1540: BLOOD VOLUME, TBW, AND BMI-BASED ENOXAPARIN DOSING STRATEGIES IN TRAUMA PATIENTS FOR VTE PROPHYLAXIS

Background: Patients admitted to hospital for surgery or acute medical illnesses have a high risk for venous thromboembolism (VTE). Today’s widespread use of low molecular weight heparins (LMWH) for VTE prophylaxis is supposed to have reduced VTE rates substantially. However, data concerning the overall effectiveness of LMWH prophylaxis is sparse. Patients and methods: We prospectively studied all patients with symptomatic and objectively confirmed VTE seen in our hospital over a three year period. Event rates in different wards were analysed and compared. VTE prophylaxis with Enoxaparin was given to all patients at risk during their hospital stay. Results: A total of 50 464 inpatients were treated during the study period. 461 examinations were carried out for symptoms suggestive of VTE and yielded 89 positive results in 85 patients. Seventy eight patients were found to have deep vein thrombosis, 7 had pulmonary embolism, and 4 had both deep venous thrombosis and pulmonary embolism. The overall in hospital VTE event rate was 0.17%. The rate decreased during the study period from 0.22 in year one to 0,16 in year two and 0.13 % in year three. It ranged highest in neurologic and trauma patients (0.32%) and lowest (0.08%) in gynecology-obstetrics. Conclusions: With a simple and strictly applied regimen of prophylaxis with LMWH the overall rate of symptomatic VTE was very low in our hospitalized patients. Beside LMWH prophylaxis, shortening hospital stays and substantial improvements in surgical and anasthesia techniques achieved during the last decades probably play an essential role in decreasing VTE rates.

Download Full-text

A Weight- and Anti-Xa-Guided Enoxaparin Dosing Protocol for VTE Prophylaxis in ICU Trauma Patients

Journal of Surgical Research ◽

10.1016/j.jss.2021.02.034 ◽

2021 ◽

Vol 265 ◽

pp. 122-130

Author(s):

Rachel Bigos ◽

Edmond Solomon ◽

Jon D. Dorfman ◽

Michael Ha

Keyword(s):

Trauma Patients ◽

Vte Prophylaxis

Download Full-text

Massive Transfusion Protocol and Subsequent Development of Venous Thromboembolism: Statewide Analysis

The American Surgeon ◽

10.1177/0003134820948905 ◽

2020 ◽

pp. 000313482094890

Author(s):

Eric H. Bradburn ◽

Kwok M. Ho ◽

Madison E. Morgan ◽

Lauren D’Andrea ◽

Tawnya M. Vernon ◽

...

Keyword(s):

Venous Thromboembolism ◽

Injury Severity ◽

Massive Transfusion ◽

Subsequent Development ◽

Multivariate Logistic Regression Model ◽

Trauma Patients ◽

Vte Prophylaxis ◽

Vein Thrombosis ◽

Hemorrhagic Event ◽

High Index Of Suspicion

Background Massive transfusion protocols (MTP) are a routine component of any major trauma center’s armamentarium in the management of exsanguinating hemorrhages. Little is known about the potential complications of those that survive a MTP. We sought to determine the incidence of venous thromboembolism (VTE) following MTP. We hypothesized that MTP would be associated with a higher risk of VTE when compared with a risk-adjusted control population without MTP. Methods The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2015 to 2018 for trauma patients who developed VTE and survived until discharge at accredited trauma centers in Pennsylvania. Patient demographics, injury severity, and clinical outcomes were compared to assess differences in VTE development between MTP and non-MTP patients. A multivariate logistic regression model assessed the adjusted impact of MTP on VTE development. Results 176 010 patients survived until discharge, meeting inclusion criteria. Of those, 1667 developed a VTE (pulmonary embolism [PE]: 662 [0.4%]; deep vein thrombosis [DVT]: 1142 [0.6%]; PE and DVT: 137 [0.1%]). 1268 patients (0.7%) received MTP and, of this subset of patients, 171 (13.5%) developed a VTE during admission. In adjusted analysis, patients who had a MTP and survived until discharge had a higher odds of developing a VTE (adjusted odds ratio: 2.62; 95% CI: 2.13-3.24; P < .001). Discussion MTP is a harbinger for higher risk of VTE in those patients who survive. This may, in part, be related to the overcorrection of coagulation deficits encountered in the hemorrhagic event. A high index of suspicion for the development of VTE as well as aggressive VTE prophylaxis is warranted in those patients who survive MTP.

