Venous Thrombo-Embolism VTE Prophylaxis for Trauma Patients

1. Venous Thrombo-Embolism (VTE) Prophylaxis for Trauma Patients J. Keenan, M.J. Hall Orthopaedics T.J.C. Nokes Haematology Plymouth

2. Traditionally no pharmacological prophylaxis Some countries all patients receive prophylaxis (EU) Conflicting evidence High risk patients difficult to identify Very busy fracture clinics No suitable score VTE Prophylaxis lower limb cast

3. Is VTE a problem in lower limb casts? Wang, Wera, Knoblich et al Pulmonary embolism following operative treatment of ankle fractures; A report of 3 case review of the literature Foot and ankle international 23(5) May 2002, 406-410 Nesheiwat F, Sergi A R Deep Venous thrombosis and pulmonary embolism following cast immobilisation of the lower extremities Journal Foot and Ankle surgery, 35(6),590 - 594, 1996 Clarke A M, Winston I G Does plaster immobilization predispose to pulmonary embolism? Injury 1992; 23(8)537-541

4. Venographic/US DVT risk in below knee cast

5. Should everyone get prophylaxis? Giannadakis K, Gehling H, Sitter H, Achenbach S, Hahne H, Gotzen L. Is a general pharmacologic thromboembolism prophylaxis necessary in ambulatory treatment by plaster cast immobilization in lower limb injuries? Unfallchirurg. 2000 Jun;103(6):475 Patil S, Ghandi J, Curzon I, Hui ACW. Incidence of deep vein thrombosis in patients with fractures of the ankle treated in a plaster cast. JBJS 2007; 89-B:1340-3 Micheli L.J. Thromboembolic complications of cast immobilization for injuries of the lower extremities. Clin Orthop Relat Research. 1975 May; 108: 191-195 These results suggest, that low risk patients with minor injuries of the lower limb and plaster cast immobilisation do not need a medical thrombosis prophylaxis.

6. A practical strategy for VTE prophylaxis? VTE Prophylaxis Scoring System to identify high risk patients Score developed jointly by Orthopaedic Surgeon and Haematologist After reviewing available evidence in literature Clinical experience used where risk evidence not clear Simple patient-administered form to be used in fracture clinic Hospital Medical Records Committee

7. Risk Factor Literature Review Samama MM An epidemiologic study of risk factors for deep vein thrombosis in medical outpatients: the Sirius study. Arch Intern Med. 2000 Dec 11-25;160(22):3415-20. Edmonds MJR, Crichton TJH, Runciman WB, Pradhan M. Evidence-based risk factors for postoperative deep vein thrombosis. ANZ journal of Surgery 2004, 74(12):1082-97 Tosetto A, Frezzato M, Rodeghiero F. Prevalence and risk factors of non-fatal venous thromboembolism in the active population of the VITA Project. Thromb Haemost. 2003 Aug;1(8):1724-9. Miller J, Chan BK, Nelson HD. Postmenopausal estrogen replacement and risk for venous thromboembolism: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Annals of Internal Medicine 2002, 136(9):680-90. Thorogood M, Mann J, Murphy M, Vessey M. Risk factors for fatal venous thromboembolism in young women: a case-control study. Int J Epidemiol. 1992 Feb;21(1):48-52 Kakkar VV, Howe CT, Nicolaides AN, Renney JTG, Clarke MB Deep vein thrombosis of the leg. Is there a high risk group? Am J Surgery 1970 Oct; 120: 527-530 More recently Prandoni P. Acquired risk factors of venous thromboembolism in medical patients. Pathophysiol Haemost Thromb. 2006;35(1-2):128-32. Ageno W, Squizzato A, Garcia D, Imberti D. Epidemiology and risk factors of venous thromboembolism. Semin Thromb Hemost. 2006 Oct;32(7):651-8

8. The Plymouth VTE Trauma Score  for Patients Immobilised in Lower Limb Casts

9. Absolute Risk Factors (3 Points) Previous Hx DVT (3 points) RRisk 5.18 Previous Hx PE (3 points) Pregnant or within 6 weeks post-partum (3 points) Complex lower limb/pelvis surgery in last 6 weeks (3 points)

