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Meta-Analysis
. 2013 Mar 28;2013(3):CD008303.
doi: 10.1002/14651858.CD008303.pub2.

Thromboprophylaxis for trauma patients

Luis M Barrera  1 , Pablo Perel, Katharine Ker, Roberto Cirocchi, Eriberto Farinella, Carlos Hernando Morales Uribe
Affiliations
Meta-Analysis

Thromboprophylaxis for trauma patients

Luis M Barrera et al. Cochrane Database Syst Rev. .

Abstract

Background: Trauma is a leading causes of death and disability in young people. Venous thromboembolism (VTE) is a principal cause of death. Trauma patients are at high risk of deep vein thrombosis (DVT). The incidence varies according to the method used to measure the DVT and the location of the thrombosis. Due to prolonged rest and coagulation abnormalities, trauma patients are at increased risk of thrombus formation. Thromboprohylaxis, either mechanical or pharmacological, may decrease mortality and morbidity in trauma patients who survive beyond the first day in hospital, by decreasing the risk of VTE in this population.A previous systematic review did not find evidence of effectiveness for either pharmacological or mechanical interventions. However, this systematic review was conducted 10 years ago and most of the included studies were of poor quality. Since then new trials have been conducted. Although current guidelines recommend the use of thromboprophylaxis in trauma patients, there has not been a comprehensive and updated systematic review since the one published.

Objectives: To assess the effects of thromboprophylaxis in trauma patients on mortality and incidence of deep vein thrombosis and pulmonary embolism. To compare the effects of different thromboprophylaxis interventions and their effects according to the type of trauma.

Search methods: We searched The Cochrane Injuries Group Specialised Register (searched April 30 2009), Cochrane Central Register of Controlled Trials 2009, issue 2 (The Cochrane Library), MEDLINE (Ovid) 1950 to April (week 3) 2009, EMBASE (Ovid) 1980 to (week 17) April 2009, PubMed (searched 29 April 2009), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to April 2009), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (1990 to April 2009).

Selection criteria: Randomized controlled clinical trials involving people of any age with major trauma defined by one or more of the following criteria: physiological: penetrating or blunt trauma with more than two organs and unstable vital signs, anatomical: people with an Injury Severity Score (ISS) higher than 9, mechanism: people who are involved in a 'high energy' event with a risk for severe injury despite stable or normal vital signs. We excluded trials that only recruited outpatients, trials that recruited people with hip fractures only, or people with acute spinal injuries.

Data collection and analysis: Four authors, in pairs (LB and CM, EF and RC), independently examined the titles and the abstracts, extracted data, assessed the risk of bias of the trials and analysed the data. PP resolved any disagreement between the authors.

Main results: Sixteen studies were included (n=3005). Four trials compared the effect of any type (mechanical and/or pharmacological) of prophylaxis versus no prophylaxis. Prophylaxis reduced the risk of DVT in people with trauma (RR 0.52; 95% CI 0.32 to 0.84). Mechanical prophylaxis reduced the risk of DVT (RR = 0.43; 95% CI 0.25 to 0.73). Pharmacological prophylaxis was more effective than mechanical methods at reducing the risk of DVT (RR 0.48; 95% CI 0.25 to 0.95). LMWH appeared to reduce the risk of DVT compared to UH (RR 0.68; 95% CI 0.50 to 0.94). People who received both mechanical and pharmacological prophylaxis had a lower risk of DVT (RR 0.34; 95% CI 0.19 to 0.60)

Authors' conclusions: We did not find evidence that thromboprophylaxis reduces mortality or PE in any of the comparisons assessed. However, we found some evidence that thromboprophylaxis prevents DVT. Although the strength of the evidence was not high, taking into account existing information from other related conditions such as surgery, we recommend the use of any DVT prophylactic method for people with severe trauma.

PubMed Disclaimer

Conflict of interest statement

None known.

