Saudi Critical Care Society clinical practice guidelines on the prevention of venous thromboembolism in adults with trauma: reviewed for evidence-based integrity and endorsed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

Amer, Marwa; Alshahrani, Mohammed S.; Arabi, Yaseen M.; Al-jedai, Ahmed; Alshaqaq, Hassan M.; Al-Sharydah, Abdulaziz; Al-Suwaidan, Faisal A.; Aljehani, Hosam; Nouh, Thamer; Mashbari, Hassan; Tarazan, Nehal; Alqahtani, Saad; Tashkandi, Wail; Maghrabi, Khalid; Albugami, Muneerah; Hashim, Samaher; Alsubaie, Norah M.; Alsenani, Mohammad; Algethamy, Haifa; Alshammari, Thamir M.; Alaklabi, Ali; Ismail, Nadia; Altawil, Esraa S.; Elhazmi, Alyaa; Nahhas, Ahmed; Aljuaid, Maha; Alsadoon, Naif; Binbraik, Yasser; Yuan, Yuhong; Alhazzani, Waleed

doi:10.1186/s13613-023-01135-8

Annals of Intensive Care

Table 1 Summary of recommendations

From: Saudi Critical Care Society clinical practice guidelines on the prevention of venous thromboembolism in adults with trauma: reviewed for evidence-based integrity and endorsed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

