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Saudi Critical Care Society clinical practice guidelines on the prevention of venous thromboembolism in adults with trauma: reviewed for evidence-based integrity and endorsed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

Saudi Critical Care Society · 2023 · Saudi Arabia

Source and licence

Authors
Marwa Amer, Mohammed S. Alshahrani, Yaseen M. Arabi et al.
Title
Saudi Critical Care Society clinical practice guidelines on the prevention of venous thromboembolism in adults with trauma: reviewed for evidence-based integrity and endorsed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine
Journal
Annals of Intensive Care, 2023
DOI
10.1186/s13613-023-01135-8
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC10172441

Licence statement of the original publication

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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Timing of Pharmacologic VTE prophylaxis in non-operative blunt solid organ injuries

  • Recommendation 1In adults with blunt solid organ injuries to liver, spleen, or kidney who are managed non-operatively and are at low risk of bleeding, we suggest starting pharmacologic VTE prophylaxis early (i.e., within 24–48 h) over delayed initiation of pharmacologic VTE prophylaxis (> 48 h)aStrength and quality of evidence: Weak, very low; GRADE evidence profile and EtD framework: https://guidelines.gradepro.org/profile/FmzyU2rljqs

Timing of pharmacologic VTE prophylaxis in TBI

  • Recommendation 2In adults with isolated blunt TBI with a low risk of bleeding progression who had stable repeated brain imaging showing no bleeding progression and stable neurologic examination, we suggest early pharmacologic VTE prophylaxis (within 24–72 h post-injury) over delayed pharmacologic VTE prophylaxis (> 72 h)bStrength and quality of evidence: Weak, very low; GRADE evidence profile and EtD framework: https://guidelines.gradepro.org/profile/aXj7XJvkfm8
  • Recommendation 3In adults with isolated blunt TBI at a high risk of bleeding progression, we suggest starting early pharmacologic VTE prophylaxis 72 h post-injury with stable brain imaging that shows no bleeding progression and stable neurologic examination over delayed pharmacologic VTE prophylaxis (> 72 h). The decision is usually made in conjunction with multidisciplinary teams’ evaluationbStrength and quality of evidence: Weak, very low; GRADE evidence profile and EtD framework: https://guidelines.gradepro.org/profile/7y-WPSqYQvw
  • Statement 4There is insufficient evidence to issue a recommendation on the use of early pharmacologic VTE prophylaxis in adults with isolated blunt TBI requiring neurosurgical intervention (including craniectomy, craniotomy, EVD, or ICP monitoring)Strength and quality of evidence: No recommendation; GRADE evidence profile and EtD framework: https://guidelines.gradepro.org/profile/v7SWl8qQGJs Additional file 2: Appendix 2, Table S6

Timing of pharmacologic VTE prophylaxis for spine trauma or fracture and/or SCI

  • Recommendation 5In adults with isolated spine trauma or fracture and/or SCI who are at low risk of bleeding and are managed non-operatively, we suggest initiating pharmacologic VTE prophylaxis within 24–48 h post-injury over delayed pharmacologic VTE prophylaxis (> 48 h)cStrength and quality of evidence: Weak, very low; GRADE evidence profile and EtD framework: https://guidelines.gradepro.org/profile/HaApoQ153kU
  • Recommendation 6In adults with isolated spine trauma or fracture and/or SCI and managed operatively, we suggest initiating early pharmacologic VTE prophylaxis within 48 h post-spinal fixation over delayed pharmacologic VTE prophylaxis (> 48 h)Strength and quality of evidence: Weak, very low; GRADE evidence profile and EtD framework: https://guidelines.gradepro.org/profile/XexGjIWaWJU

Type of pharmacologic VTE prophylaxis

  • Recommendation 7In adults with trauma who receive pharmacologic VTE prophylaxis, we suggest using LMWH (e.g., enoxaparin, dalteparin) over UFHStrength and quality of evidence: Weak, low; GRADE evidence profile and EtD framework: https://guidelines.gradepro.org/profile/xphSP0xqeg4

Dose of pharmacologic VTE prophylaxis

  • Recommendation 8In adults with trauma and low risk of bleeding who are prescribed LMWH (enoxaparin) for VTE prophylaxis, we suggest using either intermediate–high dose LMWH or conventional dosing LMWHStrength and quality of evidence: Weak, very low; GRADE evidence profile and EtD framework: https://guidelines.gradepro.org/profile/BWf_VYx4hqc

Mechanical VTE prophylaxis

  • Recommendation 9In adults with trauma who are not candidates for pharmacologic VTE prophylaxis, we recommend using mechanical VTE prophylaxis with IPC over no mechanical VTE prophylaxis when not contraindicated by lower extremity injuryStrength and quality of evidence: Strong, very low; GRADE evidence profile and EtD framework: https://guidelines.gradepro.org/profile/8om8BWmPK-s
  • Recommendation 10In adults with trauma taking pharmacologic VTE prophylaxis, we suggest either using adjunct mechanical VTE prophylaxis or pharmacologic VTE prophylaxis aloneStrength and quality of evidence: Weak, very low; GRADE evidence profile and EtD framework: https://guidelines.gradepro.org/profile/ICFXyvu8Og=

Routine duplex US surveillance

  • Recommendation 11In adults with trauma who are at an elevated risk of VTE and are not candidates for pharmacologic VTE prophylaxis, we suggest routine bilateral lower extremity US to screen for asymptomatic DVT over no routine screeningdStrength and quality of evidence: Weak, very low; GRADE evidence profile and EtD framework: https://guidelines.gradepro.org/profile/b1Vj16rY8u0

