C. Luther1, A. Strumwasser1, D. Grabo1, D. Clark1, K. Inaba1, K. Matsushima1, E. Benjamin1, L. Lam1, D. Demetriades1 1University Of Southern California,Surgery – Trauma/Critical Care,Los Angeles, CA, USA
Introduction: The use of venous thromboembolism (VTE) prophylaxis in patients with severe traumatic brain injury (TBI) and intracranial pressure monitoring (ICPM) is controversial. This study’s purpose was to determine the safety and efficacy of VTE prophylaxis in TBI patients undergoing ICPM.
Methods: A seven-year (2008-2015) retrospective analysis of patients undergoing ICPM at our academic Level I trauma center was conducted. Inclusion criteria were ICPM patients surviving ≥7 days that were eligible for VTE prophylaxis. Pediatric patients (<18 years) and patients with known VTE were excluded. Variables abstracted from the registry included patient demographics, age, sex, comorbidities, injury severity scores (ISS), injury profiles, Glasgow Coma Score (GCS), systolic blood pressure (SBP), ICP data, Marshall CT index, pharmacy data, and prior anticoagulant use. Outcomes included ICP data pre/post initiation of prophylaxis, VTE incidence, hemorrhage expansion on CT, and need for neurosurgical intervention. Data was analyzed by unpaired Student’s t-test for continuous variables and Chi Square analysis for categorical variables with significance denoted at a p value of 0.05 or less.
Results: A total of 213 patients met inclusion criteria. Of these, 104 (49%) received VTE prophylaxis (ICPM-PPx) and 109 (51%) did not (ICPM-no PPx). Groups were matched for age (p=0.1), sex (p=0.7), admission SBP (p=0.8), GCS (p=0.7) and total injury burden (mean ISS ICPM-PPx=25±1.3 vs. ICPM-no PPx=23±1.1, p=0.2). In low head bleed severity (Marshall CT Index≤3), VTE rates (ICPM-PPx=8.3% vs. ICPM-noPPx=6.3%, p=0.7) and craniotomy rates (ICPM-PPx=21% vs. ICPM-noPPx=14%, p=0.3) were similar. Among high-risk ICH (Marshall CT Index≥4), VTE rates (VTE rate ICPM-noPPx=0% vs. ICPM-PPx=3.1%, p=0.2) and craniotomy rates (craniotomy rate ICPM-no PPx=50.0% vs. ICP-PPx=31.2%, p=0.1) were similar. Among patients on prophylaxis, 40 (39%) began prophylaxis with an ICPM in place (pre-d/c) while 64 (63%) began prophylaxis with the ICPM removed (post-d/c). Among patients with ICPM in place, mean ICP did not change appreciably with prophylaxis (mean ICP pre-d/c=12±0.6 vs. post-d/c=11±0.8 mmHg, p=0.1) and there was no difference in the need for surgical intervention (pre-d/c=7.3% vs. post-d/c=3.1%, p=0.3). There was no difference in prophylaxis interruptions (0.2), duration of prophylaxis (0.7), dosing (0.9) or type of prophylaxis (0.6). The proportion of increased ICH identified by CT was similar pre-d/c vs. post-d/c (10.0% vs. 10.0%, p=0.9). Overall incidence of VTE was not significantly different (pre-d/c vs. post-d/c=14.6% vs. 9.2%, p=0.6).
Conclusion: Anticoagulant prophylaxis can be initiated safely with-or-without an ICP monitor in place. Intracranial pressures do not change significantly and there is no increased need for surgical intervention. However, the data suggests there is no decreased incidence of VTE in ICPM patients on prophylaxis.