Goal directed enoxaparin dosing provides superior chemoprophylaxis against deep vein thrombosis

Kopelman, Tammy R.; Walters, Jarvis; Bogert, James N.; Basharat, Usmaan; Pieri, Paola G.; Davis, Karole M.; Quan, Asia N; Vail, Sydney J.; Pressman, Melissa A.

doi:10.1016/j.injury.2016.10.039

Cited by 20 publications

(16 citation statements)

References 19 publications

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“…A large retrospective study in trauma patients from North America demonstrated no reduction in VTE with twice daily fractionated heparin dosed to achieve peak anti-Xa levels of 0.2-0.4 IU/ml [18] . In comparison, several other studies in trauma patients, including one prospective cohort study, have demonstrated that prophylactic anti-Xa activity can be achieved by up-titrating doses and that these adjustments were associated with a reduction in DVT [13,15,16] . Doses in these trials have been increased to a maximum of 0.55 mg/kg or 60 mg enoxaparin BD to minimise bleeding.…”

Section: Relationship With Previous Studiesmentioning

confidence: 84%

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The ATLANTIC study: Anti-Xa level assessment in trauma intensive care

Rakhra

Martin

Fitzgerald

et al. 2020

Injury

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Section: Relationship With Previous Studiesmentioning

confidence: 84%

“…Currently, it is not standard practice in ANZ to measure anti-Xa activity in patients receiving prophylactic LMWH. However, existing data suggest dose adjustment based on peak anti-Xa levels, may reduce the incidence of deep vein thrombosis (DVT) [12][13][14][15][16] .…”

Section: Introductionmentioning

confidence: 99%

The ATLANTIC study: Anti-Xa level assessment in trauma intensive care

Rakhra

Martin

Fitzgerald

et al. 2020

Injury

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“…Up to 44% of patients with traumatic injuries develop VTE, and it remains a common cause of morbidity and mortality in these patients 1 . The utilization of prophylactic enoxaparin is considered the standard of care for VTE prevention in this population, 1,2 but the longstanding fixed‐dose regimen of 30 mg twice daily may not provide adequate anti‐factor Xa (anti‐Xa) concentrations in most trauma patients 3,4 …”

Section: Introductionmentioning

confidence: 99%

Evaluation of anti‐factor Xa concentrations using a body mass index‐based enoxaparin dosing protocol for venous thromboembolism prophylaxis in trauma patients

et al. 2022

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Objective The aim of this study was to evaluate the effectiveness of a body mass index (BMI)‐based enoxaparin prophylaxis dosing protocol at achieving target anti‐factor Xa (anti‐Xa) concentrations in the trauma population. Methods This retrospective chart review evaluated anti‐Xa concentrations in adult trauma patients who received prophylactic enoxaparin over a three‐month period. The primary outcome was the percentage of patients that achieved target anti‐Xa concentrations after ≥3 doses of enoxaparin. Secondary outcomes included correlations of anti‐Xa concentrations with enoxaparin dose per BMI, total body weight (TBW), and estimated blood volume (EBV). The prevalence of clinically relevant bleeding and venous thromboembolism was also recorded. Multivariable logistic regression was used to identify associated variables for target anti‐Xa concentration attainment. Results Ninety‐nine consecutive patients were included in the study. Included patients were predominately male (69.7%) and Black (50.5%) with a mean age of 44.1 years. Target anti‐Xa concentrations were achieved in 62.6% of patients. Anti‐Xa concentrations were moderately correlated with enoxaparin dose per EBV (ρ = 0.57), followed by dose per TBW (ρ = 0.46), and dose per BMI (ρ = 0.20). Multivariable logistic regression demonstrated that categorization of enoxaparin dose per EBV and per TBW were the only statistically significant predictors of reaching target anti‐Xa concentrations (p = <0.001). Conclusions In adult trauma patients, the rate of achieving target anti‐Xa concentrations remains suboptimal and provides room for further improvement. Enoxaparin dose per EBV was more closely correlated with anti‐Xa concentrations when compared to TBW and BMI. Dosing per EBV and TBW was the only variables associated with reaching target anti‐Xa concentrations within the study. Further investigation is warranted to elucidate optimal EBV‐ and TBW‐based dosing regimens.

