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Correspondence |

Mitigating VTE in Soldiers From Operation Iraqi Freedom and Operation Enduring FreedomMitigating VTE in Soldiers FREE TO VIEW

William L. Jackson, Jr, MD, MBA, FCCP; Melanie Guerrero, MD, MBA, FCCP; Andrew F. Shorr, MD, MPH, FCCP
Author and Funding Information

From Inova Health System (Drs Jackson and Guerrero); and Washington Hospital Center (Dr Shorr).

Correspondence to: William L. Jackson Jr, MD, MBA, FCCP, Inova Health System, Inova Telemedicine Institute, 8110 Gatehouse Rd, Ste 600, W Tower, Falls Church, VA 22046; e-mail: william.jackson@inova.org


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(1):195. doi:10.1378/chest.13-2096
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To the Editor:

We read with great interest the recent article by Holley et al1 in CHEST (September 2013) detailing the nature of VTE in combat soldiers. We previously published the first report to our knowledge in this same population2 and agree that application of VTE prophylaxis in injured soldiers is often limited by bleeding risk, anatomic location of injury, and discontinuity in care arising from surgical or logistical interventions. Although it is encouraging that Holley et al1 noted a reduction in VTE events with higher doses of enoxaparin (in contrast to our data2), it is somewhat contradictory that missed dosing did not appear to influence VTE rates.

In our opinion, two developments have markedly impacted the care of patients injured in the recent conflicts in Afghanistan and Iraq: an increase in the incidence and profundity of penetrating injury3 and the impressive capability for expedited aeromedical evacuation. The emergence of the latter has decreased the time from in-theater injury to stateside ICU for injured American soldiers to < 48 h in some instances. This places lengthy transport of the injured (flight times ≥ 8 h) within the time period when VTE develops and prophylaxis is likely most essential, and the vagaries of wartime transport may compromise administration of prophylaxis. Moreover, the conditions of hypobaric hypoxia seen with air travel may increase risk of VTE independently of risk associated with prolonged immobility,4 further increasing the propensity of these patients develop clots. Although this hypobaric risk may be mitigated by low-molecular-weight heparin,5 and aggressive thromboprophylaxis in the trauma setting is certainly justifiable, as Holley et al1 note, the absence of data from the evacuation period remains problematic in developing a tailored and evidence-based approach to VTE prevention in this population.

References

Holley AB, Petteys S, Mitchell JD, Holley PR, Collen JF. Thromboprophylaxis and VTE rates in soldiers wounded in Operation Enduring Freedom and Operation Iraqi Freedom. Chest. 2013;144(3):966-973. [CrossRef] [PubMed]
 
Jackson WL Jr, Guerrero M, Chung KK, Fisk BA, Shorr AF. Observed incidence of venous thromboembolism in soldiers from Operation Iraqi Freedom and Operation Enduring Freedom admitted to a stateside intensive care unit [abstract]. Chest. 2005;128(4_MeetingAbstracts):405S.
 
Gawande A. Casualties of war—military care for the wounded from Iraq and Afghanistan. N Engl J Med. 2004;351(24):2471-2475. [CrossRef] [PubMed]
 
Bendz B, Rostrup M, Sevre K, Andersen TO, Sandset PM. Association between acute hypobaric hypoxia and activation of coagulation in human beings. Lancet. 2000;356(9242):1657-1658. [CrossRef] [PubMed]
 
Bendz B, Sevre K, Andersen TO, Sandset PM. Low molecular weight heparin prevents activation of coagulation in a hypobaric environment. Blood Coagul Fibrinolysis. 2001;12(5):371-374. [CrossRef] [PubMed]
 

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Tables

References

Holley AB, Petteys S, Mitchell JD, Holley PR, Collen JF. Thromboprophylaxis and VTE rates in soldiers wounded in Operation Enduring Freedom and Operation Iraqi Freedom. Chest. 2013;144(3):966-973. [CrossRef] [PubMed]
 
Jackson WL Jr, Guerrero M, Chung KK, Fisk BA, Shorr AF. Observed incidence of venous thromboembolism in soldiers from Operation Iraqi Freedom and Operation Enduring Freedom admitted to a stateside intensive care unit [abstract]. Chest. 2005;128(4_MeetingAbstracts):405S.
 
Gawande A. Casualties of war—military care for the wounded from Iraq and Afghanistan. N Engl J Med. 2004;351(24):2471-2475. [CrossRef] [PubMed]
 
Bendz B, Rostrup M, Sevre K, Andersen TO, Sandset PM. Association between acute hypobaric hypoxia and activation of coagulation in human beings. Lancet. 2000;356(9242):1657-1658. [CrossRef] [PubMed]
 
Bendz B, Sevre K, Andersen TO, Sandset PM. Low molecular weight heparin prevents activation of coagulation in a hypobaric environment. Blood Coagul Fibrinolysis. 2001;12(5):371-374. [CrossRef] [PubMed]
 
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