Improving Pharmacologic Prevention of VTE in Trauma: IMPACT-IT QI Project

Abstract

Enoxaparin regimens commonly used for prophylaxis fail to achieve optimal anti-factor Xa levels in up to 70 per cent of trauma patients. Accordingly, trauma services at the study institution endeavored to develop a standardized approach to optimize pharmacologic prevention with enoxaparin. An enoxaparin venous thromboembolism (VTE) prophylaxis protocol implemented in October 2015 provided weight-adjusted initial dosing parameters with subsequent dose titration to achieve targeted anti-factor Xa levels. Symptomatic VTE rate was evaluated 12 months pre- and post-implementation. Data were obtained from the trauma registry and charts were reviewed from electronic medical records. The rate of symptomatic VTE significantly declined post-implementation (2.0% vs 0.9%, P = 0.009). Enoxaparin use was comparable in these two phases validating that the decline in symptomatic VTEs was not due to an increase in enoxaparin use. Symptomatic VTE rate for patients who received enoxaparin in the post-implementation cohort decreased from 3.2 to 1.0 per cent (P = 0.023, 95% confidence interval = 0.124–0.856). There was also a significant decrease in the rate of symptomatic deep vein thrombosis (2.8% vs 0.9%, P = 0.040, 95% confidence interval = 0.117–0.950). This approach to VTE prophylaxis with enoxaparin resulted in a significant reduction in symptomatic VTE rates. Implementation of similar practices may be equally impactful in other institutions that use enoxaparin.

Enoxaparin titrated by anti-Xa levels reduces venous thromboembolism in trauma patients

“…Overall, the results support that using anti-Xa levels to guide LMWH dosing is effective in reducing the overall rate of VTE, consistent with much of the existing literature. 4,[16][17][18][19] Although this study involved thousands of patients, it was still limited by sample size. Because of the low incidence of PE events in the population, the sample size must be exceedingly large to detect small but potentially clinically significant differences.…”

“…[10][11][12][13][14][15] Research in the trauma surgery population generally supports the notion that VTE rates are reduced when anti-Xa levels are in range. 4,[16][17][18][19] However, other studies have not confirmed this relationship, finding no improvement in VTE rates despite in-range anti-Xa levels. [20][21][22] The variability in study outcomes may be explained by small study populations coupled with a very small incidence of VTE rates overall.…”

“…Other studies have implemented protocols for twice daily dosing guided by anti-Xa levels within trauma surgery or general surgery patient populations and demonstrated a reduction in VTE rates. [4][5][6] At the authors' institution, a series of protocols have been initiated to decrease rates of VTE in trauma patients, with recent attention given to modification of enoxaparin dosing based on anti-Xa levels, as well as protocol compliance. The purpose of this research was to explore changes in symptomatic VTE rates at the institution based on protocol iteration.…”

“…Based on this literature, institutions have developed formalized protocols for chemical VTE prophylaxis, but there continues to be some debate regarding the optimal protocol to reduce VTE while still maintaining a low incidence of bleeding complications. [4][5][6] In general, enoxaparin is preferred over UFH for VTE prophylaxis as it is more effective at preventing VTE (15% of patients on UFH and 6% of patients on enoxaparin in one study by Geerts et al 7 ). The anticoagulant effect of enoxaparin can be measured using anti-Xa peak or trough levels.…”

Clinical Characteristics, Management Practices, and In-hospital Outcomes among Trauma Patients with Venous Thromboembolism

“…The use of anti-Xa assay (to measure plasma heparin; UFH and LMWH)-guided thromboprophylaxis is promising for reducing VTE occurrence in trauma patients. [ 30 ] Future studies of anti-Xa-directed therapy (as opposed to prophylaxis) may provide evidence for reassurance in terms of bleeding risk.…”