1. Outpatient Venous Thromboembolism Prophylaxis in Lower Limb Injuries:
Testroote, M., Stigter, W., de Visser, D.C. & Janzing, H. (2008) Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilisation. Cochrane Database of Systematic Reviews 2008, 4, CD doi: / CD pub2.
Ettema, H.B., Kollen, B.J., Verheyen, P.M. & Buller, H.R. (2008) Prevention of venous thromboembolism in patients with immobilisation of the lower extremities: a meta-analysis of randomised controlled trials. Journal of Thrombosis and Haemostasis, 6, 1093–1098.
Nice clinical guideline 92 – Venous thromboembolism: reducing the risk
Outpatient Venous Thromboembolism Prophylaxis in Lower Limb Injuries:
A Retrospective Audit
Boddice T, Menakaya C, Shah M A, Malhotra R, Ingoe H,Muthukumar N, Mohsen A
Department of Trauma and Orthopaedics, Hull and East Yorkshire NHS Trust , Anlaby Road , Hull, HU3 2JZ
Introduction
The British Trauma Society recommends venous thromboprophylaxis (VTE) prophylaxis in trauma patients with restricted mobility. In Hull and East Yorkshire NHS trust following the death of a young patient from a pulmonary embolus resulting from ankle immobilisation after an injury as well as several episodes of venous thromboembolism - outpatient thromboprophylaxis was commenced in patients who required lower limb immobilisation. This study aimed to evaluate the efficacy of outpatient VTE prophylaxis using either dalteparin or dabigatran in patient’s with immobilised lower limb injuries following an injury.
Methods
At HEY in 2010/2011 financial year there was 12,700 new patients seen in the trauma clinic. Patients were given a choice, based on informed consent, between subcutaneous injections or oral (off-license) VTE prophylaxis (dalteparin or dabigatran respectively). Clinical data was extracted retrospectively from prospective databases (VTE database and electronic patient records).
Results
In a seven months period (May – November) there were 383 (5%) consecutive patients immobilised following lower limb injuries (LLI) of which the largest group was ankle injuries (138 fractures and 46 soft tissue injuries). 15 patients declined treatment and one was on Warfarin. The mean duration of immobilisation for dalteparin and dabigatran groups was and days respectively. While the mean duration for VTE prophylaxis was and days for dalteparin and dabigatran respectively. This is less than the mean prescription dispensed given timing of clinics. Surprisingly, a significant proportion of patients preferred injections (128) to the off-licence oral drug (239) after informed consent was obtained.
No patient developed clinical symptoms of DVT to warrant investigating. In both groups, one patient developed pulmonary embolism (PE) and survived. In the dabigatran group one patient developed haemoptysis while in the dalteparin group one patient had a gastrointestinal bleeding.
Dabigatran
(n=239)
Dalteparin
(n=128)
Mean Age (years)
45.6
45.3
Mean duration of immobilisation (days)
38.74
39.63
Mean duration of Prophylaxis (days)
36.36
36.03
Lost to follow up (n)
0(0%)
3 (2.3%)
DVT/PE (n)
1 (0.4%)
1 (0.7%)
Bleeding event
1 (0.4%)
Non-Union, Delayed union or failure of conservative management
6 (2.6%)
9 (6.6%)
Other complication
3 (1.3%)
0 (0%)
Conclusions
Although there was one failure of prophylaxis and two prophylaxis related complications, VTE prophylaxis still lead to a significant VTE reduction (0% clinical DVT and 0.5% PE rates) when compared to none prophylaxis rates.
References:
Ettema, H.B., Kollen, B.J., Verheyen, P.M. & Buller, H.R. (2008) Prevention of venous thromboembolism in patients with immobilisation of the lower extremities: a meta-analysis of randomised controlled trials. Journal of Thrombosis and Haemostasis, 6, 1093–1098.
Testroote, M., Stigter, W., de Visser, D.C. & Janzing, H. (2008) Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilisation. Cochrane Database of Systematic Reviews 2008
Nice clinical guideline 92 – Venous thromboembolism: reducing the risk