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Open Access

Does diabetes type increase the odds of venous thromboembolism following traumatic injury?

Jan Leonard, Lisa M Caputo, Matthew M Carrick, Denetta S Slone, Charles W Mains, David Bar-Or
DOI: 10.1136/tsaco-2016-000003 Published 31 August 2016
Jan Leonard
1Department of Trauma Research, Medical Center of Plano, Plano, Texas, USA
2Department of Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
3Department of Trauma Research, St. Anthony Hospital, Lakewood, Colorado, USA
4Department of Trauma Research, Penrose Hospital, Colorado Springs, Colorado, USA
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Lisa M Caputo
1Department of Trauma Research, Medical Center of Plano, Plano, Texas, USA
2Department of Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
3Department of Trauma Research, St. Anthony Hospital, Lakewood, Colorado, USA
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Matthew M Carrick
5Trauma Services Department, Medical Center of Plano, Plano, Texas, USA
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Denetta S Slone
6Trauma Services Department, Swedish Medical Center, Englewood, Colorado, USA
7Rocky Vista University, Parker, Colorado, USA
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Charles W Mains
4Department of Trauma Research, Penrose Hospital, Colorado Springs, Colorado, USA
7Rocky Vista University, Parker, Colorado, USA
8Trauma Services Department, St. Anthony Hospital, Lakewood, Colorado, USA
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David Bar-Or
1Department of Trauma Research, Medical Center of Plano, Plano, Texas, USA
2Department of Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
3Department of Trauma Research, St. Anthony Hospital, Lakewood, Colorado, USA
4Department of Trauma Research, Penrose Hospital, Colorado Springs, Colorado, USA
7Rocky Vista University, Parker, Colorado, USA
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Article Figures & Data

Tables

  • Table 1

    Hospitals’ guidelines for DVT prophylaxis within trauma patients

    Hospital 1Mechanical compression devices and TEDS applied, unless patient suffered leg fracture or has poor arterial perfusion of legs
    Trauma patients with multiple DVT risk factors, especially prior DVT, should receive subcutaneous heparin 5000 units every 12 hours.* Spinal cord injury patients should receive subcutaneous heparin, adjusted to maintain a PTT=35–40. Treatment may be discontinued when spasticity develops. Risk factors for DVT include:
    • ▸ Age >40+bed rest >3 days

    • ▸ Prior DVT

    • ▸ Coma (GCS<7)

    • ▸ Spine fracture

    • ▸ Quadriplegia/paraplegia

    • ▸ Pelvic fracture

    • ▸ Leg/hip fracture

    • ▸ Cancer

    • ▸ CHF

    • ▸ General surgery+bed rest

    • ▸ Lupus anticoagulant

    • ▸ Hereditable coagulation deficiencies

    • ▸ Nephrotic syndrome

    • ▸ Stroke

    • ▸ Urological surgery

    • ▸ Myocardial infarction

    • ▸ Older age

    • ▸ Obesity

    • ▸ Oral contraception

    • ▸ Pregnancy/postpartum

    • ▸ Ulcerative colitis/inflammatory bowel disease

    • ▸ Sepsis

    • ▸ Myeloproliferative disease

    • ▸ Varicose veins

    • ▸ Smoking

    Hospital 2Patients >16 years—mechanical compression devices and TEDS applied to uninjured leg or both legs if possible
    All patients not at risk for bleeding with anticipated stay >48 hours and non-ambulatory should receive chemical prophylaxis. Patients initially at risk for further bleeding can have chemical prophylaxis started within 72 hours of injury.
    Trauma patients without contraindications should receive enoxaparin (30 mg, subcutaneous, twice per day) unless a dose adjustment is needed due to geriatric age, weight, or renal failure. Patients with epidural catheters and ICP monitors will receive 40 mg of subcutaneous enoxaparin once a day. Enoxaparin is held 24 hours prior to placement of epidural or ICP.
    Preoperative chemical prophylaxis will not be held for surgical procedures unless requested by surgeon.
    Hospital 3No formal prophylaxis protocol. Treated per physician opinion
    • *Per communication with the trauma services department, the current practice has changed without an update to the protocol; it is standard procedure to use enoxaparin for chemical prophylaxis.

