A National Survey of Thromboprophylaxis in Traumatic Brain Injury in the United Kingdom

Introduction: Patients with traumatic brain injury (TBI) are at increased risk of venous thromboembolic events (VTE). In this survey, we aimed to assess current practice in the United Kingdom and identify areas of variation for further investigation. Methods: We distributed a case-based survey to neurosurgical consultants and trainees via e-mail. The survey included four index TBI cases commonly seen: a surgically treated acute extradural haematoma, bilateral frontal contusions treated conservatively, diffuse axonal injury requiring critical care and a conservatively managed small acute subdural haematoma. Each case vignette included questions looking at a range of areas regarding thromboprophylaxis. Results: Sixty-two responses were collected among UK neurosurgeons with a good geographic distribution. In each case, over 90% of respondents would initiate mechanical prophylaxis (MTP) at admission. There was greater variation on the decision to commence pharmacological prophylaxis (PTP). Consultants showed a higher willing to commence PTP across all cases (84%) compared to trainees (77.4%). Low molecular weight heparin (LMWH) was the favoured PTP agent in over 90% of respondents. There was significant variability in the timing of initiation of PTP within and between cases. The median times to commence PTP across all four cases ranged from 1 to 7 days. Conclusion: This survey highlighted broad consensus on the use of MTP and choice of PTP agent, when used. However, the survey also demonstrated wide intra-case variation on whether to start PTP and particularly the timing of initiation. This discordance in practice shines light on the lack of evidence guiding thromboprophyalxis in TBI and adds weight to the need for prospective randomised trials to guide clinical management.