V thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), causes significant morbidity and mortality in trauma patients. PE is the third leading cause of death for trauma patients who survive the first 24 hours following injury. Because of the magnitude of this clinical problem, it is assumed that most trauma centers manage VTE in a generally similar manner. However, evidence suggests that some degree of variation in practice exists with regard to VTE prophylaxis and treatment in trauma patients. For example, a recent analysis of the National Trauma Data Bank by Dossett et al. demonstrated unwarranted variation in the use of inferior vena cava filters (IVCFs) among trauma centers. In addition, Haut et al. found significant variability in the use of duplex ultrasound surveillance and screening for DVT in asymptomatic trauma patients. We sought to determine the extent of practice variation in the management of VTE among trauma surgeons. That is, does the variation in practice extend beyond the use of IVCF and ultrasound surveillance? We identified a group of 18 trauma surgeons (Appendix) who were opinion leaders in the subject of trauma-related VTE by virtue of an established publication record on the subject. These physicians, representing 18 distinct Level I and Level II verified trauma centers (American College of Surgeons’ Committee on Trauma or similar state specific verification), were queried about their institutional practices. The self-report survey consisted of 18 questions that focused on five general VTE topics. These questions dealt with issues that either were controversial or had little or no evidence base, as identified by the Eastern Association for the Surgery of Trauma, including DVT surveillance of asymptomatic patients, methods of pharmaceutical prophylaxis, treatment modalities for diagnosed VTE, therapeutic and prophylactic use of IVCF, and the use of adjunctive tests for thrombophilia or hypercoagulability. We found that duplex surveillance and scanning is not protocolized at many of the institutions surveyed (Table 1). When duplex scanning is used, there are disparate opinions about the type of patient to be scanned. Neither magnetic resonance venography nor traditional contrast venography is used for either screening or surveillance. While the use of pharmacologic prophylaxis is widely accepted as the standard of care for trauma patients considered at risk for VTE disease, the specific agent used, the frequency, and the dosage were found to be highly variable. The majority of surveyed physicians used a twice daily regimen of 30-mg enoxaparin for VTE prophylaxis (Table 2), but there was considerable variability among the remaining surgeons surveyed. We also found significant variation among respondents for the ‘‘standard’’ treatment of newly diagnosed VTE (Table 3). Following an in-hospital course of enoxaparin, treatment with warfarin was the most frequently cited management modality for above-the-knee (AK) DVT. More than half of the physicians surveyed said they treated newly diagnosed AK DVT for only 3 months, and one third do not treat below-the-knee DVT at all. There were disparate views on the use of prophylactic IVCF. In response to the question, ‘‘do all patients, at high risk for VTE disease, who have contraindications to pharmacologic prophylaxis, receive IVCFs at your institution?’’ three surgeons reported that ‘‘all’’ patients would receive an IVCF, five reported that ‘‘most’’ would, seven said ‘‘some’’ would receive a prophylactic filter, and three physicians stated that ‘‘very few or none’’ of their high VTE risk patients who did not receive pharmacologic prophylaxis would undergo placement of an IVCF. These differing opinions were reflected in the annual number of prophylactic and therapeutic IVCFs placed at the various institutions (Table 4). Variability also exists in how often ‘‘hypercoagulability’’ is assessed following VTE diagnosis, particularly when it appears to be ‘‘unprovoked’’ (Table 5). The majority of trauma surgeons surveyed responded that thromboelastography (TEG) is neither a part of their initial evaluation nor used to evaluate the effects of pharmacologic prophylaxis (Table 5). Variation in clinical practice for many of the routine aspects of VTE care in trauma patients may not be surprising given the lack of high-quality evidence available to generate care guidelines. The current Eastern Association for the Surgery of Trauma and American College of Chest Physicians VTE management guidelines for trauma patients acknowledge that there are several aspects of VTE management where substantive evidence is insufficient for conclusive recommendations. This lack of decisive evidence should not be interpreted as a lack of interest in the topic among trauma surgeons. Approximately 1 of every 20 abstracts accepted for presentation at the last two meetings of the American Association for the Surgery of Trauma concerned VTE. In the last 12 months alone, The Journal of Trauma and Acute Care Surgery published 157 articles with a Medical Subject Heading CURRENT OPINION
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Oct 29, 2018
Katsuhisa Yamada + 7
