So Jamie's going to talk a little bit about some of the guidelines that have come out, and then we're going to sort of go through the other talks. Dan-Michael and Jeff are going to speak as well here. And then we're going to sort of talk about some of the controversies that come up. And I think the bottom line that you're going to see as we go on here is that these solutions have to be tailored for the pathology, and that you have to realize that especially if you're looking at trauma, it's a very heterogeneous patient population. And given that, you have to make sure that you're not dealing with an underlying pathology that's evolving and getting worse. At the same time, there are certain patients who have a profoundly higher risk for DBT and PE. The immobile patient, the patient with associated long bone injuries, patients with pelvic trauma that might actually be at increased risk for a PE. Certainly any polytrauma. And these polytrauma patients in the civilian sector are something that probably you want to look at earlier versus later. Okay, thank you very much, Brocko, and welcome this morning. I'm going to talk about what the guidelines are for BTE prophylaxis and neurosurgery. Now, actually there have been a lot of guidelines, so we'll go over them. I have to warn you, though, this is really dry. But hopefully, you know, maybe you can point out. And the question is, are they really conflicting? And many of them actually are not. But you have to understand that neurosurgery really is a broad subject. And so some guidelines were very specific and some guidelines were more broad. And we'll go over that. Just as a disclosure, the only thing relevant maybe is that I was a co-author on the Brain Trauma Foundation Guidelines and TQIP. And I wanted to thank Greg Kapinos, who's neurocritical care attending, who had offered me some of the slides. So I really appreciate his input. So there are various guidelines, as you can see here. Brain Trauma Foundation, AANS, CNS, Neurocritical Care Society, American Heart Association, Stroke Association, and the American College of Chest Physicians. Obviously, the chest physicians are very interested in preventing PEs. So I'm going to start off with the TBI guidelines and the Brain Trauma Foundation. This, of course, was specific to severe traumatic brain injury. And the fourth edition came out in 2016. And what happened was this was a really pure document in terms of no consensus. This was guidelines, evidence-based. So you had to be specific to severe traumatic brain injury in order to include the study. And at first, it was going to be only class one and class two evidence. But then we had to include class three because there's not a whole lot of randomized controlled trials in neurosurgery, especially in trauma. And so we basically wanted to look very carefully at the literature. And interestingly enough, you know, here's the methodology. We wanted to determine the level of recommendation. But we wanted to see whether there was direct evidence for any of this. And it turns out for VTE prophylaxis, there was no direct evidence for severe traumatic brain injury. So at first, they were not going to include this in the fourth edition. And I said, we've got to include this. I mean, people are going to read this document. And one of the first things the trauma surgeons ask us is, when can we start chemoprophylaxis? So we included it. And it was only based on the fact that we had indirect evidence. And so here's all the levels of evidence that we used. Level one, two, three, and that's it. And at a level three recommendation, this was basically almost a reiteration of the third edition guidelines, which said that we can use low molecular weight heparin or low dose unfractionated heparin. But it may be in combination with mechanical prophylaxis. There were studies that had shown that there were increased risk of bleeding with low molecular weight heparin. But I think there's been a lot of studies since retrospective series that have said yes, no. And so it's pretty equivocal as to whether low molecular weight heparin really does, in fact, worsen hemorrhage. I think the jury is a little bit out on that as well. And I think a lot with these studies of looking at early timing of giving low molecular weight heparin will hopefully give us more information about really whether it's safe or not. But the bottom line is that there really is insufficient evidence to support the recommendations regarding the preferred agent dose or timing of pharmacological prophylaxis for DVTs. So at this point, you know, from a pure evidence standpoint, this from evidence-based medicine, this is a pure document. And we'll talk about the other documents that tend to include meta-analyses. This did not include meta-analyses. It actually included very good Class III studies that provided indirect evidence. And I won't go over these studies. But basically, the evidence was pretty low. And the quality of the evidence was essentially insufficient to make really significant conclusions. So at a Level III recommendation, you can give prophylaxis, chemoprophylaxis. I think what's pretty much ubiquitous is that pneumatic compression boots are probably the one thing that you want to give everybody. That's mechanical. And it's not chemotherapeutic. So just if you want to look, the evidentiary tables are in the guidelines that are posted on the Brain Trauma Foundation website. So American College of Surgeons actually does