Research Article: Venous thromboembolism risk stratification for patients with lower limb trauma and cast or brace immobilization

Date Published: June 20, 2019

Publisher: Public Library of Science

Author(s): D. Douillet, B. Nemeth, A. Penaloza, G. Le Gal, T. Moumneh, S. C. Cannegieter, P. M. Roy, Biswadev Mitra.

http://doi.org/10.1371/journal.pone.0217748

Abstract

Thromboprophylaxis for patients with non-surgical isolated lower-limb trauma requiring immobilization is a matter of debate. Our aim was to develop and validate a clinical risk- stratification model based on Trauma, Immobilization and Patients’ characteristics (the TIP score).

The TIP score criteria and the cut-off were selected by a consensus of international experts (n = 27) using the Delphi method. Retrospective validation was performed in a population-based case-control study (MEGA study). The potential score’s impact in anticoagulant treatment was assessed in a prospective single-center observational cohort study.

After four successive rounds, 30 items constituting the TIP score were selected: thirteen items for trauma, three for immobilization and 14 for patient characteristics were selected, each rated on a scale of 1 to 3. In the validation database, the TIP score had an AUC of 0·77 (95% CI 0.70 to 0.85). Using the cut-off proposed by the experts (≥5) and assuming a prevalence of 1·8%, the TIP scores had a sensitivity, specificity and negative predictive values of 89·9%, 30·7% and 99·4% respectively. In the prospective cohort, 84·2% (165/196) of all the patients concerned who presented at the emergency department had a low VTE risk not requiring thromboprophylaxis according to their TIP scores. The 3-month rate of symptomatic VTE was 1/196 [95% CI 0.1–2.8] this patient was in the sub-group TIP score ≥5.

For patients with non-surgical lower-limb trauma and orthopedic immobilization, the TIP score allows an individual VTE risk-assessment and shows promising results in guiding thromboprophylaxis.

Partial Text

Through a Delphi study involving an international multidisciplinary panel of experts and physicians, we classified thromboembolic risk-factors in patients with non-surgical lower-limb trauma requiring immobilization. A risk-stratification model based on trauma, immobilization and patient characteristics, i.e. the TIP score, was established. Validated retrospectively in a case-control study, the TIP score shows good prognostic performance (AUC 0·77). Using <5 as cut-off, the TIP score identified over 80% of patients as having a low risk of VTE, hence, no indication for thromboprophylaxis.   Source: http://doi.org/10.1371/journal.pone.0217748

 

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