Download Full-text

1543: NOVEL BLOOD VOLUME-BASED GUIDELINE VERSUS WESTERN TRAUMA ASSOCIATION GUIDELINE FOR VTE PROPHYLAXIS

Critical Care Medicine ◽

10.1097/01.ccm.0000812496.99917.91 ◽

2021 ◽

Vol 50 (1) ◽

pp. 775-775

Author(s):

William Peppard ◽

David Herrmann ◽

Allison Samuei ◽

Elizabeth Langenstroer ◽

Lisa Rein ◽

...

Keyword(s):

Blood Volume ◽

Vte Prophylaxis

Download Full-text

Time is of the Essence: Impact of a More Aggressive Chemical Venous Thromboembolism Prophylaxis Regimen on Trauma Patients

The American Surgeon ◽

10.1177/00031348211050839 ◽

2021 ◽

pp. 000313482110508

Author(s):

Thomas J. Schroeppel ◽

Lesley P. Clement ◽

Alyssa A. Douville ◽

Nathan H. Schmoekel ◽

Jerry Stassinopoulos ◽

...

Keyword(s):

Venous Thromboembolism ◽

Length Of Stay ◽

Injury Severity Score ◽

Severity Score ◽

Injury Severity ◽

Statistical Significance ◽

Linear Regression Analysis ◽

Trauma Patients ◽

Thromboembolism Prophylaxis ◽

Vte Prophylaxis

Background Trauma patients are at high risk for venous thromboembolism (VTE). Opportunity for chemical VTE prophylaxis improvement was identified and practice was altered to start chemoprophylaxis on admission in most patients. The purpose of this study was to determine if early VTE prophylaxis is safe and reduces VTE. Methods The trauma registry was queried over a 12-month period for patients admitted greater than 1 day for traumatic injury. The study spanned 6 months on either side of instituting aggressive chemoprophylaxis. Patients were risk adjusted on demographics, Injury Severity Score, transfusions, procedure type, length of stay, and mortality. Pre-intervention patients were then compared to patients in the aggressive cohort with the primary outcome of VTE. Secondary outcomes included transfusions, mortality, and length of stay (LOS). Results 1597 patients were identified over the study period with 754 (47%) patients in the aggressive period. There were no differences in age, sex, Injury Severity Score, transfusions, procedures, or LOS between cohorts. Pre-algorithm patients were more likely to have penetrating mechanism (9.3% vs 6.6%; P = .009) and longer time to VTE prophylaxis (23.3 vs 13.9 hours; P < .001). No differences were noted in anticoagulant, VTE rate (2.0% vs 1.2%; P = .195), or mortality. Linear regression analysis identified time to chemical prophylaxis as significant predictor of VTE (β = 43.9, P < .001). Conclusions Early aggressive chemical VTE prophylaxis is safe without increasing transfusions. Venous thromboembolism rates were decreased, but did not reach statistical significance.

Download Full-text

Increased Enoxaparin Dosing for Venous Thromboembolism Prophylaxis in General Trauma Patients

Annals of Pharmacotherapy ◽

10.1177/1060028016683970 ◽

2016 ◽

Vol 51 (4) ◽

pp. 323-331 ◽

Cited By ~ 13

Author(s):

Cheri K. Walker ◽

Elizabeth A. Sandmann ◽

Taylor J. Horyna ◽

Mark A. Gales

Keyword(s):

Venous Thromboembolism ◽

Trauma Patient ◽

Patient Population ◽

Standard Dose ◽

Bleeding Complications ◽

Trauma Patients ◽

Dosing Regimen ◽

Thromboembolism Prophylaxis ◽

General Trauma ◽

Vte Prophylaxis

Objective: To review the evidence regarding increased enoxaparin dosing for venous thromboembolism (VTE) prophylaxis in the general trauma patient population. Data Sources: A search of MEDLINE databases (1946 to October 2016) was conducted using the search terms enoxaparin, thromboembolism prophylaxis, venous thromboembolism, trauma, anti-factor Xa, and weight-based dosing. Additional references were identified from a review of literature citations. Study Selection and Data Extraction: Search results were limited to English-language studies conducted in humans. Trials that included only obese patients or nontrauma patients were excluded. Data Synthesis: A total of 7 trials (958 patients) explored the use of increased dosing of enoxaparin for VTE prophylaxis in trauma patients. Patients were divided by enoxaparin dosing strategies: standard dosing of 30 mg twice daily (BID; n = 509), higher initial dosing regimen (n = 216), or dosing based on anti-FXa level adjustments (n = 233). The majority of the 42 total VTE events (64.3%) occurred in the standard dosing regimen. Within each group, VTE was reported in 5.3% of patients in the standard dosing group, 3.2% in the higher initial dosing group, and 4% in the anti-FXa adjustment group. Initial subtherapeutic anti-FXa levels occurred in 33% to 92% of standard dose patients and 9% to 39% of higher initial dose patients. The average weight-based dose required to achieve a therapeutic level ranged between 0.43 and 0.54 mg/kg/dose BID. The overall rate of bleeding was low, with 3 incidents (0.37%) reported. Conclusion: Standard-dose enoxaparin prophylaxis may not be optimal for the general trauma patient population. Weight-based enoxaparin dosing (0.5 mg/kg/dose BID) is an option in trauma patients considered to be at a lower risk of bleeding complications.

