Survey of venous thromboembolism prophylaxis in trauma patients: current prescribing practices and concordance with clinical practice guidelines

Abstract

ObjectivesPharmacological venous thromboembolism (VTE) prophylaxis is recommended in the vast majority of trauma patients. The purpose of this study was to characterize current dosing practices and timing of initiation of pharmacological VTE chemoprophylaxis at trauma centers.MethodsThis was an international, cross-sectional survey of trauma providers. The survey was sponsored by the American Association for the Surgery of Trauma (AAST) and distributed to AAST members. The survey included 38 questions about practitioner demographics, experience, level and location of trauma center, and individual/site-specific practices regarding the dosing, selection, and timing of initiation of pharmacological VTE chemoprophylaxis in trauma patients.ResultsOne hundred eighteen trauma providers responded (estimated response rate 6.9%). Most respondents were at level 1 trauma centers (100/118; 84.7%) and had >10 years of experience (73/118; 61.9%). While multiple dosing regimens were used, the most common dose reported was enoxaparin 30 mg every 12 hours (80/118; 67.8%). The majority of respondents (88/118; 74.6%) indicated adjusting the dose in patients with obesity. Seventy-eight (66.1%) routinely use antifactor Xa levels to guide dosing. Respondents at academic institutions were more likely to use guideline-directed dosing (based on the Eastern Association of the Surgery of Trauma and the Western Trauma Association guidelines) of VTE chemoprophylaxis compared with those at non-academic centers (86.2% vs 62.5%; p=0.0158) and guideline-directed dosing was reported more often if the trauma team included a clinical pharmacist (88.2% vs 69.0%; p=0.0142). Wide variability in initial timing of VTE chemoprophylaxis after traumatic brain injury, solid organ injury, and spinal cord injuries was found.ConclusionsA high degree of variability exists in prescribing and monitoring practices for the prevention of VTE in trauma patients. Clinical pharmacists may be helpful on trauma teams to optimize dosing and increase prescribing of guideline-concordant VTE chemoprophylaxis.

A Murine Polytrauma Model for the Study of Thromboinflammation

“…Trauma-induced coagulopathy is a significant source of morbidity and mortality in trauma patients, and current therapies including standard chemoprophylaxis with low-molecular weight heparin (enoxaparin), although effective when applied as intended, come with significant challenges 20 . Specifically, trauma patients often have concurrent injuries with risk of life-threatening hemorrhage that preclude administration of early chemoprophylaxis, leading to delays in administration and increased long-term VTE risk 20 . As such, there is a pressing need to better understand the mechanisms behind TIC, specifically accelerated thrombin generation, which is a known independent predictor of VTE risk, after injury 3 .…”

‘Door-to-prophylaxis’ as a novel quality improvement metric in prevention of venous thromboembolism following traumatic injury

“…initiating CP within this time period. 17 Institutional CP protocols are commonly lacking, placing patients at risk for VTE, 17 and furthermore, the risk of unnecessarily prolonging CP initiation in severely injured patients by the hour is undefined.…”

“… 8 15 16 Despite evidence to support the safety and efficacy of “early” initiation of CP within 48 hours, many centers struggle with initiating CP within this time period. 17 Institutional CP protocols are commonly lacking, placing patients at risk for VTE, 17 and furthermore, the risk of unnecessarily prolonging CP initiation in severely injured patients by the hour is undefined.…”