    • CHF, congestive heart failure; GCS, Glasgow Coma Scale; ICP, intracranial pressure; PTT, partial thromboplastin time; TEDS, thromboembolism deterrent stockings.

  • Table 2

    Risk factors and outcomes by diabetes type

    Clinical characteristics, n (%)No diabetes (n=24 103)IDDM (n=779)NIDDM (n=2052)p*
    Hospital†<0.001
     111 909 (90.9%)426 (3.3%)771 (5.9%)
     28034 (87.8%)334 (3.7%)781 (8.5%)
     34160 (88.9%)19 (0.4%)500 (10.7%)
    Elderly, ≥65 years8322 (34.5%)439 (56.4%)1296 (63.2%)<0.001
    Male14 092 (58.5%)430 (55.2%)1081 (52.7%)<0.001
    Smoker4088 (17.0%)87 (11.2%)193 (9.4%)<0.001
    Alcohol abuse2925 (12.1%)51 (6.6%)115 (5.6%)<0.001
    Pre-existing comorbidities‡15 558 (64.6%)690 (88.6%)1869 (91.1%)<0.001
     Coagulopathy1747 (7.3%)115 (14.8%)310 (15.1%)<0.001
     Obesity1147 (4.8%)111 (14.3%)285 (13.9%)<0.001
     Cancer80 (0.3%)3 (0.4%)9 (0.4%)0.71
     Cardiac disease2347 (9.7%)162 (20.8%)526 (25.6%)<0.001
     Cerebrovascular accident536 (2.2%)50 (6.4%)114 (5.6%)<0.001
     Pregnancy143 (0.6%)0 (0%)1 (0.1%)0.001
    ISS≥16§4912 (20.4%)112 (14.4%)428 (20.9%)<0.001
    Hip fracture2722 (11.3%)127 (16.3%)319 (15.6%)<0.001
    Region of injury
     Neck/spine¶4105 (17.0%)117 (15.0%)278 (13.6%)<0.001
     Abdominal/pelvic¶1808 (7.5%)23 (3.0%)87 (4.2%)<0.001
     Chest¶4741 (19.7%)135 (17.3%)360 (17.5%)0.02
     External¶415 (1.7%)8 (1.0%)19 (0.9%)0.01
     Limb¶11 453 (47.5%)414 (53.2%)970 (47.3%)0.01
     Face¶1774 (7.4%)28 (3.6%)90 (4.4%)<0.001
     Head¶6888 (28.6%)170 (21.8%)578 (28.2%)<0.001
    Multiple injuries6278 (26.1%)134 (17.2%)384 (18.7%)<0.001
    Surgical procedure10 638 (44.1%)360 (46.2%)810 (39.5%)<0.001
    Placement of a central line1773 (7.4%)65 (8.3%)173 (8.4%)0.13
    Mechanical ventilation2597 (10.8%)77 (9.9%)184 (9.0%)0.03
    Hospital LOS, median (IQR)3 (2–6)4 (3–7)4 (2–6)<0.001
    Admitted to ICU7854 (32.6%)252 (32.4%)683 (33.3%)0.80
    Infection450 (1.9%)18 (2.3%)53 (2.6%)0.06
    No complications21 496 (89.2%)667 (85.6%)1788 (87.1%)<0.001
    VTE523 (2.2%)28 (3.6%)50 (2.4%)0.02
     DVT422 (1.8%)24 (3.1%)41 (2.0%)0.02
     PE135 (0.6%)5 (0.6%)12 (0.6%)0.95
    In-hospital death§791 (3.3%)26 (3.3%)86 (4.2%)0.09
    • *Significant p values (p<0.05) are displayed in bold.

