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

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Spinal cord injury (SCI) undergoing rehabilitation (n=185). Intervention: High D-Dimer upon admission (per doubling) in patients receiving low molecular weight heparin (4000-7500 IE once daily) and compression stockings. Primary outcome: Objectively verified deep vein thrombosis and/or pulmonary embolism between admission to and discharge from the rehabilitation clinic (HR 2.33, 95% CI 1.36-4.07, p=0.003).

Q: What does this research mean for the field?

In spinal cord injury patients undergoing rehabilitation, the 6-month cumulative probability of venous thromboembolism is 4.7%, with high admission D-dimer levels significantly predicting increased risk. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Sabine Eichinger; Lisbeth Eischer; Hana Šinkovec; Gabriela Wittgruber; Ludwig Traby; Michael Kammer; Paul Alexander Kyrle; Oskar Steinbrecher; Herbert Kaloud; Victoria Kyrle; Hartwig Moser; Renate Wildburger

doi:10.1371/journal.pone.0193735

March 28, 2018PLoS ONEOpen Access

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

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Key result

Higher admission D-dimer is linked to ~2.3-fold higher VTE risk per doubling after spinal cord injury.

HR 2.33
95% CI 1.36-4.07
P=0.003
n=185

Why the study?

Patients with spinal cord injury face risks of thrombosis and bleeding, yet data on these risks during rehabilitation are inconsistent and thromboprophylactic strategies remain heterogeneous.

What is the risk of venous thromboembolism and bleeding, and what risk factors predict VTE, in patients with spinal cord injury receiving low molecular weight heparin prophylaxis during rehabilitation?

Key Points

To evaluate the risk of venous thromboembolism and bleeding events in patients with spinal cord injury during rehabilitation.
Retrospective cohort analysis of hospital records from 263 consecutive patients with spinal cord injury admitted to a rehabilitation clinic, analyzing 185 eligible patients after exclusions.
All patients received pharmacologic thromboprophylaxis throughout a mean follow-up of 5.1±2.1 months.
Primary endpoint was objectively diagnosed venous thromboembolism, and the secondary endpoint was bleeding complications.
Venous thromboembolism was diagnosed in 8 patients; excluding five cases diagnosed within two days of admission, the cumulative probability of developing venous thromboembolism after 6 months of rehabilitation was 2% (95% CI 0-4.4%).
Only high D-Dimer upon admission was significantly associated with venous thromboembolism risk (adjusted HR per doubling 2.33, 95% CI 1.36-4.07, p=0.003).
A total of 24 bleedings occurred, with 14 (64%) presenting as hematomas at the injection site, alongside two major bleeding events and five clinically relevant non-major bleeds.

Study Design

Type

Cohort (n=185)

Multicenter

No

Structured PICO

What is the risk of venous thromboembolism and bleeding, and what risk factors predict VTE, in patients with spinal cord injury receiving low molecular weight heparin prophylaxis during rehabilitation?

P

Population

185 patients (mean age 47.8 years, 88% men) with acute traumatic spinal cord injury and lower extremity paresis admitted to an Austrian rehabilitation clinic, followed for a mean of 5.1 months.

E

Exposure

Pharmacologic thromboprophylaxis with low molecular weight heparin (LMWH, 4000–7500 IE once daily) and compression stockings throughout the rehabilitation stay (mean 5.1 ± 2.1 months), with evaluation of clinical risk factors including admission D-Dimer levels.

O

Outcome

Deep vein thrombosis and/or pulmonary embolism objectively verified by ultrasound, venography, computed tomography, or ventilation/perfusion lung scanning between admission to and discharge from the rehabilitation clinic (mean stay 5.1 ± 2.1 months).composite

Main Result

Hazard Ratio: 2.33 (95% CI 1.36–4.07)

p-value: p=0.003

Limitations

Retrospective, single-center study design
Low event rate (8 VTEs) resulting in limited statistical power to detect significant effects of risk factors
Exclusion of patients with VTE or major bleeding at the primary care center may have influenced event rates
No information on thrombotic risk in the absence of pharmacologic thromboprophylaxis as all patients received LMWH
Lack of information on thromboprophylactic regimens before admission to the rehabilitation clinic
Single-center retrospective cohort design
Low VTE event rate (8 events) limiting statistical power to detect significant effects
Exclusion of patients with VTE or major bleeding at the primary care center may have influenced event rates and limits comparability
All patients received LMWH thromboprophylaxis, providing no data on thrombotic risk without pharmacologic prophylaxis
No information available on thromboprophylactic regimens used at outside primary care centers prior to rehabilitation admission

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Implication

In patients with spinal cord injury receiving LMWH prophylaxis during rehabilitation, the 6-month probability of developing new VTE is low (2% after excluding events present on admission), though elevated admission D-Dimer identifies those at higher risk and injection-site bleeding is common.

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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Cite This Study

Eichinger et al. (2018) conducted a cohort in Spinal cord injury (SCI) undergoing rehabilitation (n=185). High D-Dimer upon admission (per doubling) in patients receiving low molecular weight heparin (4000-7500 IE once daily) and compression stockings was evaluated on Objectively verified deep vein thrombosis and/or pulmonary embolism between admission to and discharge from the rehabilitation clinic (HR 2.33, 95% CI 1.36-4.07, p=0.003). High admission D-Dimer was associated with increased VTE risk (adjusted HR 2.33 per doubling, p=0.003) among spinal cord injury patients with a 4.7% 6-month cumulative VTE probability.

synapsesocial.com/papers/6ad8a50dd34e87e823a30083 https://doi.org/10.1371/journal.pone.0193735

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

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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