Ha, Victor V, MD

Sandhu, Rovinder S, MD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of SurgeryIndications for Warfarin in Trauma PatientsVictor V. Ha MDLehigh Valley Health Network, Victor_V.Ha@lvhn.orgRovinder S. Sandhu MDLehigh Valley Health Network, Rovinder_S.Sandhu@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/surgeryPart of the Other Medical Specialties Commons, and the Surgery CommonsThis Presentation is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works byan authorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtHa, V., & Sandhu, R. (2015, May 22). Indications for Warfarin in Trauma Patients. Presentation presented at: Schaeffer Research Day,Lehigh Valley Health Network, Allentown, PA.© 2014 Lehigh Valley Health Network Indications for Warfarin in Trauma Patients Victor Ha, MD  Hypothesis ▪ Patients admitted to the trauma service on warfarin anticoagulation have inappropriate indications for anticoagulation Background • Clinical practice guidelines for anticoagulation are outlined in Chest 2012 • Fall risk currently does not factor into guidelines for anticoagulation with warfarin • Prior studies have demonstrated inferior outcomes in trauma patients on anticoagulation  Methods • Retrospective chart review of all patients admitted to the trauma service on preexisting warfarin anticoagulation at a level 1 trauma center between January 1, 2012 and December 31, 2012 • Indications for anticoagulation determined, along with whether the indications meet published guidelines • Other data points collected included admitting international normalized ratio, mechanism, length of stay, injury severity score, and inpatient mortality  Results ▪ 2,744 admissions during the study period ▪ Study group consisted of 219 patients on warfarin anticoagulation ▪ Median age 77 years ▪ Most common traumatic mechanisms were mechanical fall (84%), MVC (10%)  Indications for Anticoagulation 66%24%6%4%Indications for anticoagulationafib 66%dvt/PE 24%mechanical heart valve6%other/undertermined 4%Thromboembolic Event Risk by CHADS2 Score ▪ 1 point each for CHF, hypertension, age greater than or equal to 75, diabetes mellitus ▪ 2 points for previous stroke/TIA ▪ Anticoagulation indicated for patients with Afib and CHADS2 Score 1 or higher, per Chest guidelines  CHADS2 Score Annual risk of event (%) 0 1.9 1 2.8 2 4.0 3 5.9 4 8.5 5 12.5 6 18.2 Recommendations for Anticoagulation for DVT ▪ For patients with a proximal DVT provoked by surgery or a non-surgical transient cause, anticoagulation should be continued for 3 months ▪ For patients with an unprovoked DVT, continue anticoagulation for 3 months, followed by evaluation of risk-benefit ratio of extended therapy Meeting Guidelines ▪ Guidelines for each indication were individually examined ▪ Indications clearly fell within the Chest 2012 guidelines in 84% and did not in 4% of patients; for the remaining 12% of patients the documentation was insufficient to clearly define whether guidelines were met ▪ Specifically for the population of patients with afib, 99% met guidelines  Admission INR ▪ 62% of patients within therapeutic INR range on admission ▪ 16% subtherapeutic ▪ 22% supratherapeutic  0102030405060700 2 4 6 8frequency INR on Presentation Frequency of Presenting INR Inpatient Mortality Rates Overall Group ▪ All trauma admissions in study period (2,744 patients) – 2.9% ▪ 1,056 patients over age 65 – 4.5% ▪ Study group of 219 patients on coumadin anticoagulation – 6.8%  Inpatient Mortality by admission INR • Subtherapeutic 4.4% • Therapeutic 7.8 % • Supratherapeutic 8.5%  Conclusion • Contrary to the study’s hypothesis, the majority of the study group fell within Chest guidelines for anticoagulation • Our data supports earlier studies suggesting inferior outcomes for patients on anticoagulation  Areas for Further Study ▪ Should fall risk factor into anticoagulation schema? ▪ How will the use of newer oral direct thrombin inhibitor agents affect outcomes in trauma? References • 1. CHEST 2012; 141(2)(Suppl):7S–47S  • 2. Impact of preinjury anticoagulation in patients with traumatic brain injury. South Med J. 2009 May;102(5):476-80.  • 3. Impact of age and anticoagulation: Need for neurosurgical intervention in trauma patients with mild traumatic brain injury. J Trauma Acute Care Surg. 2012 Jul;73(1):126-30 

Indications for Warfarin in Trauma Patients

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1700&context=surgery

Indications for Warfarin in Trauma Patients

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