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The rate of deep vein thrombosis doubles in trauma patients with hypercoagulable thromboelastography

Brill, Jason B. MD; Badiee, Jayraan MPH; Zander, Ashley L. DO; Wallace, James D. MD; Lewis, Paul R. DO; Sise, Michael J. MD; Bansal, Vishal MD; Shackford, Steven R. MD

Journal of Trauma and Acute Care Surgery: September 2017 - Volume 83 - Issue 3 - p 413–419
doi: 10.1097/TA.0000000000001618
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BACKGROUND Venous thromboembolism (VTE) in trauma can occur in patients at low risk. Conventional coagulation tests do not predict VTE. Studies investigating thromboelastography (TEG) for VTE risk are conflicting and have not included routine surveillance to detect deep vein thrombosis (DVT). We undertook a prospective study of TEG to evaluate its utility in predicting VTE.

METHODS We conducted a prospective cohort study on all adult trauma patients admitted to our Level I trauma center from 2013 to 2015. TEG was performed immediately on arrival to the trauma bay. Hypercoagulable TEG was defined as reaction time (R) below, angle (α) above, or maximum amplitude (MA) above reference ranges. All patients received mechanical and/or pharmacologic prophylaxis and were followed up for DVT with our ultrasound surveillance protocol. The primary outcome was lower-extremity DVT. After bivariate analysis of variables related to DVT, those with p values of 0.100 or less were included for multivariate logistic regression.

RESULTS A total of 983 patients were evaluated with TEG on admission; of these, 684 (69.6%) received at least one surveillance ultrasound during the index admission. Lower-extremity DVT was diagnosed in 99 (14.5%) patients. Hypercoagulability based on admission TEG occurred in 582 (85.1%) patients. The lower-extremity DVT rate was higher in patients with hypercoagulable TEG than in those without hypercoagulable TEG (15.6% vs. 8%; p = 0.039). Multivariate analysis showed hypercoagulable TEG remained associated with DVT after adjustment for relevant covariates available at admission, with an odds ratio of 2.41 (95% confidence interval, 1.11–5.24; p = 0.026).

CONCLUSION Most trauma patients were hypercoagulable at admission and remained at risk of developing DVT. The rate of DVT doubled in patients with hypercoagulable TEG indices despite prophylaxis. Beyond its current clinical roles, TEG is useful for assessing DVT risk, particularly in patients otherwise perceived to be at low risk.

LEVEL OF EVIDENCE Prognostic study, level II.

From the Trauma Service (J.B.B., J.B., A.L.Z., J.D.W., P.R.L., M.J.S., V.B., S.R.S.), Scripps Mercy Hospital, San Diego, California.

Submitted: February 9, 2017, Revised: May 12, 2017, Accepted: May 29, 2017, Published online: June 9, 2017.

This study was presented at the 2016 meeting of the American College of Surgeons Committee on Trauma Region 9 Resident Paper Competition, December 3, 2016, in Los Angeles, California.

Address for reprints: Steven R. Shackford, MD, Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA 92103; email: Shackford.steven@scrippshealth.org.

© 2017 Lippincott Williams & Wilkins, Inc.