Evaluation of an Enoxaparin Dosing Calculator Using Burn Size and Weight

Faraklas, Iris; Ghanem, Maureen; Brown, Amalia; Cochran, Amalia

doi:10.1097/bcr.0b013e3182a2a855

Cited by 29 publications

(22 citation statements)

References 24 publications

(26 reference statements)

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“…The lower than target activity of enoxaparin in this case mirrors previous literature in burn and trauma patients receiving prophylactic dosing of enoxaparin . The largest of these studies is a prospective observational study in which patients were followed throughout their stay and then received a 30‐day follow‐up telephone interview to determine whether VTE events had occurred .…”

Section: Discussionsupporting

confidence: 60%

“…The authors performed linear regression to develop an equation for determining an adequate prophylactic enoxaparin dose, which used both the size of the burn and the patient's body weight. The same group of authors went on to validate this equation at the same institution, revealing an increase in target anti‐Xa level attainment when dosing was based on this equation …”

Section: Discussionmentioning

confidence: 99%

“…4 Since then, several small studies have suggested this alteration of the usual pharmacokinetic profile in both burn and trauma patients, two notably similar groups of patients. [5][6][7][8][9] Lower than target anti-Xa activity observed in this population has been attributed to augmented clearance and increased volume of distribution. 10 To our knowledge, no evidence exists assessing the efficacy of enoxaparin dosing for treatment of VTE in the burn population.…”

Section: Dosing Of Enoxaparin For Deep Vein Thrombosis (Dvt) Prophylamentioning

confidence: 93%

“…A 2004 case series first evaluated enoxaparin dosing in burn patients, detailing lower than target anti‐Xa levels with standard prophylactic doses for deep‐vein thrombosis (DVT) prophylaxis . Since then, several small studies have suggested this alteration of the usual pharmacokinetic profile in both burn and trauma patients, two notably similar groups of patients . Lower than target anti‐Xa activity observed in this population has been attributed to augmented clearance and increased volume of distribution .…”

mentioning

confidence: 99%

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Increased Enoxaparin Dosing Requirements for Treatment of Deep Vein Thrombosis in a Severely Burned Patient: Case Report and Literature Review

2018

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Dosing of enoxaparin for deep vein thrombosis (DVT) prophylaxis in acutely burned patients has been shown to result in anti‐Xa levels below target range. We describe the first case report, to our knowledge, of a severely burned patient who, despite prophylactic dosing of enoxaparin 30 mg subcutaneously twice daily, developed an acute DVT that required high‐dose enoxaparin (100 mg [1.5 mg/kg] subcutaneously every 8 hours) to maintain anti‐Xa levels within the therapeutic range (0.6–1 IU/ml). Pharmacokinetic evaluations were performed using anti‐Xa levels measured throughout the patient's hospital stay to validate the appropriateness of this high‐dose regimen based on established therapeutic anti‐Xa level ranges. These results suggest that routine anti‐Xa level monitoring, regardless of enoxaparin dosing, is necessary for burn patients who are receiving enoxaparin given their hypermetabolic state following injury.

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Section: Discussionsupporting

confidence: 60%

Section: Discussionmentioning

confidence: 99%

Section: Dosing Of Enoxaparin For Deep Vein Thrombosis (Dvt) Prophylamentioning

confidence: 93%

mentioning

confidence: 99%

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Increased Enoxaparin Dosing Requirements for Treatment of Deep Vein Thrombosis in a Severely Burned Patient: Case Report and Literature Review

2018

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“…The presence of hypercoagulability after burn is well established, and both the rate of VTE (11) and the need for increased chemo-prophylactic dosing (33, 34) are correlated with increased burn size. Further, post-mortem human studies show microvascular thrombosis in multiple organs, specifically lung and renal tissues, leading to multiple organ dysfunction syndrome (MODS) and death (35, 36).…”

Section: Discussionmentioning

confidence: 99%

Impact of Platelets and Platelet-Derived Microparticles on Hypercoagulability Following Burn Injury