Figures

1.1
1.1. Analysis
Comparison 1 Prophylaxis vs No prophylaxis, Outcome 1 Deep Venous Thrombosis (DVT).
1.2
1.2. Analysis
Comparison 1 Prophylaxis vs No prophylaxis, Outcome 2 Pulmonary Embolism (PE).
1.3
1.3. Analysis
Comparison 1 Prophylaxis vs No prophylaxis, Outcome 3 Mortality.
1.4
1.4. Analysis
Comparison 1 Prophylaxis vs No prophylaxis, Outcome 4 Bleeding.
2.1
2.1. Analysis
Comparison 2 Mechanical prophylaxis vs No prophylaxis, Outcome 1 DVT.
2.2
2.2. Analysis
Comparison 2 Mechanical prophylaxis vs No prophylaxis, Outcome 2 PE.
2.3
2.3. Analysis
Comparison 2 Mechanical prophylaxis vs No prophylaxis, Outcome 3 Mortality.
2.4
2.4. Analysis
Comparison 2 Mechanical prophylaxis vs No prophylaxis, Outcome 4 Bleeding.
3.1
3.1. Analysis
Comparison 3 Pharmacological prophylaxis vs Mechanical prophylaxis, Outcome 1 DVT.
3.2
3.2. Analysis
Comparison 3 Pharmacological prophylaxis vs Mechanical prophylaxis, Outcome 2 PE.
3.3
3.3. Analysis
Comparison 3 Pharmacological prophylaxis vs Mechanical prophylaxis, Outcome 3 Mortality.
3.4
3.4. Analysis
Comparison 3 Pharmacological prophylaxis vs Mechanical prophylaxis, Outcome 4 Bleeding.
3.5
3.5. Analysis
Comparison 3 Pharmacological prophylaxis vs Mechanical prophylaxis, Outcome 5 Major bleeding.
3.6
3.6. Analysis
Comparison 3 Pharmacological prophylaxis vs Mechanical prophylaxis, Outcome 6 Minor bleeding.
4.1
4.1. Analysis
Comparison 4 LWMH vs UH, Outcome 1 DVT.
4.2
4.2. Analysis
Comparison 4 LWMH vs UH, Outcome 2 PE.
4.3
4.3. Analysis
Comparison 4 LWMH vs UH, Outcome 3 Mortality.
4.4
4.4. Analysis
Comparison 4 LWMH vs UH, Outcome 4 Bleeding.
4.5
4.5. Analysis
Comparison 4 LWMH vs UH, Outcome 5 Major bleeding.
4.6
4.6. Analysis
Comparison 4 LWMH vs UH, Outcome 6 Minor bleeding.
5.1
5.1. Analysis
Comparison 5 Mechanical + pharmacological prophylaxis vs Pharmacological, Outcome 1 DVT.
5.2
5.2. Analysis
Comparison 5 Mechanical + pharmacological prophylaxis vs Pharmacological, Outcome 2 PE.
5.3
5.3. Analysis
Comparison 5 Mechanical + pharmacological prophylaxis vs Pharmacological, Outcome 3 Mortality.
5.4
5.4. Analysis
Comparison 5 Mechanical + pharmacological prophylaxis vs Pharmacological, Outcome 4 Bleeding.
6.1
6.1. Analysis
Comparison 6 Mechanical + pharmacological prophylaxis vs Mechanical prophylaxis, Outcome 1 DVT.
6.2
6.2. Analysis
Comparison 6 Mechanical + pharmacological prophylaxis vs Mechanical prophylaxis, Outcome 2 PE.
6.3
6.3. Analysis
Comparison 6 Mechanical + pharmacological prophylaxis vs Mechanical prophylaxis, Outcome 3 Mortality.
7.1
7.1. Analysis
Comparison 7 Thigh‐calf vs Calf‐foot, Outcome 1 DVT.
7.2
7.2. Analysis
Comparison 7 Thigh‐calf vs Calf‐foot, Outcome 2 PE.
7.3
7.3. Analysis
Comparison 7 Thigh‐calf vs Calf‐foot, Outcome 3 Mortality.
7.4
7.4. Analysis
Comparison 7 Thigh‐calf vs Calf‐foot, Outcome 4 Bleeding.
8.1
8.1. Analysis
Comparison 8 Prophylaxis vs No prophylaxis (sensitivity analysis), Outcome 1 DVT.
8.2
8.2. Analysis
Comparison 8 Prophylaxis vs No prophylaxis (sensitivity analysis), Outcome 2 PE.
9.1
9.1. Analysis
Comparison 9 Mechanical prophylaxis vs No prophylaxis (sensitivity analysis), Outcome 1 DVT.
9.2
9.2. Analysis
Comparison 9 Mechanical prophylaxis vs No prophylaxis (sensitivity analysis), Outcome 2 PE.
10.1
10.1. Analysis
Comparison 10 LMWH vs UH (Sensitivity analysis), Outcome 1 DVT.
10.2
10.2. Analysis
Comparison 10 LMWH vs UH (Sensitivity analysis), Outcome 2 PE.
10.3
10.3. Analysis
Comparison 10 LMWH vs UH (Sensitivity analysis), Outcome 3 Mortality.
10.4
10.4. Analysis
Comparison 10 LMWH vs UH (Sensitivity analysis), Outcome 4 Bleeding.
10.5
10.5. Analysis
Comparison 10 LMWH vs UH (Sensitivity analysis), Outcome 5 Major Bleeding.
10.6
10.6. Analysis
Comparison 10 LMWH vs UH (Sensitivity analysis), Outcome 6 Minor Bleeding.
11.1
11.1. Analysis
Comparison 11 Pharmacological prophylaxis vs Mechanical prophylaxis (Sensitivity analysis), Outcome 1 DVT.
11.2
11.2. Analysis
Comparison 11 Pharmacological prophylaxis vs Mechanical prophylaxis (Sensitivity analysis), Outcome 2 PE.
11.3
11.3. Analysis
Comparison 11 Pharmacological prophylaxis vs Mechanical prophylaxis (Sensitivity analysis), Outcome 3 Mortality.
11.4
11.4. Analysis
Comparison 11 Pharmacological prophylaxis vs Mechanical prophylaxis (Sensitivity analysis), Outcome 4 Bleeding.
11.5
11.5. Analysis
Comparison 11 Pharmacological prophylaxis vs Mechanical prophylaxis (Sensitivity analysis), Outcome 5 Major bleeding.
11.6
11.6. Analysis
Comparison 11 Pharmacological prophylaxis vs Mechanical prophylaxis (Sensitivity analysis), Outcome 6 Minor bleeding.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Velmahos 2005 {published data only}
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Yanar 2007 {published data only}
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