Venous thromboembolism risk after spinal cord injury: A secondary analysis of the CLOTT study

Laura N Godat; Elliott R Haut; Ernest E Moore; M Margaret Knudson; Todd W Costantini

doi:10.1097/TA.0000000000003807

Venous thromboembolism risk after spinal cord injury: A secondary analysis of the CLOTT study

J Trauma Acute Care Surg. 2023 Jan 1;94(1):23-29. doi: 10.1097/TA.0000000000003807. Epub 2022 Oct 7.

Authors

Laura N Godat¹, Elliott R Haut, Ernest E Moore, M Margaret Knudson, Todd W Costantini

Affiliation

¹ From the Department of Surgery (L.N.G., T.W.C.), Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego School of Medicine, San Diego, California; Division of Acute Care Surgery, Department of Surgery (E.R.H.), The Johns Hopkins University School of Medicine, Baltimore, Maryland; Denver Health Medical Center, Ernest E Moore Shock Trauma Center (E.E.M.), Denver, Colorado; and University of California San Francisco (M.M.K.), San Francisco, California.

PMID: 36203245
DOI: 10.1097/TA.0000000000003807

Abstract

Introduction: Patients with spinal cord injury (SCI) are at high risk of venous thromboembolism (VTE). Pharmacologic VTE prophylaxis (VTEppx) is frequently delayed in patients with SCI because of concerns for bleeding risk. Here, we hypothesized that delaying VTEppx until >48 hours would be associated with increased risk of thrombotic events.

Methods: This is a secondary analysis of the 2018 to 2020 prospective, observational, cohort Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study of patients aged 18 to 40 years, at 17 US level 1 trauma centers. Patients admitted for >48 hours with documented SCI were evaluated. Timing of initiation of VTEppx, rates of thrombotic events (deep vein thrombosis [DVT] and pulmonary embolism [PE]), and missed VTEppx doses were analyzed. The primary outcome was VTE (DVT + PE).

Results: There were 343 patients with SCI. The mean ± SD age was 29.0 ± 6.6 years, 77.3% were male, and 78.7% sustained blunt mechanism. Thrombotic events occurred in 33 patients (9.6%): 30 DVTs (8.7%) and 3 PEs (0.9%). Venous thromboembolism prophylaxis started at ≤24 hours in 21.3% of patients and 49.3% at ≤48 hours. The rate of VTE for patients started on VTEppx ≤48 hours was 7.1% versus 12.1% if started after 48 hours ( p = 0.119). After adjusting for differences in risk factors between cohorts, starting ≤48 hours was independently associated with fewer VTEs (odds ratio, 0.45; 95% confidence interval, 0.101-0.978; p = 0.044). Unfractionated heparin was associated with a VTE rate of 21.0% versus 7.5% in those receiving enoxaparin as prophylaxis ( p = 0.003). Missed doses of VTEppx were common (29.7%) and associated with increased thrombotic events, although this was not significant on multivariate analysis.

Conclusion: Rates of thrombotic events in patients with SCI are high. Prompt initiation of VTEppx with enoxaparin and efforts aimed at avoiding missed doses are critical to limit thrombotic events in these high-risk patients.

Level of evidence: Prognostic and Epidemiological; Level IV.

Publication types

Observational Study
Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

Anticoagulants / therapeutic use
Enoxaparin / therapeutic use
Female
Heparin / therapeutic use
Humans
Male
Prospective Studies
Pulmonary Embolism* / epidemiology
Pulmonary Embolism* / etiology
Pulmonary Embolism* / prevention & control
Risk Factors
Spinal Cord Injuries* / complications
Venous Thromboembolism* / epidemiology
Venous Thromboembolism* / etiology
Venous Thromboembolism* / prevention & control

Substances

Heparin
Enoxaparin
Anticoagulants