Kuethe

Rice

Veile

et al. 2016

Shock

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An acute burn induced coagulopathy develops after scald injury, which evolves into a subacute, hypercoagulable state. Microparticles, specifically platelet-derived MPs (PMPs), have been suggested as possible contributors. We first developed a model of burn-induced coagulopathy and then sought to investigate the role of platelets and PMPs in coagulation after burn. We hypothesized that changes in circulating platelet and PMP populations after injury would contribute to the post-burn, hypercoagulable state. A murine scald model with 28% TBSA full thickness burn injury was utilized and blood samples were collected at intervals after injury. Circulating MP populations, platelet counts, overall coagulation, and platelet function were determined. Burn injury led to hypercoagulability on post-burn day one (PBD1), which persisted 6 days after injury (PBD6). On PBD1, there was a significant decrease in platelet numbers and a decline in platelet contribution to clot formation with a concomitant increase in circulating procoagulant PMPs. On PBD6, there was a significant increase in platelet numbers and in platelet activation with no change in PMPs compared with sham. Further, on PBD1 decreased ADP-induced platelet activation was observed with a contrasting increase in ADP-induced platelet activation on PBD6. We therefore concluded that there was a temporal change in the mechanisms leading to a hypercoagulable state after scald injury, that PMPs are responsible for changes seen on PBD1, and finally that ADP-induced platelet activation was key to the augmented clotting mechanisms 6 days after burn.

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Assessment of Anti–Factor Xa Levels of Patients Undergoing Colorectal Surgery Given Once-Daily Enoxaparin Prophylaxis

et al. 2019

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IMPORTANCE Between 4% and 12% of patients undergoing colorectal surgery and receiving enoxaparin, 40 mg per day, have a postoperative venous thromboembolism (VTE) event. An improved understanding of why "breakthrough" VTE events occur despite guideline-compliant prophylaxis is an important patient safety question. OBJECTIVE To determine the proportion of patients undergoing colorectal surgery who received adequate anticoagulation based on peak anti-factor Xa (aFXa) levels while receiving enoxaparin at 40 mg per day. DESIGN, SETTING, AND PARTICIPANTS This prospective, nonrandomized clinical trial was conducted between February 2017 and July 2018 with 90-day follow-up at a quaternary academic medical center in the Intermountain West and included patients undergoing colorectal surgery who had surgery after receiving general anesthesia, were admitted for at least 3 days, and received enoxaparin, 40 mg once daily. INTERVENTIONS All patients had aFXa levels measured after receiving enoxaparin 40 mg per day. Patients whose aFXa level was out of range entered the trial's interventional arm where real-time enoxaparin dose adjustment and repeated aFXa measurement were performed. MAIN OUTCOMES AND MEASURES Primary outcome: in-range peak aFXa levels (goal range, 0.3-0.5 IU/mL) with enoxaparin, 40 mg per day. Secondary outcomes: (1) in-range trough aFXa levels (goal range, 0.1-0.2 IU/mL) and (2) the proportion of patients with in-range peak aFXa levels from enoxaparin, 40 mg once daily, vs the real-time enoxaparin dose adjustment protocol. RESULTS Over 16 months, 116 patients undergoing colorectal surgery (65 women [56.0%]; 99 white individuals [85.3%], 13 Hispanic or Latino individuals [11.2%], and 4 Pacific Islander individuals [3.5%]; mean [range] age, 52.1 [18-85] years) were enrolled. Among 106 patients (91.4%) whose peak aFXa level was appropriately drawn, 72 (67.9%) received inadequate anticoagulation (aFXa < 0.3 IU/mL) with enoxaparin, 40 mg per day. Weight and peak aFXa levels were inversely correlated (r 2 = 0.38). Forty-seven patients (77%) had a trough aFXa level that was not detectable (ie, most patients had no detectable level of anticoagulation for at least 12 hours per day). Real-time enoxaparin dose adjustment was effective. Patients were significantly more likely to achieve an in-range peak aFXa with real-time dose adjustment as opposed to fixed dosing alone (85.4% vs 29.2%, P < .001). CONCLUSIONS AND RELEVANCE This study supports the finding that most patients undergoing colorectal surgery receive inadequate prophylaxis from enoxaparin, 40 mg once daily. These findings may explain the high rate of "breakthrough" VTE observed in many clinical trials. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02704052

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Evaluation of an Enoxaparin Dosing Calculator Using Burn Size and Weight

Cited by 29 publications

References 24 publications

Increased Enoxaparin Dosing Requirements for Treatment of Deep Vein Thrombosis in a Severely Burned Patient: Case Report and Literature Review

Increased Enoxaparin Dosing Requirements for Treatment of Deep Vein Thrombosis in a Severely Burned Patient: Case Report and Literature Review

Impact of Platelets and Platelet-Derived Microparticles on Hypercoagulability Following Burn Injury

Assessment of Anti–Factor Xa Levels of Patients Undergoing Colorectal Surgery Given Once-Daily Enoxaparin Prophylaxis

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