Blood Clot Prevention After Injury: A New Approach

Every day, as a trauma surgeon at Oregon Health & Science University, and during my years serving in the U.S. Army, I see how common blood clots are after major injuries or illnesses. Venous thromboembolisms (VTEs) are especially common and can lead to prolonged hospitalizations, significant complications, and death.

Despite many attempts to better prevent VTEs, many patients remain at risk.

Tailoring Blood Clot Prevention to Individual Needs

Thanks to the National Trauma Institute, my team and I are currently conducting a clinical trial to determine if we can improve blood clot prevention for all patients by adjusting the dose of low molecular weight heparin (LMWH) to a patient's specific clotting characteristics, rather than relying on fixed doses of LMWH for all patients. This will involve the use of a bedside testing method known as thrombelastography (TEG). TEG provides immediate information on a patient's clotting function, allowing clinicians to adjust the dose of LMWH accordingly.

If TEG guided dosing of LMWH proves effective in reducing avoidable clots, without increasing the risk of excessive bleeding, it would represent a significant advancement in the way we approach blood clot prevention.

A New Path Forward in Trauma Care

Supported by the National Trauma Institute, my team and I are working to identify a new direction in trauma care by developing a personalized approach to blood clot prevention. Rather than adopting a "one size fits all" approach to blood clot prevention, which relies on fixed doses of medications, we seek to customize prevention according to each patient's unique situation.

To achieve this goal, we are using a tool known as thrombelastography, often referred to as TEG. TEG is a bedside testing method that evaluates a patient's clotting function by assessing how quickly a patient's blood forms a clot, how strong the formed clot is, and how long the clot takes to break down. Using TEG allows us to assess each patient's unique clotting characteristics in real-time, and then to adjust the dose of LMWH to match those characteristics.

By tailoring the dose of LMWH to each patient's actual clotting characteristics, we believe that TEG guided dosing can revolutionize the way we approach blood clot prevention.

Why Does It Matter?

When a patient suffers a life-threatening injury, surviving that event is only the beginning of the battle against complications. While not always immediately apparent, one of the most significant dangers facing a patient after a serious injury is the development of blood clots. By the time blood clots are diagnosed, they are frequently already causing damage to organs and tissues.

Risk Factors:

Patients who suffer from significant inflammation, infection, obesity or experience limited mobility post-injury have a higher risk of developing dangerous blood clots. Additionally, patients who require extended periods of bed rest, surgical procedures or significant fracture repairs are at increased risk of developing blood clots due to their immobility.

Guidelines:

While existing guidelines for preventing blood clots are well-intentioned, they were developed with less complex medical scenarios in mind. Furthermore, the variability in patients' clotting profiles and other factors, such as age, sex, body type, etc., are not adequately addressed in current guidelines. As a result, many patients continue to receive either under- or over-doses of blood clot prevention medications.

Finding Balance:

One of the greatest challenges facing trauma clinicians today is finding the correct balance between preventing blood clots and minimizing the risk of excessive bleeding associated with anticoagulant medications.

Precision-Based Approach:

Using a precision-based approach to measure a patient's clotting characteristics in real-time, we hope to find a more consistent balance between preventing blood clots and minimizing the risk of bleeding.

Potential Benefits:

If we can successfully match the dose of LMWH to a patient's actual clotting profile, we expect to see reduced numbers of avoidable blood clots and fewer instances of bleeding.

Study Design:

In our clinical trial, we are comparing the effectiveness of two different approaches to blood clot prevention. The first approach consists of administering the standard dose of LMWH as dictated by national guidelines. The second approach involves adjusting the dose of LMWH based on a patient's clotting characteristics measured via TEG. We have developed standardized criteria to determine when to increase or decrease the dose of LMWH in response to changes in a patient's clotting profile.

Tracking More Than Just Clot Formation:

In addition to evaluating clot formation, we are also tracking bleeding events, transfusion requirements, ICU length of stay, overall hospital length of stay, and whether additional surgeries are required to evaluate the impact of TEG guided dosing of LMWH.

