Trauma patients with lower extremity and pelvic fractures: Should anti-factor Xa trough level guide prophylactic enoxaparin dose?

Dhillon, Navpreet K.; Smith, Eric; Gillette, Emma; Mason, Russell; Barmparas, Galinos; Gewertz, Bruce L.; Ley, Eric J.

doi:10.1016/j.ijsu.2018.01.023

Cited by 29 publications

(43 citation statements)

References 30 publications

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“…The study showed that in the majority of patients (84.5%) who had anti-Xa trough levels measured, the initial enoxaparin dose being given was sub prophylactic. Patients who were given enoxaparin according to anti-Xa trough level had a significantly lower risk of VTE compared to those in which anti-Xa levels were not measured; (1.7% v. 13.9%, p = 0.03) [ 36 ]. Since LMWHs are mostly excreted by the kidneys, they can accumulate in patients with renal insufficiency and thus have increased the risk of causing bleeding.…”

Section: Reviewmentioning

confidence: 99%

Thromboprophylaxis in Intensive Care Unit Patients: A Literature Review

Ejaz

Ahmed

Tasleem

et al. 2018

Cureus

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Thromboembolism is a major complication in hospitalized patients. Intensive care unit (ICU) patients have a greater risk of thrombotic events due to additional risk factors such as immobilization, mechanical ventilation, and central catheters. The diagnosis and management of deep vein thrombosis (DVT) and pulmonary embolism (PE) in critically ill patients are challenging and these conditions are associated with high mortality. Medical thromboprophylaxis with low molecular weight heparin (LMWH) as well as unfractionated heparin (UFH) has been shown to reduce the incidence of thromboembolic events in such patients. For patients with high risk of bleeding, mechanical thromboprophylaxis can be used. Literature database was conducted on Medline for articles published up to 2018 using particular search terms such as thromboprophylaxis and venous thromboembolism in ICU patients. The following review summarizes the existing data regarding thromboprophylaxis in ICU patients with special consideration to the use of mechanical prophylaxis and pharmacologic prophylaxis using heparin products.

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Section: Reviewmentioning

confidence: 99%

Thromboprophylaxis in Intensive Care Unit Patients: A Literature Review

Ejaz

Ahmed

Tasleem

et al. 2018

Cureus

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“…Target AFXa-TR range was defined as 0.11 – 0.20 IU/mL, based on evidence in hip replacement patients suggesting increased VTE risk with an AFXa-TR < 0.11 IU/mL and increased bleeding risk with an AFXa-TR > 0.20 IU/mL 9. This range has also been used in recent publications assessing enoxaparin dosing in trauma patients 6,7. All statistical analyses were performed using Microsoft© Excel 15.33 and presented using descriptive statistics, including number (n) and percentage (%) for categorical data and mean and standard deviation (SD) or median and interquartile range (IQR) for continuous data.…”

Section: Methodsmentioning

confidence: 99%

“…This regimen is based on limited evidence and there are at least three studies suggesting similar VTE rates when compared to once daily enoxaparin or three times daily unfractionated heparin 2-4. Interestingly, recent evidence has identified rare achievement of target anti-factor Xa trough concentrations (AFXa-TR) and significant VTE reduction when adjusting enoxaparin dose to achieve AFXa-TRs of 0.11 - 0.20 IU/mL 5-7. Some experts, therefore, recommend adjusting enoxaparin in trauma patients based on AFXa-TR 6,7…”

Section: Introductionmentioning

confidence: 99%

“…Interestingly, recent evidence has identified rare achievement of target anti-factor Xa trough concentrations (AFXa-TR) and significant VTE reduction when adjusting enoxaparin dose to achieve AFXa-TRs of 0.11 - 0.20 IU/mL 5-7. Some experts, therefore, recommend adjusting enoxaparin in trauma patients based on AFXa-TR 6,7…”

Section: Introductionmentioning

confidence: 99%

“…In June 2017, Upstate University Hospital started adjusting enoxaparin VTE prophylaxis based on AFXa-TR in trauma patients admitted to the SICU based on discussion between pharmacy and attending trauma physicians about the above noted literature 1-7. Upstate University Hospital has a multidisciplinary SICU team that includes an attending surgical physician who specializes in trauma care, three surgical residents, a pharmacist who specializes in critical care, and nurses certified in the treatment of trauma patients.…”

Section: Introductionmentioning

confidence: 99%

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

Scrimenti¹,

Seabury²,

Miller³

et al. 2019

Pharm Pract (Granada)

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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.

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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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Trauma patients with lower extremity and pelvic fractures: Should anti-factor Xa trough level guide prophylactic enoxaparin dose?

Cited by 29 publications

References 30 publications

Thromboprophylaxis in Intensive Care Unit Patients: A Literature Review

Thromboprophylaxis in Intensive Care Unit Patients: A Literature Review

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

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

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