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      Risk of venous thromboembolism during rehabilitation of patients with spinal cord injury

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          Abstract

          Background

          Patients with spinal cord injury (SCI) are at risk of thrombosis and bleeding. Data on the risks during rehabilitation are inconsistent, and thromboprophylactic strategies are heterogeneous. We aimed to evaluate the thrombotic risk and bleeding events of SCI patients during rehabilitation.

          Methods

          We retrospectively collected hospital record data of 263 consecutive SCI patients admitted at a rehabilitation clinic. 78 patients with acute venous thromboembolism (VTE) at the primary center, without acute trauma or lower extremity paresis, less than one month rehabilitation, or reasons for long-term therapeutic anticoagulation, were excluded. All patients received pharmacologic thromboprophylaxis throughout rehabilitation. Primary endpoint was objectively diagnosed VTE; secondary endpoint was bleeding.

          Results

          Of 185 patients, 162 (88%) were men; mean age was 47.8 years. 94 patients were tetraplegic, 91 paraplegic. During a mean (±SD) time of 5.1±2.1 months, VTE was diagnosed in 8 patients. After excluding five patients with VTE detected within 2 days after admission, the probability of developing VTE after 6 months of rehabilitation was 2% (95% CI 0–4.4%). Only high D-Dimer upon admission was associated with risk of VTE (adjusted HR 2.3, 95% CI 1.4–4.1). Of 24 bleedings, 14 (64%) occurred at the heparin injection site. Two patients had major bleeding and five had clinically relevant non major bleeding.

          Conclusion

          SCI patients are at risk of VTE and bleeding during rehabilitation. Strategies need to be developed to identify these patients in order to initiate adequate anticoagulation. Direct oral anticoagulants, which have a favourable risk-benefit profile and are convenient, should be explored.

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          Most cited references23

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          The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

          Rolf Rossaint, Bertil Bouillon, Vladimir Cerny … (2016)
          Background Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. Results The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. Conclusions A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1265-x) contains supplementary material, which is available to authorized users.
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            A prospective study of venous thromboembolism after major trauma.

            W H Geerts, K I Code, R Jay … (1994)
            Although deep-vein thrombosis and pulmonary embolism are considered common complications after major trauma, their frequency and the associated risk factors have not been carefully quantified. We performed serial impedance plethysmography and lower-extremity contrast venography to detect deep-vein thrombosis in a cohort of 716 patients admitted to a regional trauma unit. Prophylaxis against thromboembolism was not used. Deep-vein thrombosis in the lower extremities was found in 201 of the 349 patients (58 percent) with adequate venographic studies, and proximal-vein thrombosis was found in 63 (18 percent). Three patients died of massive pulmonary embolism before venography could be performed. Before venography, only three of the patients with deep-vein thrombosis had clinical features suggestive of the condition. Deep-vein thrombosis was found in 65 of the 129 patients with major injuries involving the face, chest, or abdomen (50 percent); in 49 of the 91 patients with major head injuries (53.8 percent); in 41 of the 66 with spinal injuries (62 percent); and in 126 of the 182 with lower-extremity orthopedic injuries (69 percent). Thrombi were detected in 61 of the 100 patients with pelvic fractures (61 percent), in 59 of the 74 with femoral fractures (80 percent), and in 66 of the 86 with tibial fractures (77 percent). A multivariate analysis identified five independent risk factors for deep-vein thrombosis: older age (odds ratio, 1.05 per year of age; 95 percent confidence interval, 1.03 to 1.06), blood transfusion (odds ratio, 1.74; 95 percent confidence interval, 1.03 to 2.93), surgery (odds ratio, 2.30; 95 percent confidence interval, 1.08 to 4.89), fracture of the femur or tibia (odds ratio, 4.82; 95 percent confidence interval, 2.79 to 8.33), and spinal cord injury (odds ratio, 8.59; 95 percent confidence interval, 2.92 to 25.28). Venous thromboembolism is a common complication in patients with major trauma, and effective, safe prophylactic regimens are needed.
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              Recent trends in mortality and causes of death among persons with spinal cord injury.

              Michael J. De Vivo, J. Stuart Krause, Daniel P Lammertse (1999)
              To identify and quantify trends in mortality and causes of death among persons with spinal cord injury. Cohort study. Model spinal cord injury care systems and Shriner's Hospitals spinal cord injury units throughout the United States. A total of 28,239 consecutive persons admitted to the model system or to a Shriner's Hospital within 1 year of injury. Length of survival and cause of death. Among persons who were admitted to the model system within 1 day of injury, the odds of dying during the first postinjury year were reduced by 67% for persons injured between 1993 and 1998 relative to persons injured between 1973 and 1977 after adjusting for trends in age, gender, race, neurologic level of injury, Frankel grade, ventilator status, etiology of injury, sponsor of care, and model system where treatment occurred. However, mortality rates after the first anniversary of injury, which had also been declining from 1973 to 1992, increased 33% for persons injured between 1993 and 1998 relative to persons injured between 1988 and 1992. Respiratory disease was the only cause of death after the first anniversary of injury for which the relative odds increased meaningfully during the latest time period (76% increase over 1988-1992 compared to all other causes). While great improvements in life expectancy have been achieved since the Model SCI Systems program began, current data support the need for renewed efforts to improve the prevention and treatment of the complications of spinal cord injury.
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                Author and article information

