High level of venous thromboembolism in critically ill trauma patients despite early and well-driven thromboprophylaxis protocol.

BACKGROUND: Venous thromboembolism (VTE) is one of the most common preventable causes of in-hospital death in trauma patients surviving their injuries. We assessed the prevalence, incidence and risk factors for deep venous thrombosis (DVT) and pulmonary embolism (PE) in critically ill trauma patients, in the setting of a mature and early mechanical and pharmacological thromboprophylaxis protocol. METHODS: This was a prospective observational study on a cohort of patients from a surgical intensive care unit of a university level 1 trauma centre. We enrolled consecutive primary trauma patients expected to be in intensive care for ≥48 h. Thromboprophylaxis was protocol driven. DVT screening was performed by duplex ultrasound of upper and lower extremities within the first 48 h, between 5 and 7 days and then weekly until discharge. We recorded VTE risk factors at baseline and on each examination day. Independent risk factors were analysed using a multivariate logistic regression. RESULTS: In 153 patients with a mean Injury Severity Score of 23 ± 12, the prevalence of VTE was 30.7%, 95 CI [23.7-38.8] (29.4% DVT and 4.6% PE). The incidence was 18%, 95 CI [14-24] patients-week. The median time of apparition of DVT was 6 days [1; 4]. The global protocol compliance was 77.8% with a median time of introduction of the pharmacological prophylaxis of 1 day [1; 2]. We identified four independent risk factors for VTE: central venous catheter (OR 4.39, 95 CI [1.1-29]), medullar injury (OR 5.59, 95 CI [1.7-12.9]), initial systolic arterial pressure <80 mmHg (OR 3.64, 95 CI [1.3-10.8]), and pelvic fracture (OR 3.04, 95 CI [1.2-7.9]). CONCLUSION: Despite a rigorous, protocol-driven thromboprophylaxis, critically ill trauma patients showed a high incidence of VTE. Further research is needed to tailor pharmacological prophylaxis and balance the risks and benefits.

Significance of acute multiple infarcts in multiple cerebral circulations on initial diffusion weighted imaging in stroke patients.

OBJECTIVES: We attempted to assess the frequency, clinical and neuroradiological features of concomitant Acute Multiple Infarcts in Multiple Cerebral Circulations (AMIMCC) and to classify their causes. SUBJECTS AND METHODS: Consecutive patients treated for MR DWI-confirmed infarcts were included in this cohort. We retrospectively analyzed all patients with AMIMCC of our prospective database, studying clinical and radiological features. Causes of stroke were classified using TOAST and ASCO system (atherosclerosis, small vessel disease, cardiac source, other causes). RESULTS: Eighty AMIMCC were identified out of 824 consecutive patients with MR DWI-confirmed infarcts (9.7%). Compared with single infarct patients, AMIMCC patients presented similar age and risk factors. Only 24 AMIMCC patients (30%) presented symptoms suggesting multiple lesions before MRI. Cardiac origin existed in 39 of 80 patients (49%) including atrial fibrillation in 25 patients. Other sources of AMIMCC were hematologic diseases or coagulopathies such as intravascular coagulation in relation with cancer (n = 6; 7,5%) and vasculitis or systemic disorders (n = 5;6,5%). AMIMCC also appeared to originate from unilateral carotid diseases or intracranial stenosis, mostly atheromatous, in association with anatomic variations(n = 9;11%). In 21 patients, no cause was identified despite extensive investigations (26%). According to TOAST classification, 62% had a definite source for infarcts, 67% according to ASCO grade 1 classification. MRI data did not permit to orientate etiological explorations according to DWI appearance, associated leucoaraiosis or previous infarcts on FLAIR or microbleeding on gradient-echo sequences. CONCLUSIONS: AMIMCC are not rare and mostly need MRI to be detected. Multiple and various etiologies are implicated, including cardioembolic diseases in half of them, but also hematologic disorders and angeitis.