Download Full-text

Venous thromboembolism prophylaxis practices and outcomes at an Australian level-one trauma service

Trauma ◽

10.1177/14604086211019535 ◽

2021 ◽

pp. 146040862110195

Author(s):

Jordan Hamilton ◽

Annelise Cocco ◽

Rose Shakerian ◽

Michael Wu ◽

Jennifer Wang ◽

...

Keyword(s):

Venous Thromboembolism ◽

Major Trauma ◽

Assessment Tool ◽

Trauma Centre ◽

Trauma Patients ◽

Thromboembolism Prophylaxis ◽

Vte Prophylaxis ◽

Trauma Service ◽

Time To Diagnosis ◽

All Cause Mortality

Background Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major cause of potentially preventable morbidity and mortality amongst trauma patients. Venous thromboembolism prevalence varies from 1 to 58%, and traditionally, compliance with prophylaxis protocols is low in major trauma cohorts. This study aimed to describe VTE prevalence, prophylaxis practices and outcomes amongst VTE cases at an Australian level-one trauma centre. Methods A retrospective review of all VTE cases occurring in acute, major trauma admissions between 1 January 2010 and 30 June 2019 was conducted using prospectively collected registry data. Data regarding demographics, time to diagnosis, VTE prophylaxis, VTE risk assessment tool (RAT) usage and all-cause mortality were collected. Chemoprophylaxis was considered adequate if administered for 48 h prior to diagnosis. VTE cases diagnosed within 48 h of admission were excluded from prophylaxis compliance analysis. A subgroup analysis of patients with intracranial haemorrhage (ICH) was also completed. Results During the study period, 238 VTE events occurred in 237 patients from 7482 major trauma admissions, giving a VTE prevalence of 3.18%. The all-cause mortality rate was 8.0%. VTE chemoprophylaxis was administered for 109 of 211 eligible patients (51.7%). Of the remaining 102 VTE cases, 75 (73.5%) did not receive prophylaxis due to a documented contraindication, while 27 (26.5%) did not receive prophylaxis with no contraindication recorded. The VTE RAT was completed in 49.0% of cases. Conclusion Venous thromboembolism prevalence at our institution was consistent with published figures for comparable institutions. A review of compliance with prophylaxis protocols showed several potential areas for improvement.

Download Full-text

Venous Thromboembolism Prophylaxis in Underweight Hospitalized Patients

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/10760296211018752 ◽

2021 ◽

Vol 27 ◽

pp. 107602962110187

Author(s):

Douglas Buckheit ◽

Amanda Lefemine ◽

Diana M. Sobieraj ◽

Laura Hobbs

Keyword(s):

Venous Thromboembolism ◽

Major Bleeding ◽

Standard Dose ◽

Outcome Analysis ◽

Limited Evidence ◽

Thromboembolism Prophylaxis ◽

Vte Prophylaxis ◽

Reduced Dose ◽

Dosing Strategies ◽

Underweight Patients

There is limited evidence about optimal anticoagulant dosing for venous thromboembolism (VTE) prophylaxis in underweight patients. The purpose of this study was to characterize dosing strategies used in underweight patients and compare the incidence of bleeding and VTE to patients receiving a standard dose. This multi-center retrospective study evaluated medicine patients who weighed 45 kilograms or less and received VTE prophylaxis with unfractionated heparin or enoxaparin. We categorized subjects into groups as either standard or reduced dose and compared the incidence of bleeding and VTE between groups. Of the 300 patients included in the outcome analysis, 40.7% received a reduced dose regimen, most often enoxaparin 30 mg daily. Standard dose was associated with major bleeding compared with reduced dose, when adjusted for age, gender and admission hemoglobin (odds ratio 4.73, 95% confidence interval 1.05 to 21.34). Incidence of clinically relevant non-major bleeding (2.4% vs. 1.1%) and VTE (0.6% vs. 0%) were similar between groups. Anticoagulant dose reduction for VTE prophylaxis in underweight hospitalized medicine patients is common practice and associated with less major bleeding.