                Contributors
                Sabine Eichinger:
                ORCID: http://orcid.org/0000-0003-1135-4878
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Lisbeth Eischer: Role: ConceptualizationRole: Data curationRole: Project administrationRole: Writing – review & editing
                Hana Sinkovec: Role: Data curationRole: Formal analysisRole: MethodologyRole: SoftwareRole: Writing – review & editing
                Gabriela Wittgruber: Role: ConceptualizationRole: Data curationRole: Funding acquisitionRole: InvestigationRole: ResourcesRole: Writing – review & editing
                Ludwig Traby: Role: ConceptualizationRole: Data curationRole: Project administrationRole: Writing – review & editing
                Michael Kammer: Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Project administrationRole: SoftwareRole: ValidationRole: Writing – review & editing
                Paul A. Kyrle: Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Oskar Steinbrecher: Role: Data curationRole: InvestigationRole: Project administrationRole: VisualizationRole: Writing – review & editing
                Herbert Kaloud: Role: Data curationRole: InvestigationRole: ResourcesRole: Writing – review & editing
                Victoria Kyrle: Role: Data curationRole: Project administrationRole: VisualizationRole: Writing – review & editing
                Hartwig Moser: Role: Data curationRole: InvestigationRole: ResourcesRole: Writing – review & editing
                Renate Wildburger: Role: ConceptualizationRole: Data curationRole: Funding acquisitionRole: InvestigationRole: Writing – original draftRole: Writing – review & editing
                Rudolf Kirchmair: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 28 March 2018
                Publication date Collection: 2018
                Volume: 13
                Issue: 3
                Electronic Location Identifier: e0193735
                Affiliations
                [1 ] Dept. of Medicine I, Medical University of Vienna, Vienna, Austria
                [2 ] Karl Landsteiner Institute of Clinical Thrombosis Research, Vienna, Austria
                [3 ] Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
                [4 ] Allgemeine Unfallversicherungsanstalt Rehabilitation Clinic Tobelbad, Tobelbad, Austria
                Medical University Innsbruck, AUSTRIA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0003-1135-4878
                Article
                Publisher ID: PONE-D-17-40063
                DOI: 10.1371/journal.pone.0193735
                PMC ID: 5873993
                PubMed ID: 29590126
                SO-VID: 820cce44-63d3-4960-b070-c9cd7a46a596
                Copyright © © 2018 Eichinger et al
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 12 November 2017
                Date accepted : 18 February 2018
                Page count
                Figures: 0, Tables: 4, Pages: 10
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100007146, Allgemeine Unfallversicherungsanstalt;
                Award Recipient :
                Funded by Allgemeine Unfallversicherungsanstalt FK 16/14 (RW). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Subject: Research Article
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Thromboembolism
                Subject: Venous Thromboembolism
                Subject: Medicine and Health Sciences
                Subject: Diagnostic Medicine
                Subject: Signs and Symptoms
                Subject: Hemorrhage
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Signs and Symptoms
                Subject: Hemorrhage
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Hemorrhage
                Subject: Medicine and Health Sciences
                Subject: Critical Care and Emergency Medicine
                Subject: Trauma Medicine
                Subject: Traumatic Injury
                Subject: Neurotrauma
                Subject: Spinal Cord Injury
                Subject: Medicine and Health Sciences
                Subject: Neurology
                Subject: Spinal Cord Injury
                Subject: Medicine and Health Sciences
                Subject: Rehabilitation Medicine
                Subject: Medicine and Health Sciences
                Subject: Hematology
                Subject: Blood Coagulation
                Subject: Coagulation Disorders
                Subject: Thrombosis
                Subject: Medicine and Health Sciences
                Subject: Cardiovascular Medicine
                Subject: Cardiovascular Diseases
                Subject: Coagulation Disorders
                Subject: Thrombosis
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Thrombosis
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Thromboembolism
                Subject: Venous Thromboembolism
                Subject: Deep Vein Thrombosis
                Subject: Medicine and Health Sciences
                Subject: Pulmonology
                Subject: Pulmonary Embolism
                Subject: Medicine and Health Sciences
                Subject: Vascular Medicine
                Subject: Thromboembolism
                Subject: Venous Thromboembolism
                Subject: Pulmonary Embolism
                Subject: Medicine and Health Sciences
                Subject: Diagnostic Medicine
                Custom metadata
                Data Availability All relevant data are within the paper.

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