Rate of lower-extremity ultrasonography in trauma patients is associated with rate of deep venous thrombosis but not pulmonary embolism

doi:10.1016/j.surg.2015.03.052

Surgery

Volume 158, Issue 2, August 2015, Pages 379-385

Presented at the 10th Annual Academic Surgical Congress in Las Vegas, NV, February 3–5, 2015.

https://doi.org/10.1016/j.surg.2015.03.052 Get rights and content

Background

Disparate lower-extremity ultrasonography (LUS) screening practices among trauma institutions reflecta lack of consensus regarding screening indications and whether screening improves outcomes. We hypothesized that LUS screening for deep-vein thrombosis (DVT) is not associated with a reduced incidence of pulmonary embolism (PE).

Methods

The 2012 ACS National Trauma Data Bank Research Data Set was queried to identify 442,108 patients treated at institutions reporting at least one LUS and at least one DVT. Institutions performing LUS on more than 2% of admitted patients were designated high-screening facilities and remaining institutions were designated low-screening facilities. Patient characteristics and risk factors were used to develop a logistic regression model to assess the independent associations between LUS and DVT and between LUS and PE.

Results

Overall, DVT and PE were reported in 0.94% and 0.37% of the study population, respectively. DVT and PE were reported more commonly in designated high-screening than low-screening facilities (DVT: 1.12% vs 0.72%, P < .0001; PE: 0.40% vs 0.33%, P = .0004). Multivariable logistic regression demonstrated that LUS was associated independently with DVT (odds ratio 1.43, confidence interval 1.34–1.53) but not PE (odds ratio 1.01, confidence interval 0.92–1.12) (c-statistic 0.86 and 0.85, respectively). Sensitivity analyses performed at various rates for designating HS facilities did not alter the significance of these relationships.

Conclusion

LUS in trauma patients is not associated with a change in the incidence of PE. Aggressive LUS DVT screening protocols appear to detect many clinically insignificant DVTs for which subsequent therapeutic intervention may be unnecessary, and the use of these protocols should be questioned.

Section snippets

Data source

The Research Data Set (RDS) of the National Trauma Data Bank (NTDB) for admission year 2012 was used for this study with approval by the American College of Surgeons. The University of Virginia Institutional Review Board exempted this study from formal review, because the NTDB contains de-identified data, of which the use is not considered human subject research. The NTDB is a multi-institutional, clinical outcomes database that combines data from the trauma registries of more than 900 trauma

Results

Characteristics of patients and injuries as well as unadjusted outcomes are listed in Table I and stratified by hospital screening status. Using the 2% designation rate, we found that more than half of study patients were admitted to HS facilities. Patients admitted to HS facilities had an Injury Severity Score >9 more commonly and other injury characteristics associated with the development of VTE.

Table II displays results of bivariate analysis comparing rates of DVT by risk factor at HS and

Discussion

Our aim was to characterize the relationship between routine screening for DVT in trauma patients and the incidence of PE. Our results show that the rate of performance of LUS is associated with DVT but not with a decrease in the incidence of PE after appropriate risk-adjustment. These findings corroborate existing evidence that surveillance bias accounts for much of the variability in the incidence of DVT by institution. Furthermore, these results suggest that routine screening protocols may

