Venous thromboembolic disease

Studies of venous thromboembolism prevention in the trauma population are often not of sufficient quality to yield evidence-based recommendations. Given the difficulties involved in studying this group, hard evidence will likely continue to be scarce. Therefore, it is appropriate to extrapolate from what information is available in order to establish basic guidelines. It seems that LMWH should be used in all patients who have been determined by clinical risk factors to be at high risk for development of DVT/PE. Administration should start as soon as possible after surgery, in most patients this could be done safely by the first post-operative day. The optimal duration of therapy is unknown, but recent studies suggest that longer periods of prophylaxis may be warranted. In those patients who are considered high risk but who have a contraindication to anti-coagulation, mechanical prophylaxis should be used. Mechanical devices are not sufficient to prevent clotting in those who are high risk. The addition of routine screening should thus be considered in this situation. There is currently insufficient evidence to recommend routine use of IVC filters. As we gain more experience with temporary devices these recommendations may change. The optimal method of prophylaxis in patients who are low risk by clinical risk factors is even less clear. LMWH seems to be a reasonable option in these patients, given its efficacy and relatively benign safety profile. However, cost is always a consideration, and some of the available evidence would say that such a practice is not cost effective. We still have much to learn when is comes to deciding how to prevent venous thromboembolism in the trauma patient. Although LMWH seems to be effective, PE/DVT rates remain unacceptably high with its use. Future studies should concentrate on the mechanisms of failure and the potential use of other classes of anticoagulants. Appropriate duration of therapy has not been determined, and it is unclear whether patients at low risk should be treated with chemical prophylaxis, mechanical prophylaxis, or simply undergo routine screening. There is clearly a need for large, multicenter, prospective trials to establish evidence-based guidelines in the trauma population.