Timing is Everything

Objective: To examine the efficacy and safety of initiation of pharmacologic VTE prophylaxis within 24 hours of admission for major trauma patients at risk for VTE. Summary Background Data: Pharmacologic VTE prophylaxis following major trauma is essential, but there is a fear of bleeding complications. The safety of initiating treatment within 24 hours of admission has not been established. Methods: We examined the efficacy and safety of early initiation of pharmacologic VTE prophylaxis. Patients were stratified by time to initiation [≤24 h (EARLY) or >24 h (LATE)] and compared. VTE, VTE prophylaxis agents, and bleeding complications secondary to VTE prophylaxis were analyzed. A generalized linear mixed model (GLMM) was performed to identify predictors of VTE. Results: There were 3,369 EARLY group patients and 3,200 LATE group patients. More patients in the LATE group developed VTE (7.8% vs. 2.8%; P <0.001). Among 345 patients with VTE, deep venous thrombosis (DVT) alone [181 (72%) vs. 61 (65%)], pulmonary embolism (PE) alone [46 (18%) vs. 22 (23%)] and both DVT and PE [24 (10%) vs. 11 (12%)] were present in the LATE compared to the EARLY group. The LATE group had a higher incidence of increased or new intracranial hemorrhage following prophylaxis initiation (0.5% vs. 0.2%; P =0.009) and higher mortality (1.8% vs. 0.6%; P <0.001). GLMM demonstrated EARLY VTE prophylaxis was associated with a lower risk of VTE (OR 0.58;95%CI 0.44–0.78; P <0.001), after controlling for covariates. Conclusions: Initiating VTE prophylaxis within the first 24 hours after admission resulted in a 42% reduction of the risk of VTE without increased risk of bleeding and should be regarded as the standard of care, even in TBI patients.