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Of 1988 patients, 136 (6.8%) BKDVT and 23 (1.2%) AKDVT. 7 (6.9%) BKDVT progressed to AKDVT/PE. 6.9% had BKDVT progression, associated with higher ISS (36.7 vs 21.6, p = 0.005), longer prophylaxis delay (121 vs 45 h, p = 0.02) and longer hospital LOS (25.6 vs 7.8, p = 0.01). None experienced post-thrombotic syndrome.
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The current study was conducted in international databases, on all descriptive and analytical studies and clinical and semi-experimental trial studies, without time limit until November 2, 2021. The present study was designed and implemented based on PRISMA guideline. The quality of the studies was checked using STROBE checklist and meta-analysis was performed using CMA software.
Among the 3204 articles found, after the evaluations, 189 articles entered the full text review phase, and as a result, 38 articles were included in the study. The reported prevalence of thromboembolism was 1-45%. The prevalence of venous thromboembolism was 12% in overall. The chance of venous thromboembolism was higher in ICUs patients >57 years old and ICUs patients with a history of venous thromboembolism.
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The Risk Assessment Profile is suboptimal for guiding duplex ultrasound surveillance in trauma patients
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The utility of the Risk Assessment Profile (RAP) score in predicting VTE was assessed, and VTE risk factors identified to guide a duplex ultrasound (DUS) protocol in injured patients.
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Performance of RAP to predict VTE was moderate. VTE predictor variables could serve as the foundation for a novel approach guiding DUS surveillance. Derivation and validation are warranted.
The Utility of Lower Extremity Screening Duplex for The Detection of Deep Vein Thrombosis in Trauma
2022, Journal of Surgical Research
Citation Excerpt :
Those who advocate for universal screening protocols feel that all trauma patients are at elevated risk for VTE, LESDUS is cost effective,13 and that early DVT diagnosis provides clinical benefit.14-16 The opposition's argument is that the correlation with incidental DVT findings on LESDUS do not correlate with rates of adverse outcomes or PE and that screening is of little value.17-19 There is a growing cohort that advocate for a more selective LESDUS protocol in high-risk trauma patients, although the definition of “high-risk” is somewhat variable.20-23
Trauma patients are high-risk for venous thromboembolism (VTE). Lower extremity screening duplex ultrasonography (LESDUS) is controversial and not standardized for early VTE diagnosis. By implementing risk stratification and selective screening, we aim to optimize resource utilization.
A retrospective review were conducted at a Level-1 Trauma Center, January 2015-October 2019. LESDUS was performed within 72-h of presentation, then weekly. Demographics, VTE data, and outcomes were collected from the trauma registry. Risk assessment profile (RAP) score was calculated based on collected data.
Of 5,645 patients included, 2,813 (49.8%) were screened for lower extremity deep vein thrombosis (LEDVT). Of 187 patients with LEDVT, 154 were diagnosed on LESDUS, 18 after negative LESDUS, and 15 in unscreened patients. Patients with VTE were older (61y versus 55, P < 0.01), more often male (70.9% versus 29.1%, P = 0.03), had higher ISS (16 versus 10, P < 0.01), longer hospital length of stay (LOS) (11.5 d versus 3, P < 0.01), longer ICU LOS (4.5 d versus 1, P < 0.01), and increased mortality (9.1% versus 4.3%, P = 0.01). RAP was higher in VTE patients versus those without (nine versus three, P < 0.01). RAP ≥8 was 62.5% sensitive and 70.4% specific for VTE. Chemoprophylaxis delay also correlated with increased VTE (OR = 1.48, 95% CI = 1.03-2.12).
VTE remains a significant complication in trauma patients. Despite a universal LESDUS protocol, only 50% of patients underwent screening and 20% of all LE DVTs were not identified on LESDUS. To optimize resource utilization and protocol adherence, LESDUS should only be performed if RAP ≥8 or if unable to administer timely chemoprophylaxis.
Does prophylactic inferior vena cava filter reduce the hazard of pulmonary embolism and mortality in severe trauma? A single center retrospective comparative study
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Citation Excerpt :
Additionally, there was no routine surveillance program for VTE during the time-period the study was conducted. Surveillance programs may increase the awareness of VTE and may detect more subclinical DVT but may not necessarily improve clinical outcomes by reducing PE [33]. This study used time to in-hospital events and mortality.
Use of inferior vena cava (IVC) filters in patients following severe trauma without recent history of venous thromboembolism (VTE) is controversial. Our objective was to determine if IVC filter placement in the setting of severe trauma effects the hazard of in-hospital pulmonary embolism (PE), deep venous thrombosis (DVT) and mortality.
This retrospective study recruited patients from a single Level I Trauma Center between 1/2008 and 12/2013. Inclusion criteria were age>15 years, Injury Severity Score (ISS)>15 and survival>24 h after hospital admission. Patients with VTE diagnosed prior to IVC filter placement were excluded. A Cox proportional hazards regression model was used, adjusting for immortal time bias with landmark analysis at predefined time after injury. Differences between IVC filter and non-IVC filter groups were adjusted using propensity score.
In total 1451 patients were reviewed; 282 patients received an IVC filter and 1169 patients had no IVC filter placed. The mean age was 45.9 vs. 56.9 years and the mean ISS was 29.8 vs. 22.6 in the IVC filter and the non-IVC filter group, respectively. IVC filter placement was not associated with the hazard of PE (HR = 0.46; 95 % CI, 0.12,1.70; P = 0.24) or mortality (HR = 1.02; 95 % CI 0.60,1.75; P = 0.93). However, IVC filter placement was associated with the hazard of DVT (HR = 2.73; 95 % CI, 1.28,5.85; P = 0.01).
In patients with severe trauma, those with prophylactic IVC filter placement did not have a reduced hazard of PE or mortality, but an increased hazard of DVT was observed.
Acute Deep Venous Thrombosis and Pulmonary Embolism in Foot and Ankle Trauma in the National Trauma Data Bank: An Update and Reanalysis
2019, Journal of Foot and Ankle Surgery
Citation Excerpt :
Additionally, DVT may be overdiagnosed in certain settings. Dietch et al (7) examined the use of lower extremity ultrasound in trauma patients and showed that high utilization centers tended to have higher rates of both DVT and PE. However, while the relationship between DVT and ultrasound remained significant on multivariate analysis, the relationship with PE did not, indicating that many DVTs, clinically or otherwise diagnosed, are not clinically significant.
The data regarding rates of deep venous thrombosis and pulmonary embolism after foot and ankle trauma remain sparse. In this study of the National Trauma Data Bank Data set (2007–2009 and 2010–2016), these rates were reexamined and risk factors associated with these complications were assessed. Data quality is improved in the later data set; the incidence of deep venous thrombosis and pulmonary embolism was 0.28% and 0.21%, respectively, in the 2010–2016 data. Prophylaxis, male gender, treatment in a university hospital, open reduction, chronic obstructive pulmonary disease, and hypertension were notable significant risk factors for pulmonary embolism. For deep venous thrombosis, male gender, bleeding disorder, angina, and prophylaxis were risk factors. Careful, individualized assessment of the risk factors associated with deep venous thrombosis and pulmonary embolism is important, and the merits of routine prophylaxis remain in question.

