed. Mortality was higher ( P = 0.009) in the positive group (10.91%). Positive patients had longer median ICU LOS ( P = 0.0012) and total LOS ( P < 0.001). Conclusion : There were no increased rates of VTE complications between COVID-19-positive and -negative trauma patients, despite a longer time to initiation of chemoprophylaxis in the COVID-19-positive group. COVID-19-positive patients had increased ICU LOS, total LOS, and mortality, which are likely due to multifactorial causes but primarily related to their underlying COVID-19 infection.

Timing of venous thromboembolism prophylaxis initiation after injury: Findings from the consensus conference to implement optimal VTE prophylaxis in trauma.

Optimizing prophylaxis against venous thromboembolic events (VTEs) is a critical issue in the care of injured patients. Although these patients are at significant risk of developing VTE, they also present competing concerns related to exacerbation of bleeding from existing injuries. Especially after high-risk trauma, including injuries to the abdominal solid organs, brain, and spine, trauma providers must delineate the time period in which VTE prophylaxis successfully reduces VTE rates without encouraging bleeding. Although existing data are primarily retrospective in nature and further study is required, literature supports early VTE chemoprophylaxis initiation even for severely injured patients. Early initiation is most frequently defined as <48 hours from admission but varies from <24 hours to 72 hours and occasionally refers to time from initial trauma. Prior to chemical VTE prophylaxis initiation in patients at risk for bleeding, an observation period is necessary during which injuries must show themselves to be hemostatic, either clinically or radiographically. In the future, prospective examination of optimal timing of VTE prophylaxis is necessary. Further study of specific subsets of trauma patients will allow for development of effective VTE mitigation strategies based upon collective risks of VTE and hemorrhage progression.

Optimal Timing of Perioperative Chemical Thromboprophylaxis in Elective Major Abdominal Surgery: A Systematic Review and Meta-analysis.

To investigate the effect of the timing of chemoprophylaxis on venous thromboembolisms (VTEs) and bleeding rates in patients undergoing major abdominal surgery. Postoperative bleeding and VTE incur significant morbidity, mortality, and health care costs. Chemoprophylaxis is used routinely to prevent VTEs but increases bleeding risk. The perioperative timing of chemoprophylaxis initiation may influence both VTE and bleeding risks. The optimal window for commencing chemoprophylaxis in the perioperative period is unclear. MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were searched using PRISMA guidelines. Randomized trials and cohort studies published between January 1, 2000 to May 10, 2022, which reported on chemoprophylaxis timing as well as the incidence of VTE and bleeding after elective abdominal surgery were meta-analyzed. From 6175 studies, 14 (24,922 patients) were meta-analyzed. Bariatric (4 studies), antireflux (1 study), hepato-pancreatic-biliary (5 studies), colorectal (1 study), ventral hernia (1 study), and major intra-abdominal surgeries (2 studies) were included. Chemoprophylaxis was initiated before skin closure in 10,403 patients, and postoperatively in 14,519 patients. Both symptomatic [risk ratios (RR), 0.81; 95% CI, 0.45-1.43; P =0.460] and overall (RR, 0.74; 95% CI, 0.45-1.24; P =0.250) VTE rates were comparable between study groups. Compared with postoperative chemoprophylaxis, early usage increased the risk of all bleeding (RR, 1.56; 95% CI, 1.13-2.15; P =0.007), major bleeding (RR, 1.63; 95% CI, 1.16-2.28; P =0.005), blood transfusion (RR, 1.48; 95% CI, 1.24-1.76; P <0.001), and reintervention (RR, 1.94; 95% CI, 1.19-3.18; P =0.008). Our findings advocate for initiating chemoprophylaxis postoperatively in elective abdominal surgery to minimize bleeding risk without compromising VTE protection.