    • †Row percent presented for hospital.

    • ‡Pre-existing comorbidities does not include diabetes.

    • §Missing ISS on 77 patients and death outcome on 1 patient.

    • ¶AIS≥2.

    • AIS, Abbreviated Injury Score; DVT, deep vein thrombosis; ICU, intensive care unit; IDDM, insulin-dependent diabetes mellitus; ISS, Injury Severity Score; LOS, length of stay; NIDDM, non-insulin-dependent diabetes mellitus; PE, pulmonary embolism; VTE, venous thromboembolism.

  • Table 3

    Multivariate predictors of a venous thromboembolism, all ages

    AOR95% CIp*
    Model 1: any diabetes and adjustment for covariates
    Any diabetes1.150.89 to 1.490.29
    Age≥651.671.37 to 2.02<0.001
    Male1.391.15 to 1.680.001
    Obesity1.631.23 to 2.160.001
    ISS≥161.421.12 to 1.810.005
    Limb injury†1.581.28 to 1.95<0.001
    Face injury†0.670.49 to 0.910.01
    Multiple injuries1.401.11 to 1.770.01
    Surgical procedure3.552.78 to 4.52<0.001
    Hip injury†1.321.02 to 1.710.03
    Placement of a central line1.551.21 to 1.990.001
    Mechanical ventilation3.482.70 to 4.47<0.001
    Infection2.001.47 to 2.72<0.001
    Model 2: IDDM and adjustment for covariates
    IDDM1.430.95 to 2.150.09
    Age≥651.711.39 to 2.10<0.001
    Male1.491.23 to 1.82<0.001
    Obesity1.681.24 to 2.270.001
    ISS≥161.401.09 to 1.810.01
    Limb injury†1.571.26 to 1.96<0.001
    Face injury†0.660.48 to 0.910.01
    Multiple injuries1.401.09 to 1.790.01
    Surgical procedure3.442.67 to 4.43<0.001
    Hip injury†1.381.05 to 1.800.02
    Placement of a central line1.541.19 to 2.000.001
    Infection2.081.51 to 2.85<0.001
    Mechanical ventilation3.532.71 to 4.59<0.001
    Model 3: NIDDM and adjustment for covariates
    NIDDM1.030.75 to 1.400.88
    Age≥651.771.47 to 2.13<0.001
    Male1.351.12 to 1.640.002
    Obesity1.651.23 to 2.210.001
    ISS≥161.651.32 to 2.06<0.001
    Limb injury†1.901.56 to 2.32<0.001
    Surgical procedure3.622.83 to 4.61<0.001
    Placement of a central line1.541.19 to 1.980.001
    Mechanical ventilation3.482.69 to 4.50<0.001
    Infection2.001.46 to 2.74<0.001
    • *Significant p values (p<0.05) are displayed in bold.

    • †AIS≥2.

    • AIS, Abbreviated Injury Score; AOR, adjusted OR; IDDM, insulin-dependent diabetes mellitus; ISS, Injury Severity Score; NIDDM, non-insulin-dependent diabetes mellitus.

  • Table 4

    Multivariate predictors of a venous thromboembolism, patients under the age of 65 years