these best practice guidelines. And it's a part of the Trauma Quality Improvement Program, which is TQIP. And how many of centers are ACS verified? How many of you have? OK. So most ACS verified centers are now required to be part of TQIP in the database. And that really has almost supplanted the National Trauma Database. And so we have best practice documents. And a bunch of critical care traumatologists and neurosurgeons, including Jeff Manley, Andrew Moss, Al Velotka, and myself were involved in this panel to come up with the best practice document. And we have the pharmacological venous thromboembolism prophylactics. But this is pure just expert opinion based upon our best practices and a discussion over the telephone. So it was no consensus. It was just opinion of people talking. And so we have patients with TBI are at high risk for a venous thromboembolism. That's why we care about this. It should be as high as 20% to 30%. And then VT prophylaxis should be considered within the first 72 hours following TBI in most patients. And then we feel that initiation under 72 hours appears to be safe in patients at a low risk of progression of their intracranial bleed. So in our institution, we use a rule that the patient will get chemoprophylaxis 24 hours after the last stable scan. Maybe after a lot of these data are coming up in the literature, we may say that should be within 12 hours. So I think we're probably, as time goes on, we're getting more comfortable. We've moved to using low molecular weight heparin and not on fractionated heparin because there is some great literature to suggest that that's better in preventing DVTs and trauma patients overall. So here's the Neurocritical Care Society. So Neurocritical Care Society put out a bunch of guidelines for critically ill patients on different things. Ventriculostomies and VTE was one of them. They worked very hard on these guidelines. And it involved a clear literature search. They did include meta-analyses, and preliminary recommendations were formed by a working group. And they did have experts in a guidelines committee review. It was a peer-reviewed process. When the guidelines came out, they didn't really have an evidentiary table where you saw the literature that went into it. So that was sort of a little less pure than what we considered was high-level evidence-based medicine. But certainly, a lot of work went into this. And so they came up with a bunch of things for critically ill neurosurgical patients that we see. And I'll just highlight some of the ones that are relevant. So talking about TBI, which was what we've been talking about, is that they recommended initiating pneumatic compressions boots within 24 hours of presentation or within 24 hours after completion of craniotomy. And I'll tell you, this is weak evidence and low-quality stuff. So if you see weak, low, it's not great evidence for all of these recommendations. Initiating chemoprophylaxis within 24 to 48 hours after craniotomy and using, basically, you can use pneumatic compression boots based upon evidence from other neurological injuries. So they go on. And to talk about ischemic stroke and other conditions, and this is relevant to us in stroke patients undergoing hemicraniectomy, and we suggest that the use of chemoprophylaxis or boots in immediate post-surgical or endovascular period except when the patients receive TPA. So you could more or less safely operate on somebody, I think, 12 hours after TPA dose. So if anyone's worried that the patient got TPA, 12 hours later, you're pretty much, the TPA is out of the system. And so the prophylaxis, they recommend just delaying after 24 hours because they already had some thrombolytic agent on board. Again, weak, low. So recommended use in intracranial hemorrhage. So this is an important topic because we're constantly being consulted or asked to admit patients with ICH of spontaneous nature. And they recommend the use of boots or stockings over no prophylaxis. And then chemoprophylaxis in patients with stable hematomas with no ongoing coagulopathy within 48 hours. And continue these, the boots, in patients who have started on chemoprophylaxis. How many patients, how many people here actually stop boots when they're giving Wovinogs? OK. So I think it's so, it's like low-hanging fruit. You know, there's no, unless a patient has a DVT, you can continue the boots. And there is evidence that they work in synergy. So the AHA Stroke Association guidelines came out on the management of intracerebral hemorrhage in 2015. A very comprehensive document in this. Their method of grading the literature is really quite comprehensive. And there's this huge table of matrix that you really have to study hard in order to truly understand. But they do allow for consensus opinion. So is that pure? Not necessarily, but it really is comprehensive. So the ICH guidelines did say that the, so if it's class 1, it's great. If it's class 3, it's not as great. A is better than C. So just look at it that way. ICH patients should have boots beginning on day of hospitalization. So how many people start boots right away? OK. I mean, again, kind of low-hanging fruit. Unless in trauma they have a lower extremity injury, you know, it's really. Not Glasgow Coma Score, but compression stockings are not beneficial. How many people are using compression stockings routinely? So it's still allowed for in the guidelines, but I think there's a general feeling that the compression stockings