View all citing articles on Scopus

: This work was supported by National Institutes of Health grants T32 AI078875 and T32 CA163177.

: Disclosure: Committee on Trauma, American College of Surgeons. Chicago, IL, October 2013. The content reproduced from the NTDB remains the full and exclusive copyrighted property of the American College of Surgeons. The American College of Surgeons is not responsible for any claims arising from works based on the original data, text, tables, or figure.

View full text

Trauma/Critical CareRate of lower-extremity ultrasonography in trauma patients is associated with rate of deep venous thrombosis but not pulmonary embolism

Background

Methods

Results

Conclusion

Section snippets

Data source

Results

Discussion

Chest

Arch Phys Med Rehabil

Am J Surg

Ann Vasc Surg

Ann Vasc Surg

Duplex ultrasound screening for deep vein thrombosis in asymptomatic trauma patients: a survey of individual trauma surgeon opinions and current trauma center practices

J Trauma

Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group

J Trauma

Predictors of posttraumatic deep vein thrombosis (DVT): hospital practice versus patient factors-an analysis of the National Trauma Data Bank (NTDB)

J Trauma

Thromboembolism after trauma

Ann Surg

Trauma/Critical Care
Rate of lower-extremity ultrasonography in trauma patients is associated with rate of deep venous thrombosis but not pulmonary embolism