Efficacy and Safety of Low Molecular Weight Heparin Versus Unfractionated Heparin for Prevention of Venous Thromboembolism in Trauma Patients

Abstract

Trauma patients are at high risk of VTE. We summarize the efficacy and safety of LMWH versus UFH for the prevention of VTE in trauma patients. Methods: We searched 6 databases from inception through March 12, 2021. We included randomized controlled trials (RCTs) or observational studies comparing LMWH versus UFH for thromboprophylaxis in adult trauma patients. We pooled effect estimates across RCTs and observational studies separately, using random-effects model and inverse variance weighting. We assessed risk of bias using the Cochrane tool for RCTs and the Risk of Bias in Non-Randomized Studies (ROBINS)-I tool for observational studies and assessed certainty of findings using Grading of Recommendations, Assessment, Development and Evaluations methodology. Results: We included 4 RCTs (879 patients) and 8 observational studies (306,747 patients). Based on pooled RCT data, compared to UFH, LMWH reduces deep vein thrombosis (RR 0.67, 95% CI 0.50 to 0.88, moderate certainty) and VTE (RR 0.68, 95% CI 0.51 to 0.90, moderate certainty). As compared to UFH, LMWH may reduce pulmonary embolism [adjusted odds ratio from pooled observational studies 0.56 (95% CI 0.50 to 0.62)] and mortality (adjusted odds ratio from pooled observational studies 0.54, 95% CI 0.45 to 0.65), though based on low certainty evidence. There was an uncertain effect on adverse events (RR from pooled RCTs 0.80, 95% CI 0.48 to 1.33, very low certainty) and heparin induced thrombocytopenia [RR from pooled RCTs 0.26 (95% CI 0.03 to 2.38, very low certainty)]. Conclusions: Among adult trauma patients, LMWH is superior to UFH for deep vein thrombosis and VTE prevention and may additionally reduce pulmonary embolism and mortality. The impact on adverse events and heparin induced thrombocytopenia is uncertain.

A survey of critical care pharmacists on venous thromboembolism prophylaxis dosing practices with enoxaparin in adult trauma patients

“…[4][5][6][7] Historically, enoxaparin 30 mg subcutaneously (SUBQ) every 12 h has been the most common dosing regimen used in clinical practice for trauma patients. [2][3][4][5]8,9 Yet, current literature suggests that higher doses may be required to achieve anti-Factor Xa (anti-Xa) targets and further reduce VTE complications. [10][11][12][13][14][15][16] The clinical practice algorithm from the Western Trauma Association (WTA) was released in November of 2020 and was the first guideline update to recommend a higher standard initial enoxaparin dose; however, we hypothesize that implementation of these dosing recommendations has not occurred consistently in clinical practice.…”

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

“…Moreover, compared to UH, LMWH may reduce PE (adjusted OR 0.56, 95% CI 0.50–0.62) and mortality (adjusted OR 0.54, 95% CI 0.45–0.65). In keeping with the results reported by Tran et al [ 50 ], Jakob et al [ 51 ] analyzed data of 4074 patients with blunt isolated severe liver injuries selected for NOM who received VTE prophylaxis with either UH or LMWH. Notably, LMWH was independently associated with lower mortality (OR 0.36) compared to UH.…”

“…Regarding the choice between LMWH versus UH, indirect evidence from general trauma cases and liver trauma suggests that LMWH is superior to UH for DVT and VTE prevention and may additionally reduce PE and mortality. A recent systematic review and meta-analysis [ 50 ] that included four randomized trials for a total of 879 patients and eight observational studies (306,747 patients) found that, based on pooled randomized data, LMWH reduces DVT (RR 0.67, 95% CI 0.50–0.88, moderate certainty) and VTE (RR 0.68, 95% CI 0.51–0.90, moderate certainty) compared to UH. Moreover, compared to UH, LMWH may reduce PE (adjusted OR 0.56, 95% CI 0.50–0.62) and mortality (adjusted OR 0.54, 95% CI 0.45–0.65).…”

Venous thromboembolism prophylaxis with low molecular weight heparin versus unfractionated heparin for patients undergoing operative treatment of closed femoral shaft fractures

“…Both registry data and a meta-analysis of prospective and retrospective data supports the administration of LMWH over unfractionated heparin for VTE prophylaxis in all trauma patients. 10,12 Jacobs et al found decreased odds of not only mortality but also PE and DVT for LMWH compared to unfractionated heparin in an analysis of the Michigan Trauma Quality Improvement Program. 12 Additional data supporting the use of LMWH over unfractionated heparin comes from studies of spine trauma patients and patients who sustain traumatic brain injuries.…”