Blog

September Journal Club begins with a pair of articles published this year on the controversial topic of brain injury and thromboprophylaxis. Clearly, these patients are at heightened risk of thromboembolic disease. They are also at risk of severe complications from their thromboprophylactic treatment. The question is, when is it safe enough to institute pharmacotherapy. The two new Journal Club papers add some information to this area. The first describes a retrospective review of patients with "stable" brain injuries (defined as 24-48 hours after a follow up scan >24 hours after previous scan showed no progress of bleeding) who were commenced on pharmacotherapy. The major finding of the review was that the therapy appeared safe from a neurological perspective. Their assertion that it also reduced DVT rates is compromised by the bizzare decision to routine duplex screen those NOT recieving anticoagulants, and only scan those who did receive it based on clinical suspicion. The second paper compares (again retrospectively) enoxaparin and heparin in a carefully selected group of patients with significant brain injury. Heparin was associated with higher rates of bleed extension - possibly related to selection bias (heparin may have been chosen because they were felt to be at higher risk of bleeding). While interesting, these papers are limited methodologically - further prospective, well designed studies are desperately needed. In the interim of course, there are mechanical methods such as Sequential Compression Devices (SCDs) and Thromboembolic Deterent Stockings (TEDS). My personal preference, like all ICU patients, is to use both, regardless of pharmacotherapy. So, who's brave enough to start chemoprophylaxis 24 hours after a stable CT?