Chemoprophylactic Anticoagulation 72 Hours After Spinal Fracture Surgical Treatment Decreases Venous Thromboembolic Events Without Increasing Surgical Complications

BackgroundProphylactic anticoagulation is commonly used following operative treatment of spinal fractures to prevent Venous Thromboembolism (VTE) but carries a risk of bleeding complications. The purpose of the study was to compare VTE and bleeding complications for MID (≤72h) versus LATE (>72h) chemoprophylaxis timing after spinal fracture operative intervention. MethodsThis is a retrospective review of patients treated for spinal fractures that received anticoagulation chemoprophylaxis between May 2015 and June 2019. Chemoprophylaxis initiation timing (MID vs. LATE) was the primary grouping variable. Patients with traumatic brain injury or evidence of intracranial or intraspinal bleed were excluded. Demographics, injury mechanisms, operative procedures, timing of administration of VTE prophylaxis, Injury Severity Score (ISS) and Spine Abbreviated Injury Scale (AIS), and complications including VTE and bleeding complications were collected. Predictors of VTE were identified using a binary logistic regression. ResultsEighty-eight patients (65M, 23F) met inclusion criteria. The median age was 55 years, and median Injury Severity Score (ISS) was 14. MID had 68 patients and LATE had 20. Nine patients developed VTE (6 LATE, 3 MID, p<0.01). Three patients developed bleeding complications, and all occurred in the LATE group (p=0.01). ISS (p<0.01) and GCS (p<0.01) also correlated with an increased VTE rate. ConclusionsChemoprophylactic anticoagulation at 72 hours in surgically treated spinal fracture patients demonstrates a lower VTE rate without increasing complications. VTE prophylaxis can be initiated at 72 hours following spine fixation to decrease postinjury morbidity and mortality in this high-risk patient population.

Risk factors for venous thromboembolism after vascular surgery and implications for chemoprophylaxis strategies

ObjectiveVenous thromboembolism (VTE) is an important cause of postoperative morbidity and mortality. However, the reported incidence after major vascular surgery has ranged from as low as 1% to >10%. Furthermore, little is known about optimal chemoprophylaxis regimens or rates of postdischarge VTE in this population. In the present study, we aimed to better characterize the rates of in-hospital and postdischarge VTE after major vascular surgery, the role of chemoprophylaxis timing, and the association of VTE with mortality. MethodsA single-center retrospective study of 1449 major vascular operations (2013-2020) was performed and included 189 endovascular abdominal aortic aneurysm repairs (13%), 169 thoracic endovascular aortic aneurysm repairs (12%), 318 open aortic operations (22%), 640 lower extremity bypasses (44%), and 133 femoral endarterectomies (9%). The baseline characteristics, anticoagulant and antiplatelet medications, and outcomes were abstracted from an electronic database with medical record auditing. Postoperative VTE (pulmonary embolism and deep vein thrombosis) within 90 days of surgery was classified by the location, symptoms, and treatment. A cut point analysis using Youden's index identified the most VTE discriminating timing of chemoprophylaxis (including therapeutic vs prophylactic anticoagulant and antiplatelet medications) and Caprini score. Multivariable logistic regression was used to test the association of VTE with chemoprophylaxis timing, Caprini score, and additional risk factors. Cox proportional hazard modeling was used to measure the association between VTE and mortality. ResultsThe overall VTE incidence was 3.4% (65% deep vein thrombosis; 25% pulmonary embolism; 10% both), and 37% had occurred after discharge. The rate of symptomatic VTE was 2.4%, which was lowest for endovascular abdominal aortic aneurysm repair (0.0%) and highest for open aortic surgery (4.1%; P = .02). Those who had developed VTE had had a longer length of stay, higher rates of end-stage renal disease and prior VTE, and higher Caprini scores (8 vs 5 points; P < .01 for all). Those who had developed VTE were also more likely to have received ≥2 U of blood postoperatively, required an unplanned return to the operating room, had delayed chemoprophylaxis, anticoagulation, and/or antiplatelet initiation of >4 days postoperatively, and had increased 90-day mortality (P < .01 for all). A Caprini score of ≥7 (29% of patients) was associated with postdischarge VTE (2.6% vs 0.7%; P = .01), and chemoprophylaxis, anticoagulation, and antiplatelet timing of >4 days was associated with an increased adjusted odds of VTE (odds ratio, 2.4; 95% confidence interval, 1.1-4.9). Although no fatal VTEs were identified, VTE was an independent predictor of 90-day mortality (adjusted hazard ratio, 2.7; 95% confidence interval, 1.3-5.9). ConclusionsThese data have shown that patients undergoing major vascular surgery are particularly prone to the development of VTE, with frequent hypercoagulable comorbidities. The earlier initiation of chemoprophylaxis was associated with a reduced risk of VTE development. Furthermore, the postdischarge VTE rates might reach thresholds warranting postdischarge chemoprophylaxis, especially for patients with a Caprini score of ≥7.

