E. O. Yeates1, A. Grigorian1, S. D. Schubl1, C. M. Kuza2, V. Joe1, M. Lekawa1, B. Borazjani1, J. Nahmias1 2University Of Southern California,Anesthesia,Los Angeles, CA, USA 1University Of California – Irvine,General Surgery,Orange, CA, USA
Introduction: Patients presenting after severe traumatic brain injury (TBI) are at an increased risk of developing venous thromboembolism (VTE). Due to concerns of worsening intracranial hemorrhage, some clinicians are hesitant to start VTE chemoprophylaxis in this high-risk population. We hypothesized that American College of Surgeons (ACS) verified Level-I trauma centers are more likely to start VTE chemoprophylaxis in adults with severe TBI, compared to Level-II centers. Additionally, we hypothesized that Level-I centers would start VTE chemoprophylaxis earlier and have a lower risk of VTE.
Methods: The Trauma Quality Improvement Program (2010-2016) was queried for patients with a severe grade (>3) for abbreviated injury scale (AIS) of the head. Those that died within 24 hours or had an AIS grade of 6 were excluded. Patients were compared based on the treating hospital: Level-I versus Level-II. A multivariable logistic regression analysis was performed.
Results: From 204,895 patients with severe TBI, 143,818 (70.2%) were treated at a Level-I center and 61,077 (29.8%) at a Level-II center. Compared to severe TBI patients treated at a Level-II center, those at a Level-I center had a lower rate of midline shift >5 mm (26.2% vs. 27.6%, p=0.01), but higher rates of severe AIS grades for the spine (0.9% vs. 0.7%, p<0.001) and lower extremity (0.6% vs. 0.4%, p<0.001). There was no difference in total length of stay (LOS) or intensive care unit (ICU) LOS between the two groups (p>0.05). The Level-I cohort had a higher rate of using VTE chemoprophylaxis (43.2% vs. 23.3%, p<0.001) and shorter median time to chemoprophylaxis (61.9 vs. 85.9 hours, p<0.001), with a lower rate of deep vein thrombosis (4.9% vs. 5.8%, p<0.001) compared to Level-II centers. After controlling for covariates, Level-I centers had a higher likelihood of starting VTE chemoprophylaxis (OR=2.47, CI=2.39-2.56, p<0.001), but had no difference in the risk of VTE (p=0.41) compared to Level-II centers.
Conclusion: ACS Level-I trauma centers were found to be more than twice as likely to start VTE chemoprophylaxis and administered it nearly 24-hours sooner than Level-II centers. However, this did not translate to a decreased risk for VTE events at Level-I centers compared to Level-II centers on a multivariable analysis. Future prospective studies are warranted to evaluate the timing, safety, and efficacy of early VTE chemoprophylaxis in severe TBI patients.