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“…Moreover, a literature review suggested a weight-based dose of 0.5 mg/kg every 12 hours resulted in achieving a prophylactic anti-Xa concentration, but adequately powered studies are necessary to confirm the impact on VTE rate versus bleeding incidence [60,61]. In our study, 19/63 (30.15%) indicated weight-based dosing after discussion with clinical pharmacist.…”

Section: Discussionmentioning

confidence: 77%

Timing and Dose of Pharmacological Thromboprophylaxis in Adult Trauma Patients: Perceptions, Barriers, and Experience of Saudi Arabia Practicing Physicians

Amer

Bawazeer

Maghrabi

et al. 2021

Preprint

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BackgroundPharmacological venous thromboembolism prophylaxis (PVTE-Px) in trauma care is challenging and frequently delayed until post injury bleeding risk is perceived to be sufficiently low; yet data for optimal initiation time is lacking. This study assessed practice pattern of PVTE-Px initiation time and dose in traumatic brain injury (TBI), spinal cord injury (SCI), and non-operative (NOR) solid organ injuries.MethodsMulticenter, cross sectional, observational, survey-based study involving intensivists, trauma surgeons, general surgeons, spine orthopedics, and neurosurgeons practicing in trauma centers. The data of demographics, PVTE-Px timing and dose, and five clinical case scenarios were obtained. Analyses were stratified by early initiators vs. late initiators and logistic regression models were used to identify factors associated with early initiation of PVTE-Px.ResultsOf 102 physicians (29 % response rate), most respondents were intensivists (63.7%) and surgeons (who are general and trauma surgeons) (22.5%); majority were consultants (58%), practicing at level 1 trauma centers (40.6%) or academic teaching hospitals (45.1%). A third of respondents (34.2%) indicated that decision to initiate PVTE-Px in TBI and SCI was made by a consensus between surgical, critical care, and neurosurgical services. For patients with NOR solid organ injuries, 34.2% of respondents indicated trauma surgeons initiated the decision on PVTE-Px timing. About 53.7% of the respondents considered their PVTE-Px practice as appropriate, half used combined mechanical and PVTE-Px (57.1%), 52% preferred enoxaparin (40 mg once daily), and only 6.5% used anti-Xa level to guide enoxaparin prophylactic dose. Responses to clinical cases varied. For TBI and TBI with intracranial pressure monitor, 40.3% and 45.6% of the respondents were early initiators with stable repeated head computed tomography [CT], respectively. For SCI, most respondents were early initiators without repeated CT spine (36.8%). With regards to NOR solid organ injuries [gunshot wound to the liver and grade IV splenic injuries], 49.1% and 36.4% of respondents were early initiators without a repeat CT abdomen.ConclusionsVariations were observed in PVTE-Px initiation time influenced by trauma type. Our findings suggested enoxaparin is preferred in a standard prophylactic dose. More robust data from randomized trials are needed and the use of clinicians’ judgment is recommended.Key MessagesIdeal time to initiate therapy, agent selection, dosing, and monitoring of pharmacological venous thromboembolism prophylaxis (PVTE-Px) for trauma patients is challenging.Variations were observed in PVTE-Px initiation time influenced by trauma type.Our study results are relatively in line with the recent evidence-based clinical literatureOur findings suggested limited awareness of augmented renal clearance (ARC) and utilization of serum anti-factor-Xa (anti-Xa) level.

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Goal directed enoxaparin dosing provides superior chemoprophylaxis against deep vein thrombosis

Cited by 20 publications

References 19 publications

The ATLANTIC study: Anti-Xa level assessment in trauma intensive care

The ATLANTIC study: Anti-Xa level assessment in trauma intensive care

Evaluation of anti‐factor Xa concentrations using a body mass index‐based enoxaparin dosing protocol for venous thromboembolism prophylaxis in trauma patients

Timing and Dose of Pharmacological Thromboprophylaxis in Adult Trauma Patients: Perceptions, Barriers, and Experience of Saudi Arabia Practicing Physicians

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