Elsevier

Injury

Volume 41, Issue 1, January 2010, Pages 97-101
Injury

Venous thromboembolism after severe trauma: Incidence, risk factors and outcome

https://doi.org/10.1016/j.injury.2009.06.010Get rights and content

Abstract

Background

Venous thromboembolic events (VTEs) are common life-threatening complications after trauma, but epidemiology and reported risk factors still vary. The purpose of this investigation was to determine the incidence of VTEs among hospitalised trauma patients, to identify potential risk factors and to assess whether their presence was associated with: (a) the magnitude and pattern of injury, (b) therapeutic interventions and (c) outcome, all by using a large population-based registry.

Patients and methods

Patient data from the Trauma Registry of the German Society for Trauma Surgery (TR-DGU) including datasets from more than 35,000 trauma patients were screened for all clinically relevant VTEs, i.e. deep vein thrombosis (DVT) and pulmonary embolism (PE). A total of 7937 patients were identified for further investigation and multivariate logistic regression analyses were performed to assess potential risk factors for VTEs and to evaluate the effect of VTEs on outcome.

Results

One hundred forty-six of 7937 patients developed clinically relevant VTEs during post-traumatic hospitalisation corresponding to an overall incidence rate of 1.8%. Two-thirds (97/146) of all VTEs occurred during the first 3 weeks after admission.

At the time point of the event 118/146 (80.8%) patients were under either mechanical or chemical prophylaxis. Multivariate analysis with VTE as dependent variable identified injury severity score, the number of operative procedures, pelvic injury (abbreviated injury scale  2) and concomitant diseases (i.e. diabetes, renal failure, malignancies and congenital or acquired coagulation disorders) as independent risk factors. The presence of VTEs was associated with higher frequencies of sepsis (25% vs. 9.1%), single (63.6% vs. 41.3%) and multiple organ failure (49% vs. 25%) and prolonged in-hospital length of stay (52 ± 34 days vs. 29 ± 30 days; all p < 0.001). The mortality in the VTE group totaled 13.7% vs. 7.4% in the non-VTE group (p = 0.004). The presence of PE was associated with a mortality rate of 25.7%. The adjusted odds ratio of post-traumatic VTEs for hospital mortality was 2.08 (CI95 1.15–3.78; p = 0.016).

Conclusion

The occurrence of clinically apparent VTEs during post-traumatic hospitalisation is low but associated with increased morbidity and mortality. Conclusions about the effectiveness of different thromboprophylactic measures could not be drawn, since detailed information was not recorded. However, 80.8% of VTE patients had received thromboprophylaxis at the time point of the event.

Introduction

Venous thromboembolic events (VTEs) comprise deep vein thrombosis (DVT) and pulmonary embolism (PE) and represent a significant cause of death, disability and discomfort after trauma-associated hospitalisation. While DVT may present clinically silent, PE is the third most common cause of death in patients that survive the first 24 h after trauma.10, 11, 24 The information on the frequency of VTEs among hospitalised patients after trauma varies widely, ranging from less than 1% up to 58% depending upon the demographics of the study population, the nature of the injuries and other factors.4, 17, 20, 28 The increased survival of severely injured patients together with the aging population may implicate an increasing risk of VTEs after trauma.

The current literature focuses on practice guidelines with respect to diagnostic procedures and the prevention of post-traumatic VTEs. In this context, the identification of risk factors has proven to be useful to define high-risk patients.6, 7, 8, 9, 10, 13, 18, 19, 26, 27, 28, 29 The recognition of potential risk factors and corresponding prophylaxis appears mandatory for all trauma patients.

The aim of our study was to determine to what extent VTEs occur in hospitalised trauma patients and whether their occurrence was associated with: (a) the magnitude and pattern of injury, (b) therapeutic interventions and (c) outcome. In addition multivariate logistic regression was performed to identify risk factors for VTEs after trauma. For this purpose, we reviewed datasets of patients from the Trauma Registry of the German Society for Trauma Surgery (TR-DGU) comprising data from more than 35,000 multiply injured patients.

Section snippets

The Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie (TR-DGU)

The TR-DGU2 was founded in 1993 by the German Society of Trauma Surgery (DGU) for anonymous and standardised documentation of data on trauma patients requiring intensive care. Until 2007, data from a total of 35,664 trauma patients have been entered into the registry. In 2002, the online documentation system of the registry was introduced and extended the registry by additional parameters. Currently, 145 hospitals are affiliated with the TR-DGU, mostly from Germany (n = 128) (www.traumaregister.de

Results

Of the 14,679 patients registered in the relevant study period (2005–2007), 3797 partially incomplete data forms were excluded from further analysis. Two thousand nine hundred and forty-five patients were excluded according to the inclusion/exclusion criteria.

Thus, a total of 7937 trauma patients with complete datasets were retrieved from the registry and analysed. For 146/7937 patients a VTE during post-traumatic hospitalisation was reported. This corresponded to an overall frequency for VTEs

Discussion

The present study was conducted to assess the overall frequency of VTEs in hospitalised trauma patients, to elucidate potential risk factors for the development of VTEs after severe trauma and to evaluate their effects on outcome using a large country-wide population-based registry containing data from more than 35,000 injured patients in Germany.

In our population the frequency of VTEs after trauma-associated hospitalisation was 1.8%. Similar frequencies from injured patients have been reported

Conflict of interest

None.

References (31)

  • J.W. Dennis et al.

    Efficacy of deep venous thrombosis prophylaxis in trauma patients and identification of high-risk groups

    J Trauma

    (1993)
  • W.H. Geerts et al.

    A prospective study of venous thromboembolism after major trauma

    N Engl J Med

    (1994)
  • W.H. Geerts et al.

    A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma

    N Engl J Med

    (1996)
  • D. Green et al.

    Prevention of thromboembolism after spinal cord injury using low-molecular-weight heparin

    Ann Intern Med

    (1990)
  • L.J. Greenfield et al.

    Posttrauma thromboembolism prophylaxis

    J Trauma

    (1997)
  • Cited by (163)

    • The long-term risks of venous thromboembolism among non-operatively managed spinal fracture patients: A nationwide analysis

      2023, American Journal of Surgery
      Citation Excerpt :

      It is well-established that trauma is associated with increased rates of venous thromboembolism (VTE), including both deep venous thrombosis (DVT) and pulmonary embolism (PE). Published rates of VTE complications in injured patients ranges from <1% to 100% depending upon the injury severity and pattern, and VTE prophylaxis practices.13–16 For spinal trauma patients specifically, the rate of VTE complications has been reported as 4% in those with spinal cord injury,17 8% for those patients managed operatively18 and 5% for those managed non-operatively.19

    View all citing articles on Scopus
    1

    These two authors are joint first authors and contributed equally to the study.

    2

    Committee on Emergency Medicine, Intensive and Trauma Care (Sektion NIS) of the German Society for Trauma Surgery (DGU).

    View full text