Optimal timing of venous thromboembolic chemoprophylaxis initiation following blunt solid organ injury: meta-analysis and systematic review.

The need to prevent venous thromboembolism (VTE) following blunt solid organ injury must be balanced against the concern for exacerbation of hemorrhage. The optimal timing for initiation of VTE chemoprophylaxis is not known. The objective was to determine the safety and efficacy of early (≤ 48h) VTE chemoprophylaxis initiation following blunt solid organ injury. An electronic search was performed of medical libraries for English language studies on timing of VTE chemoprophylaxis initiation following blunt solid organ injury published from inception to April 2020. Included studies compared early (≤ 48h) versus late (> 48h) initiation of VTE chemoprophylaxis in adults with blunt splenic, liver, and/or kidney injury. Estimates were pooled using random-effects meta-analysis. Odds ratios were utilized to quantify differences in failure of nonoperative management, need for blood transfusion and rates of VTE. The search identified 2,111 studies. Of these, ten studies comprising 14,675 patients were included. All studies were non-randomized and only one was prospective. The overall odds of failure of nonoperative management were no different between early and late groups, OR 1.09 (95%CI 0.92-1.29). Similarly, there was no difference in the need for blood transfusion either during overall hospital stay, OR 0.91 (95%CI 0.70-1.18), or post prophylaxis initiation, OR 1.23 (95%CI 0.55-2.73). There were significantly lower odds of VTE when patients received early VTE chemoprophylaxis, OR 0.51 (95%CI 0.33-0.81). Patients undergoing nonoperative management for blunt solid organ injury can be safely and effectively prescribed early VTE chemoprophylaxis. This results in significantly lower VTE rates without demonstrable harm.

Challenges Perceived by Health Care Providers for Implementation of Contact Screening and Isoniazid Chemoprophylaxis in Karnataka, India.

Background: In India, challenges in pediatric TB contact screening and chemoprophylaxis initiation are still underexplored. Elucidating these challenges will help in better implementation of the programme at the grass-roots level thereby helping in early detection of pediatric cases and timely initiation of preventive therapy. This study aimed at exploring the challenges faced by the health care provider in contact screening and chemoprophylaxis initiation implementation of the pediatric household contacts. Methods: A qualitative study was conducted in the districts of Bengaluru and Udupi and in-depth interviews of key participants were adopted to explore the challenges. Qualitative data analysis was done after developing transcripts by generating themes and codes. Results: The key challenges were identified as stigma towards the disease, migrant patients with changing address, difficulty in sample collection, anxiety among parents due to long duration of the prophylactic treatment and adherence to IPT is not well documented, inadequate transportation from rural areas, and the ongoing COVID-19 pandemic. Conclusions: It is important for the National TB programme to address these challenges efficiently and effectively. Innovative solutions, feasible engagements, and massive efforts are to be taken by the programme to improve contact screening and isoniazid chemoprophylaxis implementation.

