Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study

Asanthi M. Ratnasekera, Department of Surgery, Division of Trauma and Surgical Critical Care, Associate Professor of Surgery, Drexel College of Medicine, Philadelphia, PA, United States; Crozer Health Upland PA, Currently at Christianacare Health, Newark, DE, United States. Electronic address: ashanthi27@hotmail.com.
Sirivan S. Seng, Department of Surgery, Crozer Health, Upland, PA, United States.
Daniel Kim, Department of Surgery, Crozer Health, Upland, PA, United States.
Wenyan Ji, Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Polytechnic Institute and State University, Roanoke, VA, United States.
Christina L. Jacovides, Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States; Currently at Temple University, Philadelphia, PA, United States.Follow
Elinore J. Kaufman, Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States.
Hannah M. Sadek, Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States.
Lindsey L. Perea, Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, United States.
Christina Monaco Poloni, Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States.
Ilya Shnaydman, Department of Surgery, Medical Director, Surgical Intensive Care Unit, New York Medical College, West Chester Medical Center, Valhalla, NY, United States.
Alexandra Jeongyoon Lee, Department of Surgery, West Chester Medical Center, Valhalla, NY, United States.
Victoria Sharp, Department of Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, United States.
Angela Miciura, Department of Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, United States.
Eric Trevizo, Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States.
Martin G. Rosenthal, Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States.
Lawrence Lottenberg, Department of Surgery, St. Mary's Medical Center, West Palm Beach, FL, United States; Florida Atlantic University, Boca Raton, FL, United States.
William Zhao, Department of Surgery, St. Mary's Medical Center, West Palm Beach, FL, United States; Florida Atlantic University, Boca Raton, FL, United States.
Alicia Keininger, Department of Surgery, Trinity Health Oakland, Pontiac, MI, United States.
Michele Hunt, Department of Surgery, Trinity Health Oakland, Pontiac, MI, United States.
John Cull, Department of Surgery, Prisma Health Upstate, Greenville, SC, United States.
Chassidy Balentine, Department of Surgery, Prisma Health Upstate, Greenville, SC, United States.
Tanya Egodage, Department of Surgery, Cooper University Hospital, Camden, NJ, United States.Follow
Aleem T. Mohamed, Department of Surgery, Cooper University Hospital, Camden, NJ, United States.
Michelle Kincaid, Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH, United States.Follow
Stephanie Doris, Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH, United States.
Robert Cotterman, Department of Surgery, Promedica Toledo Hospital, Toledo, OH, United States.
Sara Seegert, Department of Research, Promedica Toledo Hospital, Toledo, OH, United States.
Lewis E. Jacobson, Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, United States.Follow
Jamie Williams, Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, United States.
Melissa Moncrief, Department of Trauma & Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, United States.
Brandi Palmer, Department of Trauma & Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, United States.
Caleb Mentzer, Department of Surgery, Spartanburg Medical Center, Spartanburg, SC, United States.

Document Type

Article

Publication Title

Injury

Abstract

BACKGROUND: In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI. METHODS: Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest. RESULTS: 984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant. CONCLUSION: In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH. LEVEL OF EVIDENCE: Level III, Therapeutic Care Management.

First Page

111523

DOI

10.1016/j.injury.2024.111523

Publication Date

9-1-2024

Identifier

38614835 (pubmed); 10.1016/j.injury.2024.111523 (doi); S0020-1383(24)00210-9 (pii)

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