Importance: The efficacy of anti-factor Xa (anti-Xa)-guided dosing of thromboprophylaxis after trauma remains controversial. Objective: To assess whether dosing of enoxaparin sodium based on peak anti-Xa levels is associated with the venous thromboembolism (VTE) rate after trauma. Design, Setting, and Participants: Retrospective review of 950 consecutive adults admitted to a single level I trauma intensive care unit for more than 48 hours from December 1, 2014, through March 31, 2017. Within 24 hours of admission, these trauma patients were screened with the Greenfield Risk Assessment Profile (RAP) (possible score range, 0-46). Patients younger than 18 years and those with VTE on admission were excluded, resulting in a study population of 792 patients. Exposures: The control group received fixed doses of either heparin sodium, 5000 U 3 times a day, or enoxaparin sodium, 30 mg twice a day. The adjustment cohort initially received enoxaparin sodium, 30 mg twice a day. A peak anti-Xa level was drawn 4 hours after the third dose. If the anti-Xa level was 0.2 IU/mL or higher, no adjustment was made. If the anti-Xa level was less than 0.2 IU/mL, each dose was increased by 10 mg. The process was repeated up to a maximum dose of 60 mg twice a day. Main Outcomes and Measures: Rates of VTE were measured. Venous duplex ultrasonography and computed tomographic angiography were used for diagnosis. Results: The study population comprised 792 patients with a mean (SD) age of 46 (19) years and was composed of 598 men (75.5%). The control group comprised 570 patients, was older, and had a longer time to thromboprophylaxis initiation. The adjustment group consisted of 222 patients, was more severely injured, and had a longer hospital length of stay. The mean (SD) RAP scores were 9 (4) for the control group and 9 (5) for the adjustment group (P = .28). The VTE rates were similar for both groups (34 patients [6.0%] vs 15 [6.8%]; P = .68). Prophylactic anti-Xa levels were reached in 119 patients (53.6%) in the adjustment group. No difference in VTE rates was observed between those who became prophylactic and those who did not (7 patients [5.9%] vs 8 [7.8%]; P = .58). To control for confounders, 132 patients receiving standard fixed-dose enoxaparin were propensity matched to 84 patients receiving dose-adjusted enoxaparin. The VTE rates remained similar between the control and adjustment groups (3 patients [2.3%] vs 3 [3.6%]; P = .57). Conclusions and Relevance: Rates of VTE were not reduced with anti-Xa-guided dosing, and almost half of the patients never reached prophylactic anti-Xa levels; achieving those levels did not decrease VTE rates. Thus, other targets, such as platelets, may be necessary to optimize thromboprophylaxis after trauma.
Importance: The efficacy of anti-factor Xa (anti-Xa)-guided dosing of thromboprophylaxis after trauma remains controversial. Objective: To assess whether dosing of enoxaparin sodium based on peak anti-Xa levels is associated with the venous thromboembolism (VTE) rate after trauma. Design, Setting, and Participants: Retrospective review of 950 consecutive adults admitted to a single level I trauma intensive care unit for more than 48 hours from December 1, 2014, through March 31, 2017. Within 24 hours of admission, these traumapatients were screened with the Greenfield Risk Assessment Profile (RAP) (possible score range, 0-46). Patients younger than 18 years and those with VTE on admission were excluded, resulting in a study population of 792 patients. Exposures: The control group received fixed doses of either heparin sodium, 5000 U 3 times a day, or enoxaparin sodium, 30 mg twice a day. The adjustment cohort initially received enoxaparin sodium, 30 mg twice a day. A peak anti-Xa level was drawn 4 hours after the third dose. If the anti-Xa level was 0.2 IU/mL or higher, no adjustment was made. If the anti-Xa level was less than 0.2 IU/mL, each dose was increased by 10 mg. The process was repeated up to a maximum dose of 60 mg twice a day. Main Outcomes and Measures: Rates of VTE were measured. Venous duplex ultrasonography and computed tomographic angiography were used for diagnosis. Results: The study population comprised 792 patients with a mean (SD) age of 46 (19) years and was composed of 598 men (75.5%). The control group comprised 570 patients, was older, and had a longer time to thromboprophylaxis initiation. The adjustment group consisted of 222 patients, was more severely injured, and had a longer hospital length of stay. The mean (SD) RAP scores were 9 (4) for the control group and 9 (5) for the adjustment group (P = .28). The VTE rates were similar for both groups (34 patients [6.0%] vs 15 [6.8%]; P = .68). Prophylactic anti-Xa levels were reached in 119 patients (53.6%) in the adjustment group. No difference in VTE rates was observed between those who became prophylactic and those who did not (7 patients [5.9%] vs 8 [7.8%]; P = .58). To control for confounders, 132 patients receiving standard fixed-dose enoxaparin were propensity matched to 84 patients receiving dose-adjusted enoxaparin. The VTE rates remained similar between the control and adjustment groups (3 patients [2.3%] vs 3 [3.6%]; P = .57). Conclusions and Relevance: Rates of VTE were not reduced with anti-Xa-guided dosing, and almost half of the patients never reached prophylactic anti-Xa levels; achieving those levels did not decrease VTE rates. Thus, other targets, such as platelets, may be necessary to optimize thromboprophylaxis after trauma.