Prophylactic IVCFs

  • Recommendation 12In adults with trauma who are not candidates for pharmacologic VTE prophylaxis, we suggest against the routine placement of prophylactic IVCFsStrength and quality of evidence: Weak, very low; GRADE evidence profile and EtD framework: https://guidelines.gradepro.org/profile/BHbLqHtu0Gc

Timing of pharmacologic VTE prophylaxis in non-operative blunt solid organ injuries

  • Recommendation 1In adults with blunt solid organ injuries to liver, spleen, or kidney who are managed non-operatively and are at low risk of bleeding, we suggest starting pharmacologic VTE prophylaxis early (i.e., within 24–48 h) over delayed initiation of pharmacologic VTE prophylaxis (> 48 h)weak recommendation, very low quality evidence

Timing of pharmacologic VTE prophylaxis in TBI

  • Recommendation 2In adults with isolated blunt TBI with a low risk of bleeding progression who had stable repeated brain imaging showing no bleeding progression and stable neurologic examination, we suggest early pharmacologic VTE prophylaxis (within 24–72 h post-injury) over delayed pharmacologic VTE prophylaxis (> 72 h)weak recommendation, very low quality of evidence
  • Recommendation 3In adults with isolated blunt TBI at an elevated risk of bleeding progression, we suggest starting early pharmacologic VTE prophylaxis 72 h post-injury with stable brain imaging that shows no bleeding progression and stable neurologic examination over delayed pharmacologic VTE prophylaxis (> 72 h). The decision is usually made in conjunction with multidisciplinary teams’ evaluation (trauma, neuro/neurosurgical, critical care, and clinical pharmacist)weak recommendation, very low quality of evidence

Timing of pharmacologic VTE prophylaxis for spine trauma or fracture and/or SCI

  • Recommendation 5In adults with isolated spine trauma or fracture and/or SCI who are at low risk of bleeding and are managed non-operatively, we suggest initiating pharmacologic VTE prophylaxis within 24–48 h post-injury over delayed pharmacologic VTE prophylaxis (> 48 h)weak recommendation, very low quality of evidence

Routine duplex US surveillance

  • Recommendation 11In adults with trauma who are at an elevated risk of VTE and are not candidates for pharmacologic VTE prophylaxis, we suggest routine bilateral lower extremity US to screen for asymptomatic DVT over no routine screeningweak recommendation, very low quality evidence

Abstract

Background: To develop evidence-based clinical practice guidelines on venous thromboembolism (VTE) prevention in adults with trauma in inpatient settings.

Methods: The Saudi Critical Care Society (SCCS) sponsored guidelines development and included 22 multidisciplinary panel members who completed conflict-of-interest forms. The panel developed and answered structured guidelines questions. For each question, the literature was searched for relevant studies. To summarize treatment effects, meta-analyses were conducted or updated. Quality of evidence was assessed using the Grading Recommendations, Assessment, Development, and Evaluation (GRADE) approach, then the evidence-to-decision (EtD) framework was used to generate recommendations. Recommendations covered the following prioritized domains: timing of pharmacologic VTE prophylaxis initiation in non-operative blunt solid organ injuries; isolated blunt traumatic brain injury (TBI); isolated blunt spine trauma or fracture and/or spinal cord injury (SCI); type and dose of pharmacologic VTE prophylaxis; mechanical VTE prophylaxis; routine duplex ultrasonography (US) surveillance; and inferior vena cava filters (IVCFs).

Results: The panel issued 12 clinical practice recommendations—one, a strong recommendation, 10 weak, and one with no recommendation due to insufficient evidence. The panel suggests starting early pharmacologic VTE prophylaxis for non-operative blunt solid organ injuries, isolated blunt TBIs, and SCIs. The panel suggests using low molecular weight heparin (LMWH) over unfractionated heparin (UFH) and suggests either intermediate–high dose LMWH or conventional dosing LMWH. For adults with trauma who are not pharmacologic candidates, the panel strongly recommends using mechanical VTE prophylaxis with intermittent pneumatic compression (IPC). The panel suggests using either combined VTE prophylaxis with mechanical and pharmacologic methods or pharmacologic VTE prophylaxis alone. Additionally, the panel suggests routine bilateral lower extremity US in adults with trauma with elevated risk of VTE who are ineligible for pharmacologic VTE prophylaxis and suggests against the routine placement of prophylactic IVCFs. Because of insufficient evidence, the panel did not issue any recommendation on the use of early pharmacologic VTE prophylaxis in adults with isolated blunt TBI requiring neurosurgical intervention.

Conclusion: The SCCS guidelines for VTE prevention in adults with trauma were based on the best available evidence and identified areas for further research. The framework may facilitate adaptation of recommendations by national/international guideline policymakers.

Supplementary Information: The online version contains supplementary material available at 10.1186/s13613-023-01135-8.

Contents of the original publication

The section headings of the original.

  • Introduction
  • Objectives
  • Guidelines scope and target users
  • Methods
  • Panel selection
  • Management of conflict of interests (COI)
  • Question development and outcome prioritization
  • Patient engagement
  • Search strategy and study inclusion
  • Data abstraction and risk of bias assessment
  • Analysis
  • Quality of evidence and grading of recommendations
  • Recommendation formulation and voting process
  • Results
  • Timing of pharmacologic VTE prophylaxis in non-operative blunt solid organ injuries
  • Timing of pharmacologic VTE prophylaxis in TBI
  • Timing of pharmacologic VTE prophylaxis for spine trauma or fracture and/or SCI
  • Type of pharmacologic VTE prophylaxis
  • Dose of pharmacologic VTE prophylaxis
  • Mechanical VTE prophylaxis
  • Routine duplex US surveillance
  • Prophylactic IVCFs
  • Discussion
  • Results from the most recent guidelines
  • Conclusion

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