29. Early postoperative anticoagulation after spinal fracture surgery decreases venous thromboembolism rates

<h3>BACKGROUND CONTEXT</h3> Prophylactic anticoagulation effectively lowers venous thromboembolism (VTE) after operative treatment of spinal fractures. Optimal initiation has not been fully described. Early anticoagulation has been presumed to increase bleeding and wound complications. In 2017, our institutional protocol began initiating VTE chemoprophylaxis 72 hours after operative spinal fixation. <h3>PURPOSE</h3> The purpose of the study was to compare VTE rates and bleeding complications for early (within 72h) vs late (no prophylaxis or after 10-14 days) chemoprophylaxis timing after spinal fracture operative intervention. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study at University of Kansas Medical Center. <h3>PATIENT SAMPLE</h3> Trauma patients 18 years or older treated for spinal fractures who received postoperative anticoagulation between May 2015 and June 2019. <h3>OUTCOME MEASURES</h3> Postoperative bleeding and VTE complications. <h3>METHODS</h3> A review of patients treated for spinal fractures that received anticoagulation chemoprophylaxis administration between May 2015 and June 2019 were studied. Chemoprophylaxis initiation timing (early vs late) was the primary grouping variable. Patients with GCS<13 or evidence of intracranial or intraspinal bleed were excluded. Demographics, injury mechanisms, operative procedures, timing of administration of VTE prophylaxis, injury severity score (ISS) and spine abbreviated injury scale (AIS), and complications including VTE and bleeding complications were collected. Predictors of VTE and bleeding complications were identified using a bivariate analysis. <h3>RESULTS</h3> One-hundred patients (74M, 26F) met inclusion criteria. Median age was 54 years, and median ISS was 13. The early group had 68 patients and the late group had 32. Ten patients developed VTE (7 late, 3 early, P=0.007). Three patients developed bleeding complications, and all occurred in the late group (P=0.010). ISS (P=0.024) and AIS (P=0.017) also correlated with increased VTE rate. <h3>CONCLUSIONS</h3> Chemoprophylactic anticoagulation within 72 hours in surgically treated spinal fracture patients reduces VTE rates without increasing complications. VTE prophylaxis can be initiated at 72 hours following spine fixation to decrease postinjury morbidity and mortality in this high-risk patient population. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Early Chemoprophylaxis Against Venous Thromboembolism in Patients With Traumatic Brain Injury.

Timing to start of chemoprophylaxis for venous thromboembolism (VTE) in patients with traumatic brain injury (TBI) remains controversial. We hypothesize that early administration is not associated with increased intracranial hemorrhage. A retrospective study of adult patients with TBI following blunt injury was performed. Patients with penetrating brain injury, any moderate/severe organ injury other than the brain, need for craniotomy/craniectomy, death within 24hours of admission, or progression of bleed on 6hour follow-up head computed tomography scan were excluded. Patients were divided into early (≤24hours) and late (>24hours) cohorts based on time to initiation of chemoprophylaxis. Progression of bleed was the primary outcome. 264 patients were enrolled, 40% of whom were in the early cohort. The average time to VTE prophylaxis initiation was 17hours and 47hours in the early and late groups, respectively (P < .0001). There was no difference in progression of bleed (5.6% vs. 7%, P = .67), craniectomy/-craniotomy rate (1.9% vs. 2.5%, P = .81), or VTE rate (0% vs. 2.5%, P = .1). Early chemoprophylaxis is not associated with progression of hemorrhage or need for neurosurgical intervention in patients with TBI and a stable head CT 7hours following injury.

Postexposure prophylaxis with oseltamivir in outbreak control of pH1N1 influenza onboard a naval warship: An observational study

Background: Control measures such as maintenance of social distancing, hand hygiene, respiratory hygiene, regular disinfection, and keeping a high index of suspicion for probable cases form the basis of containing a pH 1N1 outbreak onboard a Naval ship. As per the present guidelines, though a quadrivalent vaccine is recommended for health-care workers in close contact, anti-flu postexposure prophylaxis strategies have been predicted to be effective in some mathematical models. Chemoprophylaxis with oseltamivir was assumed to be an effective measure to control the outbreak onboard ship while at sea. Materials and Methods: A total of 275 asymptomatic individuals were started on oral oseltamivir prophylaxis on board from day 17 onward for a duration of 10 days and side effects of the medication were noted. Results: With chemoprophylaxis of the entire crew with oseltamivir, the number of positive cases per day reduced. The outbreak cleared within 3 days of initiation of chemoprophylaxis. Active surveillance was continued for 14 days since the last positive case. Conclusion: In an afloat setting, with a rapidly spreading outbreak of airborne disease, mass chemoprophylaxis with oral oseltamivir along with aggressive public health control measures were found to have contained the spread with only mild side effects which were reported.

