A 39-year-old female has just been admitted to your unit with severe multiple injuries following a motor vehicle accident. Her injuries are right sided frontal intra-cerebral haemorrhage (ICH), multiple rib fractures with bilateral flail segments and lung contusions, grade III liver laceration, bilateral pubic rami and sacral fractures. She has a BMI of 39.
a) Outline the advantages and disadvantages of methods available to reduce the risks of pulmonary embolism (PE) in this patient. (40% marks)
On day 4 of the patient’s ICU admission, they develop multiple pulmonary emboli.
b) Outline the rationale of inserting an IVC filter in this patient. (30% marks)
c) List the advantages and disadvantages of using an IVC filter in this patient. (30% marks)
VTE prophylaxis in the bleeding-prone trauma patient is always challenging, especially in this situation where the head is involved (thus raising the stakes), further surgery may be required (eg. rib fixation), and the liver is involved (thus lowering the clotting factor levels).
The methods-advantages-disadvantages answer would probably work better as a table:
|Low molecular weight
b) Rationale for IVC filter insertion:
Advantages of the IVC filter
Disadvantages of the IVC filter
Jacobs, Benjamin N., et al. "Unfractionated heparin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in trauma." The journal of trauma and acute care surgery 83.1 (2017): 151.
PulmCCM: April 12, 2013. "Inferior vena cava filters: debatable benefit; rarely removed"
ACCP: Radiologic management of IVC filters, 2012
Prasad, Vinay, Jason Rho, and Adam Cifu. "The inferior vena cava filter: how could a medical device be so well accepted without any evidence of efficacy?." JAMA internal medicine 173.7 (2013): 493-495.
You, John J., et al. "Antithrombotic therapy for atrial fibrillation: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines." CHEST Journal 141.2_suppl (2012): e531S-e575S.
Sarosiek, Shayna, Mark Crowther, and J. Mark Sloan. "Indications, complications, and management of inferior vena cava filters: the experience in 952 patients at an academic hospital with a level I trauma center." JAMA internal medicine 173.7 (2013): 513-517.
Linsenmaier, Ulrich, et al. "Indications, management, and complications of temporary inferior vena cava filters." Cardiovascular and interventional radiology21.6 (1998): 464-469.
Baglin, T. P., J. Brush, and M. Streiff. "Guidelines on use of vena cava filters."British journal of haematology 134.6 (2006): 590-595.
Young, Tim, Hangwi Tang, and Rodney Hughes. "Vena caval filters for the prevention of pulmonary embolism." Cochrane Database Syst Rev 2.2 (2010).
Tola, Juan C., Robert Holtzman, and Lawrence Lottenberg. "Bedside placement of inferior vena cava filters in the intensive care unit." The American Surgeon65.9 (1999): 833-7.
Rohrer, Michael J., et al. "Extended indications for placement of an inferior vena cava filter." Journal of vascular surgery 10.1 (1989): 44-50.
These are the papers quoted at the end of the college answer:
Arcasoy, Selim M., and John W. Kreit. "Thrombolytic therapy of pulmonary embolism: a comprehensive review of current evidence." CHEST Journal 115.6 (1999): 1695-1707.
Goldhaber, Samuel Z. "Pulmonary Embolism" NEJM 339(2); 1998 p93·104
Greenfield, Lazar J., and Robert B. Rutherford. "Recommended reporting standards for vena caval filter placement and patient follow-up." Journal of vascular and interventional radiology 10.8 (1999): 1013-1019.
PREPIC Study Group. "Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism the PREPIC (prévention du risque d’embolie pulmonaire par interruption cave) randomized study." Circulation 112.3 (2005): 416-422.
White, Richard H., et al. "A population-based study of the effectiveness of inferior vena cava filter use among patients with venous thromboembolism." Archives of Internal Medicine 160.13 (2000): 2033-2041.
Hemmila, Mark R., et al. "Prophylactic Inferior Vena Cava Filter Placement Does Not Result in a Survival Benefit for Trauma Patients." Annals of surgery 262.4 (2015): 577-585.
Sharifi, Mohsen, et al. "Role of IVC filters in endovenous therapy for deep venous thrombosis: the FILTER-PEVI (filter implantation to lower thromboembolic risk in percutaneous endovenous intervention) trial." Cardiovascular and interventional radiology 35.6 (2012): 1408-1413.
Ho, Kwok M., et al. "A multicenter trial of vena cava filters in severely injured patients." New England Journal of Medicine 381.4 (2019): 328-337.
Young, Tim, and Krishna Bajee Sriram. "Vena caval filters for the prevention of pulmonary embolism." Cochrane Database of Systematic Reviews 10 (2020).