Brendan J Cronin1, Laura N Godat2, Allison E Berndtson3, Arielle Pham4, Shobha Kolan5, Kevin Box6, Jeanne G Lee7, Todd W Costantini8. 1. Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, United States. Electronic address: bjcronin@ucsd.edu. 2. Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, United States. Electronic address: lgodat@ucsd.edu. 3. Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, United States. Electronic address: aberndtson@ucsd.edu. 4. Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, United States. Electronic address: aepham@ucsd.edu. 5. Department of Pharmacy, UC San Diego Health,United States. Electronic address: skolan@ucsd.edu. 6. Department of Pharmacy, UC San Diego Health,United States. Electronic address: kbox@ucsd.edu. 7. Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, United States. Electronic address: jgl003@ucsd.edu. 8. Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, United States. Electronic address: tcostantini@ucsd.edu.
Abstract
INTRODUCTION: Patients recovering from burn injury are at high risk of developing deep venous thrombosis (DVT). While 30-mg twice-daily enoxaparin is accepted as the standard prophylactic dose, recent evidence in injured patients suggests this dosing strategy may result in sub-optimal pharmacologic DVT prophylaxis. We hypothesized that standard enoxaparin dosing would result in inadequate DVT prophylaxis in burn patients. METHODS: A retrospective review of an ABA-verified Burn center's registry from January 2012 - December 2016 identified patients with peak plasma anti-Xa levels to monitor the efficacy of pharmacologic DVT prophylaxis. Patients ≥18 years old were included if they received at least 3 doses of enoxaparin and had appropriately timed peak anti-Xa levels. We analyzed data including patient demographics, body weight, body mass index (BMI) and total body surface area burn (TBSA). Diagnosis of DVT was collected. RESULTS: During the study period, 393 patients were screened with a plasma anti-Xa levels. Of the 157 patients that met inclusion criteria, 81 (51.6%) achieved target peak plasma anti-Xa levels (0.2-0.4 IU/mL) on standard 30-mg twice-daily prophylactic enoxaparin and 76 (48.4%) had sub-prophylactic levels. Sub-prophylactic patients were more likely to be male, have increased body weight and elevated BMI. 49 of the 76 sub-prophylactic patients received a dose-adjustment in order to reach target anti-Xa levels; 37 patients required 40mg twice-daily, 10 required 50mg twice-daily and 2 required 60mg twice-daily. The overall DVT rate was 3.8%. CONCLUSIONS: The current recommended prophylactic dose of 30-mg twice-daily enoxaparin is inadequate in many burn patients. Alternate dosing strategies should be considered to increase the number of burn patients achieving target prophylactic anti-Xa levels. Determining whether prophylactic enoxaparin dose adjustment decreases DVT rates in burn injured patients should be evaluated in future prospective trials.
INTRODUCTION:Patients recovering from burn injury are at high risk of developing deep venous thrombosis (DVT). While 30-mg twice-daily enoxaparin is accepted as the standard prophylactic dose, recent evidence in injured patients suggests this dosing strategy may result in sub-optimal pharmacologic DVT prophylaxis. We hypothesized that standard enoxaparin dosing would result in inadequate DVT prophylaxis in burn patients. METHODS: A retrospective review of an ABA-verified Burn center's registry from January 2012 - December 2016 identified patients with peak plasma anti-Xa levels to monitor the efficacy of pharmacologic DVT prophylaxis. Patients ≥18 years old were included if they received at least 3 doses of enoxaparin and had appropriately timed peak anti-Xa levels. We analyzed data including patient demographics, body weight, body mass index (BMI) and total body surface area burn (TBSA). Diagnosis of DVT was collected. RESULTS: During the study period, 393 patients were screened with a plasma anti-Xa levels. Of the 157 patients that met inclusion criteria, 81 (51.6%) achieved target peak plasma anti-Xa levels (0.2-0.4 IU/mL) on standard 30-mg twice-daily prophylactic enoxaparin and 76 (48.4%) had sub-prophylactic levels. Sub-prophylactic patients were more likely to be male, have increased body weight and elevated BMI. 49 of the 76 sub-prophylactic patients received a dose-adjustment in order to reach target anti-Xa levels; 37 patients required 40mg twice-daily, 10 required 50mg twice-daily and 2 required 60mg twice-daily. The overall DVT rate was 3.8%. CONCLUSIONS: The current recommended prophylactic dose of 30-mg twice-daily enoxaparin is inadequate in many burn patients. Alternate dosing strategies should be considered to increase the number of burn patients achieving target prophylactic anti-Xa levels. Determining whether prophylactic enoxaparin dose adjustment decreases DVT rates in burn injured patients should be evaluated in future prospective trials.
Authors: Eric J Ley; Carlos V R Brown; Ernest E Moore; Jack A Sava; Kimberly Peck; David J Ciesla; Jason L Sperry; Anne G Rizzo; Nelson G Rosen; Karen J Brasel; Rosemary Kozar; Kenji Inaba; Matthew J Martin Journal: J Trauma Acute Care Surg Date: 2020-11 Impact factor: 3.313
Authors: Navpreet K Dhillon; Yassar M Hashim; Naomi Berezin; Felix Yong; Geena Conde; Russell Mason; Eric J Ley Journal: Trauma Surg Acute Care Open Date: 2021-05-10