Standard Prophylactic Enoxaparin Dosing Leads to Inadequate Anti-Xa Levels and Increased Deep Venous Thrombosis Rates in Critically Ill Trauma and Surgical Patients

Malinoski, Darren; Jafari, Fariba; Ewing, Tyler; Ardary, Chris; Conniff, Heather; Baje, Mark; Kong, Allen; Lekawa, Michael; Dolich, Matthew; Cinat, Marianne; Barrios, Cristobal; Hoyt, David B.

doi:10.1097/ta.0b013e3181d32271

Cited by 151 publications

(164 citation statements)

References 28 publications

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“…However, evidence that implementation of anti-Xa monitoring might reduce the risk of VTE in critically ill patients is still scarce [23]. Variability and lack of standardization are the most relevant drawbacks of anti-Xa assays [24], and evidence of a strong relationship between anti-Xa and the occurrence of thromboembolic events is still lacking [25].…”

Section: 00mentioning

confidence: 99%

Thromboelastographic predictors of venous thromboembolic events in critically ill patients

Tartamella

Vassallo

Berlot

et al. 2016

Blood Coagulation &Amp; Fibrinolysis

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Deep venous thromboembolism and pulmonary embolism are still underdiagnosed in the ICU. Thromboelastography (TEG) has shown considerable variability in sensitivity and specificity as a predictor of venous thromboembolism (VTE). We designed a prospective double-blind observational study to predict the risk of VTE using TEG in a cohort of critically ill patients. Seventy-two hours after admission in the ICU and consequent prophylaxis with low-molecular-weight heparin, we performed compressive color-Doppler ultrasound and diagnosed deep venous thrombosis. Computed tomography scan was performed for the diagnosis of pulmonary embolism if pulmonary embolism was suspected based on physical examination and transthoracic echocardiography. Whole blood samples were obtained from central venous lines 6-8 h after subcutaneous administration of low-molecular-weight heparin. Native TEG and modified heparinase TEG were performed using a Thromboelastograph Coagulation Analyzer. Fifty-seven patients were consecutively enrolled of which six (10.5%) developed deep venous thrombosis; two (3.5%) also developed pulmonary embolism. The native thrombodynamic ratio (TDR) was an independent predictor of the odds of thrombosis (odds ratio 1.016, P < 0.05, 95% confidence interval 1.008-1.047), with a 0.93 area under the ROC curve. Using 10.6 as the lower cut-off point, TDR showed 100% sensitivity and 0 negative likelihood ratio (95% confidence interval 0-0.4) in excluding the clinical diagnosis of VTE. Our results show that TDR predicts VTE in the ICU. Our findings are in agreement with those reported by other investigators, who demonstrated that a TDR less that 10 is associated with prophylactic levels of anti-Xa.

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Section: 00mentioning

confidence: 99%

Thromboelastographic predictors of venous thromboembolic events in critically ill patients

Tartamella

Vassallo

Berlot

et al. 2016

Blood Coagulation &Amp; Fibrinolysis

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“…24 Indeed while much of the existing literature has focused on altered antibiotic drug handling with this phenomenon, 25,26 ARC has the potential to influence the pharmacokinetics of any renally cleared agent. Examples in the neurocritical care environment include low molecular weight heparins, 27,28 and anti-seizure medications, 29 both of which manifest largely silent pharmacodynamic endpoints. In this fashion, inadequate dosing in the setting of ARC primarily manifests as adverse clinical consequences from treatment failure (e.g.…”

Section: Page 14 Of 28mentioning

confidence: 99%

Augmented Renal Clearance in Traumatic Brain Injury: A Single-Center Observational Study of Atrial Natriuretic Peptide, Cardiac Output, and Creatinine Clearance

Udy

Jarrett

Lassig-Smith

et al. 2017

Journal of Neurotrauma

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Augmented renal clearance (ARC) is being increasingly described in neurocritical care practice. The mechanisms driving this phenomenon are largely unknown. The aim of this project was therefore to explore changes in renal function, cardiac output (CO), and atrial natriuretic peptide (ANP) concentrations in patients with isolated traumatic brain injury (TBI). This prospective observational cohort study was conducted in a tertiary-level, university-affiliated intensive care unit (ICU). Patients with normal plasma creatinine concentrations (<120 μmol/L) at admission and no history of chronic kidney disease, admitted with isolated TBI, were eligible for enrollment. Continuous CO measures were obtained using arterial pulse waveform analysis. Eight-hour urinary creatinine clearances (CL) were used to quantify renal function. ANP concentrations in plasma were measured on alternate days. Data were collected from study enrollment until ICU discharge, death, or day 15, which ever came first. Eleven patients, contributing 100 ICU days of physiological data, were enrolled into the study. Most participants were young men, requiring mechanical ventilation. Median ICU length of stay was 9.6 [7.8-13.0] days. Elevated CL measures (>150 mL/min) were frequent and appeared to parallel changes in CO. Plasma ANP concentrations were also significantly elevated over the study period (minimum value = 243 pg/mL). These data suggest that ARC is likely to complicate the care of TBI patients with normal plasma creatinine concentrations, and may be driven by associated cardiovascular changes and/or elevated plasma ANP concentrations. However, significant additional research is required to further understand these findings.

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“…Recent studies show that VTE rates may be directly correlated with anti-factor Xa activity levels, so some VTE prophylaxis protocols incorporate activity level monitoring to ensure adequacy [22]. Activity level monitoring is generally not available prior to role 3 care and consensus does not exist for the monitoring requirement.…”

Section: Prevention Of Deep Venous Thrombosismentioning

confidence: 99%

Venous Thromboembolism Among Military Combat Casualties

Fang

Rodríguez

2016

Curr Trauma Rep

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Venous thromboembolism (VTE) complicates trauma no matter whether injuries occur in the civilian or combat setting. Combat casualty care is further challenged by the requirement to rapidly evacuate patients by air from the combat zone to definitive care destinations in the USA. The Joint Trauma System (JTS) is charged with ensuring optimal management of the combat injured across the global care continuum. The JTS first released guidelines for BPrevention of deep venous thrombosis^in December 2004 and regularly revises it to ensure it reflects current, best practice. This review presents a perspective on VTE impact on wartime care and the US military medical system's effort to prevent these complications.

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Standard Prophylactic Enoxaparin Dosing Leads to Inadequate Anti-Xa Levels and Increased Deep Venous Thrombosis Rates in Critically Ill Trauma and Surgical Patients

Abstract: Standard dosing of enoxaparin leads to low anti-Xa levels in half of surgical ICU patients. Low levels are associated with a significant increase in the risk of DVT. These data support future studies using adjusted-dose enoxaparin.

Cited by 151 publications

References 28 publications

Thromboelastographic predictors of venous thromboembolic events in critically ill patients

Thromboelastographic predictors of venous thromboembolic events in critically ill patients

Augmented Renal Clearance in Traumatic Brain Injury: A Single-Center Observational Study of Atrial Natriuretic Peptide, Cardiac Output, and Creatinine Clearance

Venous Thromboembolism Among Military Combat Casualties

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