Authors: Benjamin N Jacobs; Anne H Cain-Nielsen; Jill L Jakubus; Judy N Mikhail; John J Fath; Scott E Regenbogen; Mark R Hemmila Journal: J Trauma Acute Care Surg Date: 2017-07 Impact factor: 3.313
Authors: Chad M Thorson; Mark L Ryan; Robert M Van Haren; Emiliano Curia; Jose M Barrera; Gerardo A Guarch; Alexander M Busko; Nicholas Namias; Alan S Livingstone; Kenneth G Proctor Journal: Crit Care Med Date: 2012-11 Impact factor: 7.598
Authors: Jeffrey N Harr; Ernest E Moore; Theresa L Chin; Arsen Ghasabyan; Eduardo Gonzalez; Max V Wohlauer; Anirban Banerjee; Christopher C Silliman; Angela Sauaia Journal: J Trauma Acute Care Surg Date: 2013-03 Impact factor: 3.313
Authors: Charles A Pierce; Elliott R Haut; Shahrzad Kardooni; David C Chang; David T Efron; Adil Haider; Peter J Pronovost; Edward E Cornwell Journal: J Trauma Date: 2008-04
Authors: Sunil X Anand; Michael C Kim; Mazullah Kamran; Samin K Sharma; Annapoorna S Kini; Jawed Fareed; Debra A Hoppensteadt; Frank Carbon; Erdal Cavusoglu; David Varon; Juan F Viles-Gonzalez; Juan J Badimon; Jonathan D Marmur Journal: Am J Cardiol Date: 2007-06-13 Impact factor: 2.778
Authors: Jessica C Cardenas; Yao-Wei Wang; Jay V Karri; Seenya Vincent; Andrew P Cap; Bryan A Cotton; Charles E Wade Journal: Thromb Res Date: 2020-01-15 Impact factor: 3.944
Authors: Mitchell R Dyer; Wyeth Alexander; Adnan Hassoune; Qiwei Chen; Tomasz Brzoska; Jurgis Alvikas; Yingjie Liu; Shannon Haldeman; Will Plautz; Patricia Loughran; Hui Li; Brian Boone; Yoel Sadovsky; Prithu Sundd; Brian S Zuckerbraun; Matthew D Neal Journal: J Thromb Haemost Date: 2019-07-28 Impact factor: 5.824
Authors: Molly Elizabeth Droege; Christopher Allen Droege; Carolyn Dosen Philpott; Megan Leslie Webb; Neil Edward Ernst; Krishna Athota; Devin Wakefield; Joseph Richard Dowd; Dina Gomaa; Bryce H R Robinson; Dennis Hanseman; Joel Elterman; Eric William Mueller Journal: J Thromb Thrombolysis Date: 2021-05-12 Impact factor: 2.300
Authors: Joseph F Rappold; Forest R Sheppard; Samuel P Carmichael Ii; Joseph Cuschieri; Eric Ley; Erika Rangel; Anupamaa J Seshadri; Christopher P Michetti Journal: Trauma Surg Acute Care Open Date: 2021-02-24
Authors: Jan Benes; Roman Skulec; Jakub Jobanek; Vladimir Cerny Journal: Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub Date: 2021-05-27 Impact factor: 1.245