Incidence of Venous Thromboembolism (VTE) and Hemorrhage in Patients with Bleeding Disorders Hospitalized for Major Surgery/ Trauma: Analysis from National Inpatient Sample

Introduction

Venous thromboembolism (VTE) is a common complication in patients after major surgery (MS) or major trauma (MT), with at least 10 times higher odds of VTE development. The American Society of Hematology (ASH) recommends pharmacologic VTE thromboprophylaxis (Thppx) for at-risk hospitalized MS or MT patients. In patients without bleeding disorders (BD) the risk of hemorrhage (hge) with Thppx is low (<3%). However, there is limited information on the risk of VTE and hge in patients with BD hospitalized for MS or MT, and guidelines for the use of Thppx in such patients are lacking. Our study aims to study the risk of VTE and hge in patients with BD, compared to those without BD.

Methods

This is a retrospective cohort study using data from the National Inpatient Sample (NIS) 2019. Study participants were identified using ICD10 codes for major trauma (MT), major surgery (MS) (surgery requiring > 30min of anesthesia), lower extremity long bone fracture (LLF), and knee or hip arthroplasty (KA/HA) and stratified according to their BD diagnosis, identified by ICD-10 codes for Hemophilia A, B, C, and Von Willebrand disease (VWD). Hemorrhagic manifestations included intracranial bleeding, GI bleeding (GIB), retroperitoneal and postoperative hemorrhage or hematoma. The OR of VTE and hge in patients with BD compared to patients without BD was calculated by adjusting for age, sex, race, income, insurance, hospital teaching status, hospital bed size and Charlson Comorbidity Index. Sampling weights were applied to generate nationally representative estimates.

Results

A total of 2,137,386 patients were included of which 1,395 (0.1%) had BD. The incidence of VTE among patients with BD was higher than their counterparts without BD (2.5% vs 0.9%). Patients with BD were more likely to develop DVT than patients without BD (71% vs. 51.7%) and less likely to develop PE (28.6% versus 48.3%). The incidence of VTE in patients with Hemophilia A, B, C and VWD was 2.3%, 0.0%, 3.3%, 2.7% respectively (p=1.0). The incidence of VTE among patients who had major MT, MS, LLF and KA/HA was 2.8%, 1.5%, 1.4%, 0.3% respectively (p <0.01). The odds of VTE among patients with BD were 3 times the odds of VTE in patients without BD (Adjusted Odds Ratio aOR= 3.0, 95% CI 1.4-6.4, p< 0.01). The odds of DVT among patients with BD were 3.6 times the odds of DVT in patients without BD (95% CI 1.5-8.7). The odds of PE among patients with BD were 1.8 times the odds of PE in patients without BD, however, this was not significant (95% CI 0.4-7.0).

The frequency of hge was higher in patients with BD compared to patients without BD (4.0% vs 0.6%). GIB were the most prevalent (64.0%). The incidence of hge in patients with Hemophilia A, B, C and VWD was 4.5%, 0.0%, 0.0%, 4.7% respectively (p=0.81). The incidence of hge among patients who had MT, MS, LLF, KA/HA was 1.1%, 1.2%, 1.0%, and 0.3% respectively (p <0.01). The odds of hemorrhage in patients with BD were 7.2 times the odds of hemorrhage in patients without BD (aOR= 7.2, 95% CI 4.0-13.2, p<0.01).

Conclusion

Patients with BD hospitalized for major surgery or trauma are at increased risk for VTE and hemorrhage. We hypothesize that reduced use of risk-appropriate prophylaxis may be responsible for the increased frequency of VTE in patients with BD. These data underscore the need for additional further studies of VTE prophylaxis in patients with BD.