An Evaluation of the Clinical Utility of Thrombelastography (TEG) in Guiding Low Molecular Weight Heparin (LMWH) and Antiplatelet Prophylaxis of Venous Thromboembolism (VTE) Following Trauma
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 50
- 试验地点
- 1
- 主要终点
- Hypercoagulability
研究概览
简要总结
This study plans to learn more about how to prevent blood clots in the veins of your extremities. You are at risk of forming these clots after a major injury and when you have had surgery and are hospitalized on bed rest.
Usually, patients in the SICU at Denver Health who are at risk for blood clots receive preventative treatment with a FDA-approved medicine called Fragmin. Fragmin is intended to prevent blood clots from forming but, with the way it is generally used, some patients may still develop blood clots. All patients treated with Fragmin to prevent blood clots at Denver Health, currently receive the same Fragmin dose. This treatment is called the "standard of care".
So far, in the US, there has not been a commonly available test that can tell us:
- if the standard dose of Fragmin is enough to prevent blood clots for everyone, or
- if different patients need different doses, or
- if other blood clot preventing medicines, that work in a different way, should be used in addition to Fragmin.
The ability of your blood to clot and the strength of the clot formed can be described by a FDA-approved blood test called thrombelastography, referred to as TEG. TEG may provide us with answers to each of the questions above. Our preliminary data indicate that it is helpful in assessing both clotting and bleeding tendencies and may prove useful in guiding treatment for the prevention of blood clots.
The aim of this study is to determine if a treatment plan using Fragmin, and, if indicated, one or two additional FDA-approved medicines called anti-platelet drugs, guided by the results of TEG testing, may be better at preventing blood clots than our current standard of care.
详细描述
This preliminary/pilot study involves a prospective, randomized, open-label, parallel group comparison of Denver Health's current standard of care for prevention of venous thromboembolism (VTE), commonly known as blood clots, using LMWH (Fragmin) 5000IU subcutaneously daily, with a thrombelastography (TEG)-guided, algorithm-based, individualized regimen of LMWH (Fragmin) plus/minus anti-platelet therapy (aspirin) guided by platelet mapping, in patients admitted to the SICU following trauma.
Approximately 50 trauma patients for whom prevention of VTE with LMWH is indicated, will be enrolled over a six month period.
The specific aims of this study are as follows:
-
To determine the incidence of, and to characterize, hypercoagulability using TEG and conventional clinical coagulation testing (APTT, INR), Antithrombin III levels and Protein C activity.
-
In the group of patients receiving LMWH (Fragmin) therapy alone for prevention of VTE:
-
to assess the anticoagulant effect of standard LMWH (Fragmin) dosing (5000IU subcutaneously once daily) using TEG and Anti-Factor Xa level measurement, and
-
to determine the extent of correlation of relevant TEG parameters with measured Anti-Factor Xa levels (U/ml).
-
To assess whether TEG is a useful clinical tool for monitoring and optimizing prophylactic LMWH (Fragmin) therapy and for identifying the need for anti-platelet therapy to minimize the risk of VTE in these patients.
-
To evaluate the clinical utility of platelet mapping for guiding anti-platelet therapy in those patients for whom it is indicated by TEG results.
-
To determine the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in each randomized group and in the subgroup receiving anti-platelet therapy in addition to LMWH (Fragmin) for prevention of VTE.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Prevention
- 盲法
- None
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •age at least 18 years,
- •blunt or penetrating trauma requiring admission to the SICU
- •requirement for LMWH (Fragmin) therapy for prophylaxis of VTE as standard of care, and
- •informed consent by patient, legally authorized representative or proxy decision maker (if patient incompetent to provide) obtained and documented.
排除标准
- •Presence of any of the following absolute contraindications to LMWH (Fragmin) therapy:
- •known hypersensitivity to dalteparin sodium,
- •known hypersensitivity to heparin or pork products,
- •thrombocytopenia associated with positive tests for antiplatelet antibody in the presence of Fragmin,
- •history of heparin-induced thrombocytopenia (HIT),
- •chronic liver disease (bilirubin >2 mg/dl) or kidney insufficiency (CrCl <30mL/min),
- •intravascular thrombolytic therapy within 24 hours,
- •resuscitation that required massive transfusion (>10 units RBC within 6 hours),
- •ongoing resuscitation for hemorrhagic shock,
- •known bleeding disorder or coagulopathy (INR >2 not on warfarin),
- •thrombocytopenia (platelets <20K/uL),
- •subdural or epidural hematoma.
- •Presence of any of the following relative contraindications to LMWH (Fragmin) therapy:
- •new intracranial lesions, neoplasms or monitoring devices,
- •extravascular thrombolytic therapy,
- •severe uncontrolled hypertension,
- •arterial dissection
- •recent (within 12 hours) intraocular surgery (prior or planned),
- •recent (within 72 hours) intracranial or spine surgery (prior or planned),
- •conditions associated with increased risk of hemorrhage, e.g. active gastrointestinal ulceration, angiodysplastic disease, gastrointestinal bleeding within the past six months, bacterial endocarditis, history of hemorrhagic stroke, diabetic retinopathy.
- •Presence, or removal within the last 12 hours, of an indwelling epidural or spinal catheter, OR recent (within the last 12 hours) or planned neuraxial (spinal/epidural) anesthesia or spinal puncture.
- •Per history taken from patient or family, concomitant or known use within one week prior to hospitalization, of drugs affecting hemostasis such as NSAIDS, platelet inhibitors or other anticoagulants, except as specified in this protocol.
研究组 & 干预措施
Control (standard of care)
Dalteparin sodium 5000IU subcutaneously daily
干预措施: Dalteparin sodium (Drug)
TEG-guided thromboprophylaxis
Dalteparin sodium plus/minus anti-platelet medication (aspirin) per a TEG-guided algorithm
干预措施: Dalteparin sodium/aspirin (Drug)
结局指标
主要结局
Hypercoagulability
时间窗: Study day five.
To determine the incidence of, and to characterize, hypercoagulability in a sample of trauma patients admitted to the SICU at DHMC using TEG and conventional clinical coagulation testing (APTT, INR), antithrombin III levels and protein C activity. Hypercoagulability is defined as TEG parameter G (clot strength) \>10.9.
Incidence of VTE
时间窗: Day 28 or discharge, whichever comes first.
The incidence and nature of hypercoagulability and the incidence of deep vein thrombosis and pulmonary embolism in each randomized group and in the subgroup receiving anti-platelet therapy in addition to Fragmin (descriptive analysis only)
次要结局
- TEG Parameters(Study day five.)
- International Normalized Ratio (INR)(Study day five.)
- Platelet Count(Study day five.)
- Conventional Coagulation Testing Parameters(Study day five.)
研究者
Ernest E. Moore, MD
Chief, Department of Surgery and Trauma Services Rocky Mountain Regional Trauma Center
Denver Health and Hospital Authority