Download Full-text

Polygeline in patients with hypovolemia caused by accidental trauma: a prospective, multicentric, safety study

International Surgery Journal ◽

10.18203/2349-2902.isj20181125 ◽

2018 ◽

Vol 5 (4) ◽

pp. 1432 ◽

Cited By ~ 1

Author(s):

Sanjay Shah ◽

Ajai Singh ◽

Sanjay Kala ◽

Rohita Shetty

Keyword(s):

Blood Volume ◽

Vital Sign ◽

Central Venous Oxygen Saturation ◽

Trauma Patients ◽

Volume Loss ◽

Accidental Trauma ◽

Post Marketing ◽

Clinically Significant ◽

Lactate Levels ◽

Time Of Admission

Background: Objective of present study was to evaluate the safety of polygeline (Haemaccel®) and its effect on vital sign parameters in patients with hypovolemia caused by accidental trauma.Methods: Adverse drug reactions (ADRs) of polygeline within 6 hours after administration, and the effect of polygeline infusion on vital sign parameters, in trauma patients hospitalized at the emergency department, were evaluated in this prospective, multicentric, post-marketing observational study.Results: One hundred forty patients (men: 81.4%; women: 18.6%), with a mean (±standard deviation) age of 33.7±10.6 years, were enrolled. At the time of admission, mean blood volume loss was 1400.1±558.8ml, with 86.4% patients reporting blood volume loss of >15%; 49.3% patients presented with class-II hypovolemia. No ADRs or any unusual clinically significant changes were reported within 6 hours of polygeline administration. All vital parameters (blood pressure and pulse rate) significantly improved at 1 hour of polygeline administration; this trend was sustained until 6 hours (p<0.001). Reduction in respiratory rate was significant at 1 and 6 hours versus baseline (p<0.001). Urine output and central venous oxygen saturation also showed significant improvement at 1 and 6 hours after treatment initiation (p<0.001). Arterial pH and mean blood lactate levels also showed a significant change from the baseline (p<0.05) at both 1 and 6 hours.Conclusions: Polygeline was found to be safe and effective in improving hemodynamic stability in patients with hypovolemia due to accidental trauma.

Download Full-text

Enoxaparin Dosing at Extremes of Weight: Literature Review and Dosing Recommendations

Annals of Pharmacotherapy ◽

10.1177/1060028018768449 ◽

2018 ◽

Vol 52 (9) ◽

pp. 898-909 ◽

Cited By ~ 15

Author(s):

Jamie Sebaaly ◽

Kelly Covert

Keyword(s):

Body Weight ◽

Data Extraction ◽

Vte Prophylaxis ◽

High Body Weight ◽

High Body ◽

Study Selection ◽

Treatment Dose ◽

Dosing Regimens ◽

Dosing Strategies ◽

Higher Doses

Objective: To review the literature on both thromboprophylaxis and treatment of venous thromboembolism (VTE) with enoxaparin in low- and high-body-weight patients and to make dosing and monitoring recommendations in these patient populations. Data Sources: A search using PubMed was conducted (1995 to January 2018) using the following key words: enoxaparin, body weight, AND thromboprophylaxis, or AND treatment. Additional references were identified from a review of citations. Study Selection and Data Extraction: Studies included examined the effect of body weight and/or body mass index (BMI) on VTE, bleeding, enoxaparin dosing, and/or anti-Xa concentrations for thromboprophylaxis and treatment-dose enoxaparin. Studies in pediatric and pregnant patients were excluded. Data Synthesis: Optimal enoxaparin dosing strategies for VTE prophylaxis and treatment for patients at extremes of weight have not yet been elucidated by clinical trials; however, data suggest that standard dosing regimens may not be appropriate in these patients. Relevance to Patient Care and Clinical Practice: This review provides a thorough discussion on both thromboprophylaxis and treatment of VTE with enoxaparin in low- and high-body-weight patients. It includes dosing recommendations to guide clinicians caring for these patient populations. Conclusions: Patients at extremes of weight require special consideration to determine appropriate enoxaparin doses. Specifically, low-body-weight patients may benefit from 30 mg subcutaneously daily for VTE prophylaxis, and standard weight-based dosing for VTE treatment. Conversely, in patients with BMIs ≥40 kg/m2, 40 mg subcutaneously twice daily is recommended, with consideration for higher doses in patients with BMIs ≥50 kg/m2.

Download Full-text