themselves are not as good as the pneumatic boots. And after documented bleeding cessation, starting chemoprophylaxis in patients with lack of mobility after one to four days from onset. So here's a nice large range allowing you to use your judgment in between. Systemic anticoagulation or IVC filter is probably indicated in patients with DVT or PE. But the choice to take into account is the timing of the bleeding onset, stability of the hemorrhage, causes of the hemorrhage overall, the patient's condition. And clearly, if they have an ongoing reason for having more bleeding, then perhaps you might want to move towards an IVC filter rather than full anticoagulation. So in aneurysmal subarachnoid hemorrhage, they felt that using unfractionated heparin. So they're not talking about this. The evidence probably was not there for the low molecular weight heparin. Unfractionated heparin in all patients with aneurysmal subarachnoid hemorrhage, except in patients with unsecured ruptured aneurysms expected to undergo surgery. So this was strong, high. And so here, and then the next one is strong, moderate. Initiate boots. And then you could have unfractionated heparin at least 24 hours after an aneurysm has been secured. Jamie, can I just point something out? It's interesting. I'm assuming that relates to surgical securing of an aneurysm. I mean, all patients who get coiled, you're running 5,000 units per liter continuously while you're doing that procedure. And they often will get at least that amount. Now, these came out earlier, 2016, right? So what I would say is that probably, I don't know whether there was a difference in practice in 2016. And you'll see a little bit later that they do mention endovascular in this document, which is actually very good that they do that. And it will be interesting to hear your thoughts about whether that's commensurate with your current practice. But that's very true. Here's the AHA guidelines for the management of aneurysmal subarachnoid hemorrhage. This came out in 2012. This was a second edition update of a previous guideline. And they talked about, this is the only thing they talked about, really, was that heparin-induced thrombo cytopenia and DBT are relatively frequent and early identification and targeted treatment is indicated. So they don't really give much of a recommendation at all in these guidelines. This was class 1, and the level of evidence was B. So the highest recommendation was really very vague. So for brain tumors, all right, prophylaxis with either with chemoprophylaxis upon hospitalization for patients who are at low risk for major bleeding who lack signs of hemorrhagic conversion. So this was very strong with moderate quality of evidence. For elective craniotomies, boots with either with chemoprophylaxis should be done within, started within 24 hours after craniotomy. a lot of these patients are going to get them put on as long as they're in bed from day zero. And then boots plus chemoprophylaxis within 24 hours after a standard craniotomy in the setting of glioma resection. So it's clear that patients with malignancies and gliomas have a very high incidence of thromboembolism. And so it's very important for those patients to have some sort of prophylaxis. So for elective, I wasn't exactly sure what they meant by this, elective intracranial slash intraarterial procedures as opposed to endovascular. I wasn't entirely sure why the distinction. They suggested the use of boots or stockings until the patient is ambulatory and suggest immediate prophylactic anticoagulation with heparin or low molecular weight heparin. So for endovascular, so here's where we had their recommendations here, initiate unfractionated heparin and or stockings in patients with hemiparesis within 24 hours if activated prothrombin time is measured and using recombinant TPA. If patient got recombinant TPA or other thrombolytics, use extra caution and delay it for 24 hours. An elective procedure may actually not require chemoprophylaxis. So how does that differ from what you're doing now? Is that essentially what you would do? I think, you know what, I would interpret this as that looks like it's more related to stroke and mechanical thrombectomy. But again, anytime you put a catheter in an artery, they're going to get a lot of heparin during that. So I think they're getting it anyway. So it's really built into the process. And I think the idea is that when you look at intracranial hemorrhages associated with stroke, it has a relationship to how high the ACT is, activated clotting time. So I think the objective here is to avoid an overshoot of activated clotting time. And the activity to the TPA with the heparin simultaneously might set up a situation where you might have increased risk for hemorrhage. When we do give heparin during our drips, during interventional procedures, it's interesting because we don't see as high of a rate of intracranial hemorrhages as you might think. But if these patients have a neurologic deficit afterwards, they're not normal, they're going to be immobile, they're going to be in bed, they're set up for a DVT. So we typically will wait within 24 hours before we start our prophylaxis on these patients. Again, in these patients, after you open the vessel, the big concern is that you're going to create a reperfusion hemorrhage. So that's part of the reason why we tend to wait at least 24 hours. Selective spine surgery, very important to all of us. So for ambulatory back