1615. Influenza Outbreaks in Long-Term Care Facilities, 2017–2018 Influenza Season, Dallas, Texas

BackgroundHigh rates of influenza-related hospitalizations and deaths occurred in the United States during the 2017–2018 influenza season. A record number of influenza outbreaks were reported in long-term care facilities (LTCF) in Dallas County. Public health surveillance of influenza-related intensive care unit (ICU) admissions and deaths in acute care hospitals improved early identification of outbreaks in LTCFs.MethodsA confirmed LTCF influenza outbreak was defined as at least 1 lab-confirmed influenza case plus at least 1 case of influenza-like illness among residents or staff within 72 hours. Outbreaks were self-reported by facilities or identified by the health department during investigations of ICU hospitalizations and deaths. CDC guidance for influenza outbreak management was provided and daily active surveillance was continued for at least 1 week after the last case was identified. Data collected included: numbers of ill residents and staff, vaccination rates, dates of illness and chemoprophylaxis initiation, hospitalizations and deaths. Fisher exact tests and Chi-square were performed using SAS 9.4.ResultsDuring this influenza season, 32 confirmed influenza outbreaks were identified in Dallas County LTCFs: 17 in skilled nursing facilities (SNF), 13 in assisted-living facilities (ALF) and 2 in hybrid SNF/ALF. The average attack rate in residents was 9.8% (range: 1–35%). Influenza hospitalization rates were higher in ALF compared with SNF outbreaks (OR: 2.2). Influenza-associated mortality rates were higher in ALF compared with SNF (OR: 3.1). Of the 32 outbreaks, 20 (63%) were self-reported by facilities to public health and 12 (38%) were identified through health department review of influenza-associated ICU hospitalizations. Facilities where outbreak cases were identified through public health surveillance of ICU admissions had significantly lower overall attack rates (5.9% vs. 12.1%, P = 0.01) and shorter time to initiation of facility-wide chemoprophylaxis (0.4 vs. 2.4 days, P = 0.05).ConclusionActive surveillance of influenza-associated ICU admissions in acute-care hospitals facilitated the early identification of influenza outbreaks in LTCFs, which was associated with lower overall attack rates and shorter time to initiation of facility-wide chemoprophylaxis.Disclosures All authors: No reported disclosures.

Dynamic coagulability after injury: Is delaying venous thromboembolism chemoprophylaxis worth the wait?

Severely injured patients often progress from early hypocoagulable to normal and eventually hypercoagulable states, developing increased risk for venous thromboembolism (VTE). Prophylactic anticoagulation can decrease this risk, but its initiation is frequently delayed for extended periods due to concerns for bleeding. To facilitate timely introduction of VTE chemoprophylaxis, we characterized the transition from hypo- to hypercoagulability and hypothesized that trauma-induced coagulopathy resolves within 24 hours after injury. Serial blood samples were collected prospectively from critically injured patients for 120 hours after arrival at an urban Level I trauma center. Extrinsic thromboelastometry maximum clot firmness was used to classify patients as hypocoagulable (HYPO, <49 mm), normocoagulable (NORM, 49-71 mm), or hypercoagulable (HYPER, >71 mm) at each time point. Changes in coagulability over hospital course, VTE occurrence, and timing of prophylaxis initiation were analyzed. 898 patients (median Injury Severity Score, 13; mortality, 12%; VTE, 8%) were enrolled. Upon arrival, 3% were HYPO (90% NORM, 7% HYPER), which increased to 9% at 6 hours before down-trending. Ninety-seven percent were NORM by 24 hours, and 53% were HYPER at 120 hours. Median maximum clot firmness began in the NORM range, up-trended gradually, and entered the HYPER range at 120 hours. Patients with traumatic brain injury (TBI) followed a similar course and were not more HYPO at any time point than those without TBI. Failure to initiate prophylaxis by 72 hours was predicted by TBI and associated with VTE development (27% vs 16%, p < 0.05). Regardless of injury pattern, trauma-induced coagulopathy largely resolves within 24 hours, after which hypercoagulability becomes increasingly more prevalent. Deferring initiation of chemoprophylaxis, which is often biased toward patients with intracranial injuries, is associated with VTE development. Prognostic study, level III; Therapeutic, level IV.