Which Trauma Patients Require Lower Enoxaparin Dosing for Venous Thromboembolism Prophylaxis?

Veatch, Jessica M; Hashim, Yassar; Dhillon, Navpreet K.; Toscano, Samantha; Mason, Russell; Lin, Tsan‐Shiun; Barmparas, Galinos; Ley, Eric J.

doi:10.1177/0003134820964497

Cited by 7 publications

(9 citation statements)

References 13 publications

(24 reference statements)

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“…Care should be taken when dosing enoxaparin by weight in middle age or elderly obese trauma patients who have a low to normal creatinine clearance and, therefore, may require less than the predicted enoxaparin dose 31 . Similarly, young thin trauma patients with a high creatinine clearance may require a higher than predicted enoxaparin dose 32 . Whatever the dose, pharmacologic prophylaxis should be provided early and continuously for most trauma patients while avoiding missed doses for orthopedic and other surgical procedures 22 .…”

Section: Protocol Rationale and Goalsmentioning

confidence: 99%

“…31 Similarly, young thin trauma patients with a high creatinine clearance may require a higher than predicted enoxaparin dose. 32 Whatever the dose, pharmacologic prophylaxis should be provided early and continuously for most trauma patients while avoiding missed doses for orthopedic and other surgical procedures. 22 For patients with end-stage renal disease or a creatinine clearance of less than 30 mL/min, subcutaneous unfractionated heparin (UH) at 5000 units every 8 hours is the preferred pharmacologic VTE prophylaxis.…”

Section: Dosing Of Pharmacologic Vte Prophylaxismentioning

confidence: 99%

“…29 Importantly, weight is not a significant predictor of which patients require a high or low enoxaparin dose, rather the creatinine clearance is the only independent factor that predicts the dose in high and low weight patients. 31,32 Care should be taken when dosing enoxaparin by weight in middle age or elderly obese trauma patients who have a low to normal creatinine clearance and, therefore, may require less than the predicted enoxaparin dose. 31 Similarly, young thin trauma patients with a high creatinine clearance may require a higher than predicted enoxaparin dose.…”

Section: Dosing Of Pharmacologic Vte Prophylaxismentioning

confidence: 99%

“…For patients with a body mass index greater than 30, enoxaparin may be dosed at 0.5 mg/kg twice daily 29 . Importantly, weight is not a significant predictor of which patients require a high or low enoxaparin dose, rather the creatinine clearance is the only independent factor that predicts the dose in high and low weight patients 31,32 . Care should be taken when dosing enoxaparin by weight in middle age or elderly obese trauma patients who have a low to normal creatinine clearance and, therefore, may require less than the predicted enoxaparin dose 31 .…”

Section: Protocol Rationale and Goalsmentioning

confidence: 99%

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American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma

Yorkgitis

Berndtson

Cross

et al. 2021

J Trauma Acute Care Surg

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Trauma patients are at increased risk of venous thromboembolism (VTE), which includes both deep vein thrombosis and pulmonary embolism. Pharmacologic VTE prophylaxis is a critical component of optimal trauma care that significantly decreases VTE risk. Optimal VTE prophylaxis protocols must manage the risk of VTE with the competing risk of hemorrhage in patients following significant trauma. Currently, there is variability in VTE prophylaxis protocols across trauma centers. In an attempt to optimize VTE prophylaxis for the injured patient, stakeholders from the American Association for the Surgery of Trauma and the American College of Surgeons-Committee on Trauma collaborated to develop a group of consensus recommendations as a resource for trauma centers. The primary goal of these recommendations is to help standardize VTE prophylaxis strategies for adult trauma patients (age ≥15 years) across all trauma centers. This clinical protocol has been developed to (1) provide standardized medication dosing for VTE prophylaxis in the injured patient; and (2) promote evidence-based, prompt VTE prophylaxis in common, high-risk traumatic injuries.

