ANCROD AS PROPHYLAXIS OR TREATMENT FOR THROMBOEMBOLISM IN PATIENTS WITH MULTIPLE TRAUMA

Objective: To report the initial clinical experience with fibrinogen d epletion using ancrod as prophylaxis and treatment for deep vein throm bosis and pulmonary embolism (DVT/PE) in patients with multiple trauma . Design: A series of cases, selected because of their extreme risk of DVT/PE or because of the appearance of thromboembolic complications d espite prophylaxis using conventional methods. Setting: University tea ching hospital. Patients: A referred sample comprising 30 patients wit h multiple blunt trauma. The mean injury severity score was 30. Most c ases involved a combination of lower extremity, pelvic and chest injur ies. Interventions: Fibrinogen was slowly depleted over 24 to 36 hours and the concentration maintained at 0.2 to 0.5 g/L thereafter. Ancrod was continued prophylactically (22 patients) or for established DVT/P E (8 patients) until the patients were mobilized or until there was no longer a contraindication to heparin, or until treatment with warfari n became practical. Main Outcome Measure: Monitoring for DVT by duplex ultrasonography or iodine-125-labelled-fibrinogen scanning, whichever could be applied. Results: Twenty patients were treated with ancrod f or prophylaxis from the outset because it offered theoretic and practi cal benefits over other methods. No patient treated with ancrod for pr ophylaxis suffered a clinically significant DVT/PE. Patients in whom h eparin prophylaxis failed and who experienced thromboembolic complicat ions were effectively managed with ancrod. There were no deaths and no bleeding complications specifically due to the therapy. Conclusions: Slow depletion of fibrinogen with ancrod may provide a safe and effect ive means to prevent DVT/PE in multiple trauma patients or to treat DV T/PE when the risk of bleeding from heparin is great. This initial exp erience should be evaluated by a randomized controlled trial.