Practical Considerations:

For this approach to be successful, it must not only be effective, but also practical. Therefore, we are also studying the feasibility of implementing this approach in busy hospitals where multiple clinicians and teams of caregivers are involved. Specifically, we want to know whether nurses, pharmacists, and physicians can collaborate to quickly and accurately interpret TEG results, and whether this process can be safely repeated.

Lessons Learned From My Experience:

Throughout my career as a clinician and researcher, I have come to understand that true advancements in medicine are rarely achieved through dramatic breakthroughs, but rather through incremental improvements to everyday practices. I have witnessed firsthand how a relatively minor change in a practice can make a significant difference in patient outcomes. I have also learned that research must maintain its connection to real-world clinical practice. The value of an innovative concept tested in a laboratory setting is diminished significantly if it cannot be translated into practical application at the bedside. Therefore, we are committed to creating solutions that are both feasible and easily integrated into any trauma team's workflow. Ultimately, the best medicine is that which brings together innovation and practicality.

Action Steps for Clinicians:

Even before the completion of our study, there are several action steps that clinicians can take to begin applying the principles behind our research to their own practices. First and foremost, clinicians should ask themselves whether the standard dose of LMWH they are prescribing for a particular patient is appropriate for that patient. For example, a patient with significant inflammation, a high body mass index (BMI), or extensive injuries may require closer monitoring or dosing adjustments.

Secondly, while medication plays a critical role in preventing blood clots, awareness and education among patients and their families can also help. For instance, encouraging patients to engage in early and safe mobilization when possible, using compression devices as directed, and managing IV lines carefully to minimize the risk of clots forming around them are all simple yet highly effective measures.

Lastly, if a hospital uses TEG or another form of blood monitoring, clinicians should explore how this tool can inform their decision-making regarding the management of anticoagulants and the prevention of blood clots.

What Patients and Their Families Need to Know:

Preventing blood clots is a routine aspect of trauma care, and one of the most crucial components of ensuring the best possible outcome for a patient recovering from a serious injury. Anticoagulant medications are designed to prevent clots while minimizing the risk of excessive bleeding. However, there is always room for improvement in terms of the safety and efficacy of these medications.

Therefore, if you or a loved one is recovering from a serious injury, it is entirely reasonable to inquire with the healthcare providers responsible for your care regarding how they plan to prevent clots, including the medications they plan to use, and how they intend to monitor their effectiveness. Educated patients and families are essential partners in the pursuit of safety, and contribute to improving the quality of care provided.

Broader Implications:

If TEG guided dosing of LMWH proves effective, we anticipate that this success will translate into benefits far beyond the intensive care units. Reduced rates of clots will likely result in reduced rates of complications, decreased hospital lengths of stay, and ultimately, cost savings. Hospitals will benefit from increased efficiencies; clinicians will have enhanced tools to guide their decision-making processes; and most importantly, patients will be exposed to fewer risks and enjoy improved recoveries.

It is for these reasons that research such as ours is so vital. Every incremental improvement in medicine has the potential to positively affect countless lives. To say that precision in trauma care is simply about technology overlooks the fact that it is fundamentally about harnessing knowledge to deliver more thoughtful, more individualized, and more compassionate care.

Continuing to Evolve Trauma Care:

As trauma clinicians, we continually strive to improve our ability to provide optimal care to our patients. Each patient we treat offers us opportunities to learn and grow as clinicians and researchers. Our current study represents the continuation of this mission to improve the quality of care we deliver. It reflects the conviction that true advances in medicine occur through the thoughtful and collaborative application of knowledge and observation, as opposed to chance.

If we can successfully develop the capability to personalize blood clot prevention, we will not only improve patient outcomes, but we will also establish a new benchmark for trauma care globally. This is the purpose of our research and the mission that drives my work every day.