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Section: Protocol Rationale and Goalsmentioning

confidence: 99%

Section: Dosing Of Pharmacologic Vte Prophylaxismentioning

confidence: 99%

Section: Dosing Of Pharmacologic Vte Prophylaxismentioning

confidence: 99%

Section: Protocol Rationale and Goalsmentioning

confidence: 99%

See 2 more Smart Citations

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma

Yorkgitis

Berndtson

Cross

et al. 2021

J Trauma Acute Care Surg

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“…Customized dosing using the patient’s creatinine dosing may result in better optimized initial enoxaparin dosing. 34 35 …”

Section: Discussionmentioning

confidence: 99%

Characterizing the delays in adequate thromboprophylaxis after TBI

Dhillon

Hashim

Berezin

et al. 2021

Trauma Surg Acute Care Open

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BackgroundWe sought to compare enoxaparin dosing for venous thromboembolism (VTE) prophylaxis in trauma patients with and without traumatic brain injury (TBI) to better understand the time and dose required to reach target anti-Xa levels. Our hypothesis was that patients with TBI have significant delays in the initiation of adequate pharmacological prophylaxis and require a higher enoxaparin dose than currently recommended.MethodsThe medical records of trauma patients who received enoxaparin dosing based on anti-Xa trough levels between August 2014 and October 2016 were reviewed. Patients were included if their anti-Xa trough level reached the target range (0.1 IU/mL to 0.2 IU/mL).ResultsA total of 163 patients had anti-Xa levels within the target range of which 41 (25.2%) had TBI. Patients with TBI had longer delays before initiating enoxaparin (7.5 days vs. 1.5 days after admission, p<0.01) and were more likely to receive unfractionated heparin prior to enoxaparin (46.3% vs. 11.5%, p<0.01). Anti-Xa levels reached the target range later in patients with TBI (11 days vs. 5 days after admission, p<0.01). Enoxaparin 40 mg two times per day was the median dose required to reach the target anti-Xa levels for both cohorts. VTE rates were higher among patients with TBI (22.0% vs. 9.0%, p=0.03). Four patients (9.8%) had progression of their intracranial hemorrhage prior to receiving enoxaparin, although none progressed during enoxaparin administration.ConclusionAmong patients with TBI who reached target anti-Xa levels, 11 days after admission were required to reach a median enoxaparin dose of 40 mg two times per day. Unfractionated heparin was used as pharmacological prophylaxis in about half of these patients. The delay in reaching the target anti-Xa levels and the use of unfractionated heparin likely contribute to the higher VTE rate in patients with TBI.Level of evidenceLevel III, therapeutic.

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A survey of critical care pharmacists on venous thromboembolism prophylaxis dosing practices with enoxaparin in adult trauma patients

McNeill

Alexander

Ladd

et al. 2023

J Am Coll Clin Pharm

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Enoxaparin is the preferred treatment for venous thromboembolism (VTE) prophylaxis in trauma patients, but timing of initiation, optimal dosing, and therapeutic drug monitoring remain controversial. The objective of this study was to evaluate enoxaparin VTE prophylaxis practices in adult trauma patients across trauma centers in the United States and compare results to current guideline recommendations. An online survey designed by the study investigators was sent to pharmacist members of the American College of Clinical Pharmacy (ACCP) Critical Care Practice Research Network (PRN) and residency directors of institutions with accredited Critical Care Pharmacy Residency programs in the fall of 2021. This survey queried pharmacists' self‐reported practices regarding enoxaparin dosing and monitoring in trauma patients. One hundred five responses were collected with an estimated response rate of 5.3%. Most respondents reported using a standard enoxaparin dose of 30 mg subcutaneously (SUBQ) every 12 h (67%; 70/104) in trauma patients with normal renal function and higher initial dosing for obese trauma patients (75%; 78/104). The most common body mass index (BMI) threshold for dose adjustments in obesity was a BMI ≥40 kg/m2; whereas 100 kg or more was commonly reported for a weight threshold. Multiple alternative enoxaparin dosing regimens were reported for obese and overweight patients. Of respondents who monitor anti‐Factor Xa (anti‐Xa) levels, 84% (61/73) reported monitoring peak levels with 47% (29/61) targeting a peak anti‐Xa goal of 0.2–0.4 units/ml. Seventy‐five percent (51/68) of respondents who adjust enoxaparin dosing based on anti‐Xa level monitoring reported adjusting doses by increments of 10 mg SUBQ every 12 h, and 41% (28/68) indicated having a pharmacist‐driven protocol for dose adjustments. Significant variation exists in enoxaparin dosing and monitoring strategies for VTE prophylaxis. Consensus among clinical practice guidelines is needed to standardize practice nationally.

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Which Trauma Patients Require Lower Enoxaparin Dosing for Venous Thromboembolism Prophylaxis?

Cited by 7 publications

References 13 publications

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma

Characterizing the delays in adequate thromboprophylaxis after TBI

A survey of critical care pharmacists on venous thromboembolism prophylaxis dosing practices with enoxaparin in adult trauma patients

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