Journal Review in Trauma Surgery: VTE Prophylaxis

VTE prophylaxis is more than just some squeezy leg socks and a one-size fits all dose of enoxaparin!  Ever wonder how VTE prophylaxis is similar to constipation?  Have you or a loved one been hurt by a hospital administrator telling you that VTE is a never event?  Come with us, and our special guest Dr. Bryan Cotton, on this journey to the frontier of research attempting to debunk this myth and improve patient care by reducing VTE rates in trauma patients.  

Hosts:
- Michael Cobler-Lichter, MD, PGY4/R2:
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@mdcobler (X/twitter)

- Eva Urrechaga, MD, PGY-8, Vascular Surgery Fellow
University of Pennsylvania
Recent graduate of University of Miami/Jackson Memorial Hospital/Ryder Trauma Center General Surgery Residency
@urrechisme (X/twitter)

- Eugenia Kwon, MD, Trauma/Surgical Critical Care Attending:
Loma Linda University
Recent graduate of University of Miami/Jackson Memorial Hospital/Ryder Trauma Center Trauma/CC Fellowship

- Brandon Parker, DO, Assistant Professor of Surgery, 5 years in practice
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@BrandonParkerDO (X/twitter)

- Bryan Cotton, MD, MPH, FACS, Professor of Surgery, 20 years in practice
 University of Texas Health Science Center at Houston/Red Duke Trauma Institute at Memorial Herman Hospital
@bryanacotton1 (X/twitter)

Learning Objectives:

- Describe the rationale for the addition of aspirin to chemoprophylactic regimens for VTE

-  Identify appropriate screening systems for trauma patients at high risk for VTE

-  Describe the rationale for monitoring anti factor Xa levels in the trauma population receiving VTE chemoprophylaxis

- List the major conclusions of the two studies discussed regarding the addition of aspirin to VTE chemoprophylaxis regimens in trauma patients, and the change in antithrombin activity levels over time in relation to enoxaparin responsiveness in polytrauma patients

Quick Hits:

1.     On adjusted analysis, the standard VTE PPX plus aspirin group had a lower OR of developing VTE, though limitations of this study highlight need for future prospective work
2.     Trauma patients often suffer from decreased activity of antithrombin 3, which may mediate the relatively higher rates of VTE in this population.
3.     Trauma patients who went on to develop VTE were more likely to not achieve satisfactory anti Xa levels, with a VTE rate of 30% in the never-responder group, the group for which Xa levels were never higher than 0.2
4.     Ex vivo supplementation of antithrombin seems to improve enoxaparin responsiveness.  Remember, enoxaparin and heparin are HELPING AT3, not the other way around

References

1.     Lammers D, Scerbo M, Davidson A, et al. Addition of aspirin to venous thromboembolism chemoprophylaxis safely decreases venous thromboembolism rates in trauma patients. Trauma Surg Acute Care Open. 2023;8(1):e001140. doi:10.1136/tsaco-2023-001140
https://pubmed.ncbi.nlm.nih.gov/37936904/

2.     Vincent LE, Talanker MM, Butler DD, et al. Association of Changes in Antithrombin Activity Over Time With Responsiveness to Enoxaparin Prophylaxis and Risk of Trauma-Related Venous Thromboembolism. JAMA Surg. 2022;157(8):713-721. doi:10.1001/jamasurg.2022.2214
https://pubmed.ncbi.nlm.nih.gov/35731524/

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