Timing of Chemoprophylaxis Initiation in Trauma Patients Undergoing Spinal Fixation
Stacy B. Sanders, M.D., M.S., M.H.A, Heena P. Santry, M.D., M.S.
University of Massachusetts, Worcester, MA, USA
Background: Trauma patients with spinal injuries are at increased risk for venous thromboembolism (VTE), typically due to limited mobility. Although use of mechanical prophylaxis is widely accepted, use of chemoprophylaxis in the subset of these patients requiring surgery is controversial. The existing literature does not currently support an ideal time to begin chemoprophylaxis and many remain reluctant to do so given fear of epidural hematoma or other serious bleeding complications.
Methods: Charts of trauma patients undergoing spinal fixation at our institution between 2007-2015 were retrospectively reviewed. Patients were divided into those started on early (≤48 hours after admission) and late (>48 hours) chemoprophylaxis. The cohorts were then compared with respect to rate of VTE, post-operative bleeding complications, and mortality.
Results: 275 patients underwent spinal fixation for traumatic spine injuries. Chemoprophylaxis was prescribed early for 55(20%) and late for 136 (53%). Rate of VTE was higher in the late prophylaxis group (8% vs. 1.8%, p<0.03). No patients sustained an epidural hematoma. Other bleeding complications were more frequent in those started on late prophylaxis. Of those who had bleeding complications, there was no difference in those placed on unfractionated vs. low-molecular-weight heparin (6 vs. 5, p=0.47).
Conclusion: Trauma patients undergoing spinal fixation started on chemoprophylaxis ≤48 hours after admission are at lower risk for sustaining a VTE and no increased risk for sustaining an epidural hematoma. Paradoxically, rates of other bleeding complications may be higher when chemoprophylaxis is started late (>48 hours). Bleeding complications are not more frequently associated with use of unfractionated vs. low-molecular-weight heparin.
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