surgery with unique positioning strategies such as prone or kneeling, there's actually been an association with zero rates of VTE. I guess they go home pretty quickly and they're being mobilized very quickly, so perhaps the risk is really, really, really low. And they suggested considering the use of boots only for that reason. So how many people, did anyone here do ambulatory spine surgery routinely? Is that commensurate with your experience? Would anyone change that for a patient who has spinal stenosis and less mobile? Yeah, I think, you know, that's very strange that they would make such a statement that prone positioning is associated with zero rates of VTE. They never looked at my experience. Because, you know, you have to consider comorbidities in the spine. If you're operating on obese patients with other risk factors for VTE, it's not zero. I mean, it really isn't. So I don't find this a particularly helpful guideline. But the whole approach, the whole modern approach to spine surgery is minimally invasive and cutting down on how much, you know, dissection you use. And so with the goal of getting the patient out of bed as soon as possible after the procedure, that night, or, you know, certainly no later than the first day of physical therapy rather than right about the day after, okay? So don't tell me that strapping down those boots doesn't hold the patient to bed. Because I think it does. They don't get up out of bed and tie down those things. So there's actually the benefit of not ordering. Right. Right. Coming. Okay. So in standard elective spine surgery, they recommend ambulation with mechanical VTE or combined with chemoprophylaxis in patients with increased risk for VTE, combined therapy with ambulation and stockings or boots is strongly recommended. Now, complicated spine surgery. So recommend boots with chemoprophylaxis, strong, moderate, and recommend against the routine use of IVC filters. This is what they say about that. Again, they also say consider removable prophylactic ICP filter as a temporary measure only in patients with PE and DVT who cannot be anticoagulated. So I don't think neurocritical care society guidelines are particularly helpful with your question, but there will be guidelines that are more helpful with that question. For spinal cord injury, initiate VTE prophylaxis as early as possible within 72 hours. Recommend use of mechanical alone. And then chemoprophylaxis, low molecular weight heparin or adjusted dose, so you're going to give maybe higher dosages in higher weight patients as soon as bleeding is controlled. If it's not possible, suggest boots if you can't get chemoprophylaxis. They do not address the IVC filter question at all. So cervical spine guidelines, which came out by the AANS-CNS section on spine, came out here in 2013. Pretty good methodology. So it's very similar to the Brain Trauma Foundation guidelines methodology. Bev Walters was a methodologist who used to be the methodologist for the BTF guidelines. And so here at a level one recommendation, prophylactic treatment in patients is recommended. Use of low molecular weight heparins, rotating beds or a combination thereof is recommended. Low dose heparin in combination with pneumatic compression stockings is recommended. So low dose heparin alone is not recommended. Oral anticoagulation alone is not recommended. Early administration within 72 hours is recommended. That appears to be pretty consistent. A three-month duration of prophylactic treatment for DVT is recommended in patients who then go off to the rehab setting. So if you're wondering how long a quadriplegic or a paraplegic should be on, they're recommending three months. Vena cava filters are not recommended as a routine prophylactic measure. A lot of us in the past have their quad, let's put a filter in. I think those patients can easily get Lovenox unless there's a contraindication to that. For select patients who fail anticoagulation who are not candidates, they can get vena cava filters. So they address that issue. And the rest is just you can use a Doppler to diagnose the DVT. So here's the THRACO lumbar trauma guidelines that just came out. Again, very similar methodology, quite excellent methodology. They basically said there's insufficient evidence to recommend for or against routine screening for DVT. So if people want to just do duplex after five days, you know, there's not enough evidence to say you really shouldn't do that. If you want to screen, then it's up to you. A specific regimen for VTE prophylaxis. And there is no insufficient evidence for or against a specific treatment regimen. So again, very vague. If you're looking purely at the evidence, the evidence is probably just not there for THRACO lumbar fractures. They did say based upon published data from the cervical and THRACO lumbar populations in spinal cord injury that you want to use VTE prophylaxis and chemoprophylaxis. So that was a consensus statement from the workgroup. So this methodology wasn't excluding consensus statements if there really wasn't a burning issue that needed to be addressed. The CHESS guide, in CHESS, the ACCP guidelines, extremely comprehensive. It's like a guideline for every possible condition you could possibly find that would require anticoagulation. It's a great document. It's like the first edition was like 900 pages long. This edition I think was like 500 pages long. But they did publish an executive summary. And in 2016, they had an update. But they