Recommendation	Strength and quality of evidence	Practical considerations	GRADE evidence profile and EtD framework
Timing of Pharmacologic VTE prophylaxis in non-operative blunt solid organ injuries
Recommendation 1: In adults with blunt solid organ injuries to liver, spleen, or kidney who are managed non-operatively and are at low risk of bleeding, we suggest starting pharmacologic VTE prophylaxis early (i.e., within 24–48 h) over delayed initiation of pharmacologic VTE prophylaxis (> 48 h)^a	Weak, very low	Clinicians should assess risk of bleeding. This recommendation is inapplicable to patients at high risk of major bleeding (e.g., high grade solid organ injuries and large hemoperitoneum) and those with hemodynamic instability	https://guidelines.gradepro.org/profile/FmzyU2rljqs
Timing of pharmacologic VTE prophylaxis in TBI
Recommendation 2: In adults with isolated blunt TBI with a low risk of bleeding progression who had stable repeated brain imaging showing no bleeding progression and stable neurologic examination, we suggest early pharmacologic VTE prophylaxis (within 24–72 h post-injury) over delayed pharmacologic VTE prophylaxis (> 72 h)^b	Weak, very low	This recommendation is inapplicable to patients with high risk of ICH spontaneous progression demonstrated at baseline or repeated brain imaging or patients with worsening of neurologic examination findings that necessitate upgrading care or emergent neurosurgical intervention	https://guidelines.gradepro.org/profile/aXj7XJvkfm8
Recommendation 3: In adults with isolated blunt TBI at a high risk of bleeding progression, we suggest starting early pharmacologic VTE prophylaxis 72 h post-injury with stable brain imaging that shows no bleeding progression and stable neurologic examination over delayed pharmacologic VTE prophylaxis (> 72 h). The decision is usually made in conjunction with multidisciplinary teams’ evaluation^b	Weak, very low	Early pharmacologic VTE prophylaxis should be held until follow-up brain imaging (e.g., brain CT) demonstrates no bleeding progression. If progression is demonstrated, mechanical VTE prophylaxis (if no contradictions) should be continued and prophylactic IVCF and/or US screening to be considered This recommendation is inapplicable for patients with known coagulopathy (INR > 1.5, a partial thromboplastin time > 40 s, a platelet counts of < 100 × 10⁹/l)	https://guidelines.gradepro.org/profile/7y-WPSqYQvw
Statement 4: There is insufficient evidence to issue a recommendation on the use of early pharmacologic VTE prophylaxis in adults with isolated blunt TBI requiring neurosurgical intervention (including craniectomy, craniotomy, EVD, or ICP monitoring)	No recommendation	We agree that best practice includes withholding early pharmacologic VTE prophylaxis until follow-up brain imaging (e.g., brain CT) demonstrates no bleeding progression. If progression is demonstrated, we agree that best practice includes continuation of mechanical VTE prophylaxis (if no contradictions) and prophylactic IVCF and/or US screening to be considered (Best Practice Statement) We agree that best practice includes evaluation of timely initiation of pharmacologic VTE prophylaxis by multidisciplinary teams (trauma, neuro/neurosurgical, critical care, and clinical pharmacist) (Best Practice Statement)	https://guidelines.gradepro.org/profile/v7SWl8qQGJs Additional file 2: Appendix 2, Table S6
Timing of pharmacologic VTE prophylaxis for spine trauma or fracture and/or SCI
Recommendation 5: In adults with isolated spine trauma or fracture and/or SCI who are at low risk of bleeding and are managed non-operatively, we suggest initiating pharmacologic VTE prophylaxis within 24–48 h post-injury over delayed pharmacologic VTE prophylaxis (> 48 h)^c	Weak, very low	The presence of neurological deficit and presence/or expansion of intraspinal hematoma or epidural hematoma demonstrated on radiologic spine images (CT and/or MRI) should prompt discussion among multidisciplinary teams prior to initiating pharmacologic VTE prophylaxis Mechanical VTE prophylaxis (if no contradictions) should be initiated for all SCI patients. If initiation of pharmacologic VTE prophylaxis is anticipated to be delayed or interrupted, US screening and/or prophylactic IVCF may be considered	https://guidelines.gradepro.org/profile/HaApoQ153kU
Recommendation 6: In adults with isolated spine trauma or fracture and/or SCI and managed operatively, we suggest initiating early pharmacologic VTE prophylaxis within 48 h post-spinal fixation over delayed pharmacologic VTE prophylaxis (> 48 h)	Weak, very low	The presence of neurological deficit and presence/or expansion of intraspinal hematoma or epidural hematoma demonstrated on radiologic spine images (CT and/or MRI) should prompt discussion among multidisciplinary teams prior to initiating pharmacologic VTE prophylaxis Mechanical VTE prophylaxis (if no contradictions) should be initiated for all SCI patients. If initiation of pharmacologic VTE prophylaxis is anticipated to be delayed or interrupted, US screening and/or prophylactic IVCF may be considered	https://guidelines.gradepro.org/profile/XexGjIWaWJU
Type of pharmacologic VTE prophylaxis
Recommendation 7: In adults with trauma who receive pharmacologic VTE prophylaxis, we suggest using LMWH (e.g., enoxaparin, dalteparin) over UFH	Weak, low	UFH is preferred in patients with end-stage renal disease and in those with low creatinine clearance (< 30 ml/min)	https://guidelines.gradepro.org/profile/xphSP0xqeg4
Dose of pharmacologic VTE prophylaxis
Recommendation 8: In adults with trauma and low risk of bleeding who are prescribed LMWH (enoxaparin) for VTE prophylaxis, we suggest using either intermediate–high dose LMWH or conventional dosing LMWH	Weak, very low	Most common regimen used was enoxaparin 40 mg subcutaneous every 12 h This recommendation is inapplicable to those at a high risk for bleeding (patients older than 65 year, < 50 kg, have low creatinine clearance, and TBI or SCI patients who are high risk for bleeding)	https://guidelines.gradepro.org/profile/BWf_VYx4hqc
Mechanical VTE prophylaxis
Recommendation 9: In adults with trauma who are not candidates for pharmacologic VTE prophylaxis, we recommend using mechanical VTE prophylaxis with IPC over no mechanical VTE prophylaxis when not contraindicated by lower extremity injury	Strong, very low		https://guidelines.gradepro.org/profile/8om8BWmPK-s
Recommendation 10: In adults with trauma taking pharmacologic VTE prophylaxis, we suggest either using adjunct mechanical VTE prophylaxis or pharmacologic VTE prophylaxis alone	Weak, very low		https://guidelines.gradepro.org/profile/ICFXyvu8Og=
Routine duplex US surveillance
Recommendation 11: In adults with trauma who are at an elevated risk of VTE and are not candidates for pharmacologic VTE prophylaxis, we suggest routine bilateral lower extremity US to screen for asymptomatic DVT over no routine screening^d	Weak, very low	This recommendation is inapplicable to trauma patients who are ambulating, those at low VTE risk, and patients with signs or symptoms of DVT in whom diagnostic imaging is indicated	https://guidelines.gradepro.org/profile/b1Vj16rY8u0
Prophylactic IVCFs
Recommendation 12: In adults with trauma who are not candidates for pharmacologic VTE prophylaxis, we suggest against the routine placement of prophylactic IVCFs	Weak, very low	Clinicians may consider using temporary retrievable IVCF in patients who are expected to be off pharmacologic VTE prophylaxis for > 7 days (e.g., severely injured patients with an ongoing bleeding risk)	https://guidelines.gradepro.org/profile/BHbLqHtu0Gc

EVD, external ventricular drain; DVT, deep vein thrombosis; ICH, intracranial hemorrhage; ICP, intracranial pressure; IPC, intermittent pneumatic compression; IVCF, inferior vena cava filters; LMWH, low molecular weight heparin; SCI, spinal cord injury; TBI, traumatic brain injury; UFH, unfractionated heparin; US, Ultrasonography; VTE, venous thromboembolism
^aLow risk of bleeding likely represent those with injury grade < 3 and hemodynamic stability ( please refer to Additional file 2: Appendix 2, Table S4 for more details)
^bLow and high risk for spontaneous bleeding progression in TBI is defined as per Parkland protocol
^cThere is no standardized definition of a low risk of bleeding in spine trauma or fracture and/or SCI. Some studies defined this category as the absence of the following: paraspinal or epidural hematoma on advanced images, ICH progression (in patients with concurrent TBI), unstable clinically significant extracranial bleeding, neurological deficit, and medical contraindication to pharmacologic VTE prophylaxis
^dThere was no consensus on what factors define a high-risk trauma patient. Greenfield risk assessment profile (RAP score) has been suggested to identify trauma patients at high risk for VTE

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