Pharmacist recommendations for prophylactic enoxaparin monitoring and dose adjustment in trauma patients admitted to a surgical intensive care unit

Abstract

Background:There is limited information describing pharmacist participation in prophylactic enoxaparin monitoring in the surgical intensive care unit (SICU).Objective:Our study sought to: 1) characterize pharmacist recommendations for enoxaparin monitoring in trauma patients admitted to the SICU, 2) describe the frequency that medical providers accept pharmacist recommendations for enoxaparin monitoring in trauma patients admitted to the SICU, and 3) illustrate the frequency that trauma patients admitted to our SICU service achieve anti-factor Xa trough concentrations (AFXa-TRs) of 0.11 - 0.20 IU/mL following pharmacist recommendation to adjust prophylactic enoxaparin dosing.Methods:Adult patients who had an AFXa-TR drawn after at least three consecutive prophylactic enoxaparin doses between June 1, 2017 and March 1, 2018 were identified through chart review and included in this study. Patients were excluded based on the following criteria: 1) age less than 18 years, 2) anti-factor Xa (AFXa) level not representative of a trough concentration, 3) AFXa-TR not representative of steady state concentration, and 4) non-trauma based prophylactic enoxaparin dosing. This study was exempt from IRB review.Results:The final analysis consisted of 42 patients. A pharmacist provided at least one recommendation in 97.6% (41/42) of trauma patients with enoxaparin monitoring during their SICU stay. In total, a pharmacist made 170 recommendations, mean of 4.2 (SD 1.8) recommendations per patient. Recommendations were: 1) obtain an AFXa-TR, n=90; 2) adjust enoxaparin dose based on AFXa-TR, n=58; and 3) maintain enoxaparin dose based on AFXa-TR, n=22. Medical providers accepted 89.4% (152/170) of pharmacist recommendations for enoxaparin monitoring. Dose adjustments were made in 33 patients following pharmacist recommendation; of these, 27 had a repeat AFXa-TR following at least one dose adjustment. Target AFXa-TRs were achieved in 19/27 patients, indicating 70.4% had recommended AFXa concentrations.Conclusions:Pharmacists provided recommendations for prophylactic enoxaparin monitoring and dose adjustment in trauma patients admitted to the SICU. Medical providers regularly accepted pharmacist recommendations and trauma patients commonly achieved target AFXa-TR following pharmacist recommendation for dose adjustment. Further research is required to identify the optimal enoxaparin dose for VTE prophylaxis in trauma patients.

Current status survey of the extramural hospital management of venous thromboembolism after total hip and knee arthroplasty in China

“…However, a considerable number of patients might discontinue anticoagulant therapy when they are discharged or after a short period of anticoagulant treatment. For such patients, health education, strengthening communication between them and their doctors, paying attention to the control of risk factors, and regular monitoring are helpful to improve the compliance with anticoagulation treatment and reduce the risk of bleeding [30]. The results of understanding VTE disease demonstrated that most enrolled patients knew basic disease information and were able to respond to different situations during VTE treatment.…”

Venous thromboembolism prevention protocol for adapting prophylaxis recommendations to the potential risk post total knee replacement: a randomized controlled trial

“…22 In this study, a debate could emerge about what is exactly behind the findings, what is the real effect of patients' educational programs or even the novel risk stratification procedure. Actually, these findings should be attributed to the clinical pharmacists' interventions, whether in patients' educational programs or VTE prophylaxis recommendations through the usage of the novel risk stratification procedure, as stated by Scrimenti et al (2019), that all clinical pharmacists can provide education and make recommendations, interpret, and adjust VTE prophylaxis medications' dosing, and this is exactly what is done in this study, when the clinical pharmacist are allowed to intervene, directly the differences in the outcomes will be apparent. 23 Caprini risk assessment tool includes general points for all medical and surgical patients, but the novel risk stratification procedure is specific for TKR patients, in which TKR patients can be categorized into low, moderate, or high VTE risk, which is, in turn, will allow to choose the suitable preventive therapy and duration for each patient according to his/her risk category.…”

Impact of a clinical pharmacist in ultrasound-guided venous thromboembolism screening in hospitalized COVID-19 patients: a pilot prospective study.

“…This clinical pharmacist facilitated COVID-19 patients' ultrasound screening, diagnosis, and monitoring of prophylactic and full anticoagulation treatment. [18][19][20][21]47 This multidisciplinary team was adapted from previous programs that utilized a similar dynamic for management of trauma-related anticoagulation…”

“…In such models, the clinical pharmacist's duties include medication stewardship in addition to the screening, diagnosis, and monitoring of prophylactic and full anticoagulation treatment. [18][19][20][21] Since the start of the COVID-19 pandemic, experience from China, Europe and the United States has revealed that clinical pharmacists are essential for providing event-driven pharmaceutical care which goes beyond routine activities such as medication review, prescription support, and patient counselling. 13,14,[22][23][24][25] Here, the coordination of four-extremity screening ultrasound for all admitted COVID-19 patients was added to the workload of the clinical pharmacist.…”