did not include anything relevant to us. So I just want to make sure you knew that. So it was evidence-based. But it did take into account meta-analysis. And they may have created their own meta-analyses as well as some expert opinion. They also used the Delphi approach to create consensus on the recommendations. So it's a combination of a lot of evidence, but also with expert consensus based upon a methodological approach. So for craniotomies, suggest mechanical prophylaxis, preferably with boots over no prophylaxis. For patients at very high risk for VTE, such as people with malignancies, suggest pharmacological prophylaxis in addition to mechanical. In patients with spine surgery, based on the analysis of literature, there is a baseline risk of VTE in spine surgery is low for most patients with non-malignant disease and moderate for those with malignancies. And they did feel that the baseline risk of major bleeding in spinal surgery is probably pretty low, like 0.5%. But the consequences are potentially severe. So given that, this is what helped to inform their guidelines. Mechanical prophylaxis is preferable with boots. And patients with high risk for VTE should have pharmacological prophylaxis. And then they suggest a low dose heparin or low molecular weight heparin or mechanical prophylaxis over none for major trauma. And for patients at high risk for VTE with acute spinal cord injury, traumatic brain injury, and spinal surgery for trauma, adding mechanical prophylaxis to the pharmacological prophylaxis if you don't have a lower extremity injury that would preclude it. For other major trauma, for patients in whom the chemoprophylaxis is contraindicated, use mechanical prophylaxis and suggest adding pharmacological prophylaxis when the bleeding risk diminishes. So again, for major trauma, suggest that IVC filter should not be used for primary prevention. I think a lot of us, you know, how many people are using a filter for primary prevention in their trauma cases? Okay. All right. So it's pretty well known that this is something that you just want to use when it's necessary. And suggest... It was a mechanical device which can be removed. So why is there this push against it? Oh, because of, you know, I have to say I've never, I've seen, I don't think I've seen maybe just one or two complications for the many IVC filters that I've seen put in. They're usually fairly safe. But there's been a history, and if you've gone on television, the lawyers are saying, do you have an IVC filter or have you been harmed? Because they can migrate up to the heart. There have been incidents of that. You can get a lot of huge clot burden under the IVC filter, and then it's not, of course, 100% that you can't get a PE. It's not 100% effective. So there is, there are complications. And the migration is probably the most concerning complication for IVC filter. So I think in patients that we don't need to put one in, we shouldn't, but I don't refrain from putting one in in a patient that has a contraindication for anticoagulation. And I think if you talk to the vascular surgeons or people who are doing these, they say that it's not as protective as the, you know, chemoprophylaxis. So if you have somebody who you're trying to prevent, then you're looking at, you know, the role for chemoprophylaxis, because they can still get, you know, PEs with a filter in place. And I think, you know, you have to tailor it to what the polytrauma injuries are, too, in some cases. But there are some severe complications that these patients have had with IVC occlusions and other venous occlusions that can progress. So they recommend that you should not do surveillance. Now, this is the last. We're getting towards the end here. This is an interesting guideline. It's from the European Society of Anesthesiologists. And it's a very nice guideline on venous thromboembolism prophylaxis in surgical patients. And they do include a chapter on neurosurgery. And for craniotomy, they believe that you should have boots continuously since admission. And one of the panelists here was on the ACCP panel as well. So they felt that this was an extension of the ACCP guidelines and what was not addressed in terms of surgical interest. And they suggest delayed initiation of chemoprophylaxis for at least 24 hours. And patients with high risk for VTE consider chemoprophylaxis when risk of bleeding is decreased. So whenever you feel comfortable. And then continuing it until discharge. For non-traumatic ICH, suggest use of boots continuously. Again, chemoprophylaxis when risk of bleeding is decreased. And then continue prophylaxis until fully mobilized. For spinal surgery, for patients with no additional risk factors, no prophylaxis is necessary apart from early mobilization. So they do endorse that concept. And additional factors such as limited mobility, cancer, you should give mechanical prophylaxis. And suggest an addition of low molecular weight heparin post-op when the risk of bleeding is decreased. And delay initiation until 24 hours after surgery. Continue prophylaxis until discharge in high risk patients. And in patients with spinal cord injury or significant motor impairments, suggest extending that into the rehab phase. So now we've gotten to the OASIS. We're done with the talk. Thank you very much for your attention and participation. Thank you.

VTE prophylaxis

neurosurgical conditions

guidelines

brain trauma

spine surgery

mechanical prophylaxis

chemoprophylaxis