10. Relative Risk Factors Family History VTE (2 points) Abdominal Surgery in last 6 weeks (2 points) Age > 60 years (1 point) BMI > 30kg/m (1 point) RR 1.43 Unable to WB before injury (1 point) OCP (1 point) RR 2.48 HRT (1 point) RR 2.05 - 3.75 Varicose Veins (1 point) RR 2.39 IHD/MI in last 6 weeks (1 pt)RR 1.53 / 2.51

11. Plymouth VTE Trauma Score Patient treated with lower limb cast Immobilisation Patient completes The Plymouth VTE Trauma Score Score achieved and treatment protocol assigned

12. Plymouth VTE Trauma Score 240 consecutive patients immobilized in a lower limb cast treated in fracture clinic over a 6 month period The patients completed the score sheet at the time of cast application (Test 1). A comparative score-sheet (Test 2) was completed at cast removal.

13. Results Plymouth VTE Trauma Score 240 patients (M:F 108:132) Average age 45yrs (16-90) 99% of the scoring forms were successfully completed. (3 forms spoilt) 10% of the patients were deemed high risk on initial scoring and received a course of prophylaxis with Enoxaparin.

14. Scale Evaluation Reliability Reproduciblity Group High test-retest reproducibilty (T1 � T2); Wilcoxon test, p=0.85, showed no overall significant difference between two scores High Intraclass corrrelation (ICC) = 0.99 = (criteria > 0.80) Individual Complete agreement in scores 80% (189/240) 92% (218/240) had a score difference of +/-1pt Would change decision ? 10/240 (4.2%) Test (3+) Tx given, re test (<3) = 4/240 (1.7 %) Test (<3) Tx not given, re test (3+) = 6/240 (2.5%) Internal consistency (is it statistically legit. to sum item scores?) =YES Cronbach�s alpha = 0.94 (criteria > 0.90-0.95)

15. Scale Evaluation Validity Clinical validity Applied known risk factors and clinical experience No DVT in study group (Small numbers) Predictive validity � being evaluated

16. NICE GuidelinesTaken from NICE Draft Guidelines, Venous Thromboembolism � Reducing the Risk. March 2009 Recommendation : Consider VTE prophylaxis for patients with lower limb plaster casts who are assessed to be at increased risk of VTE (NICE RISK FACTORS) after carefully evaluating the risks and benefits. Offer one of the following pharmacological methods until plaster cast removal, based on clinical judgement: LMWH Fondaparinux sodium

17. NICE GuidelinesTaken from NICE Draft Guidelines, Venous Thromboembolism � Reducing the Risk. March 2009 VTE risk assessment � surgical patients Regard surgical patients as being at increased risk of VTE if they have one or more of the following risk factors: Active cancer or cancer treatment Acute admission for a surgical condition Age > 60 years Dehydration Expected significant reduction in mobility Known thrombophilias Obesity (BMI > 30 kg/m2) One or more significant medical comorbidities (IHD, metabolic, endocrine or respiratory pathologies, or inflammatory joint diseases) Personal or family history of VTE Pregnancy or = 6 weeks post partum Surgical procedure with a total anaesthetic and surgical time of more than 90 minutes, or 60 minutes if the surgery involves the lower limb Use of hormone replacement therapy. Use of oestrogen-containing contraceptive therapy Varicose veins with phlebitis.

18. NICE Guidelines Applying NICE draft guidelines 2009 to this dataset 240 patients AT LEAST 120 / 240 (50%) patients would receive VTE prophylaxis Compares to 10% treatment rate using VTE trauma score Complications / morbidity of treatment Significant resource implications

19. Conclusions Plymouth VTE Trauma score Practical tool (Fracture clinic or ED) which identifies intrinsic and acquired risk factors for VTE Enables targeted therapy to high risk group Reproducible Prophylaxis tailored to patient Needs validating as a predictive scoring system