    AOR95% CIp*
    Model 4: any diabetes and adjustment for covariates
    Any diabetes1.410.95 to 2.090.08
    Male1.511.16 to 1.960.002
    Obesity1.761.25 to 2.470.001
    ISS≥161.581.19 to 2.090.002
    Limb injury†1.851.44 to 2.37<0.001
    Surgical procedure3.382.42 to 4.72<0.001
    Hip injury†1.571.05 to 2.360.03
    Placement of a central line1.531.13 to 2.080.01
    Mechanical ventilation4.042.94 to 5.53<0.001
    Infection2.351.62 to 3.43<0.001
    Model 5: IDDM and adjustment for covariates
    IDDM1.861.01 to 3.410.045
    Male1.521.16 to 2.000.003
    Obesity1.781.24 to 2.550.002
    ISS≥161.531.14 to 2.050.005
    Limb injury†1.791.39 to 2.31<0.001
    Surgical procedure3.422.42 to 4.83<0.001
    Hip injury†1.631.07 to 2.460.02
    Placement of a central line1.491.09 to 2.040.01
    Mechanical ventilation4.062.93 to 5.62<0.001
    Infection2.531.73 to 3.70<0.001
    Model 6: NIDDM and adjustment for covariates 
    NIDDM1.210.74 to 1.990.44
    Male1.451.11 to 1.900.01
    Obesity1.761.24 to 2.500.002
    ISS≥161.631.22 to 2.170.001
    Limb injury†1.931.49 to 2.48<0.001
    Surgical procedure3.282.33 to 4.60<0.001
    Hip injury†1.561.02 to 2.370.04
    Placement of a central line1.491.09 to 2.030.01
    Mechanical ventilation4.092.97 to 5.64<0.001
    Infection2.261.54 to 3.32<0.001
    • *Significant p values (p<0.05) are displayed in bold.

    • †AIS≥2.

    • AIS, Abbreviated Injury Score; AOR, adjusted OR; IDDM, insulin-dependent diabetes mellitus; ISS, Injury Severity Score; NIDDM, non-insulin-dependent diabetes mellitus.

  • Table 5

    Multivariate predictors of a venous thromboembolism, patients 65 years and older

    AOR95% CIp*
    Model 7: any diabetes and adjustment for covariates
    Any diabetes1.060.76 to 1.480.74
    Multiple injuries1.741.28 to 2.36<0.001
    Surgical procedure4.783.46 to 6.59<0.001
    Placement of a central line1.761.15 to 2.710.01
    Mechanical ventilation2.771.86 to 4.13<0.001
    Model 8: IDDM and adjustment for covariates
    IDDM1.250.72 to 2.170.43
    Male1.481.10 to 1.980.01
    Limb injuries†1.491.07 to 2.090.02
    Multiple injuries1.541.10 to 2.170.01
    Surgical procedure3.852.67 to 5.54<0.001
    Placement of a central line1.821.14 to 2.910.01
    Mechanical ventilation2.941.87 to 4.61<0.001
    Model 9: NIDDM and adjustment for covariates
    NIDDM0.980.66 to 1.450.91
    Multiple injuries1.841.34 to 2.520.001
    Surgical procedure5.013.59 to 7.01<0.001
    Placement of a central line1.701.09 to 2.640.02
    Mechanical ventilation2.721.80 to 4.10<0.001
    • *Significant p values (p<0.05) are displayed in bold.

    • †AIS≥2.

    • AIS, Abbreviated Injury Score; AOR, adjusted OR; IDDM, insulin-dependent diabetes mellitus; ISS, Injury Severity Score; NIDDM, non-insulin-dependent diabetes mellitus.

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Does diabetes type increase the odds of venous thromboembolism following traumatic injury?
Jan Leonard, Lisa M Caputo, Matthew M Carrick, Denetta S Slone, Charles W Mains, David Bar-Or
Trauma Surg Acute Care Open Aug 2016, 1 (1) e000003; DOI: 10.1136/tsaco-2016-000003

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Does diabetes type increase the odds of venous thromboembolism following traumatic injury?
Jan Leonard, Lisa M Caputo, Matthew M Carrick, Denetta S Slone, Charles W Mains, David Bar-Or
Trauma Surg Acute Care Open Aug 2016, 1 (1) e000003; DOI: 10.1136/tsaco-2016-000003
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Does diabetes type increase the odds of venous thromboembolism following traumatic injury?
Jan Leonard, Lisa M Caputo, Matthew M Carrick, Denetta S Slone, Charles W Mains, David Bar-Or
Trauma Surgery & Acute Care Open Aug 2016, 1 (1) e000003; DOI: 10.1136/tsaco-2016-000003
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