Anti-Xa Guided Enoxaparin Thromboprophylaxis Reduces Rate Of Deep Venous Thromboembolism In High-Risk Trauma Patients

George A. Singer, Gina Riggi, Charles A. Karcutskie, Tanaz M. Vaghaiwalla, Howard M Lieberman, Enrique Ginzburg, Nicholas Namias, Edward Lineen

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Abstract

BACKGROUND: Appropriate prophylaxis against venous thromboembolism (VTE) remains undefined. This study evaluated an anti-Xa-guided enoxaparin thromboprophylaxis protocol on the incidence of VTE in high-risk trauma patients based upon Greenfield’s Risk Assessment Profile (RAP) score. METHODS: This is a retrospective observational study of patients admitted to a trauma ICU over a 12-month period. Patients were included if they received anti-Xa-guided enoxaparin thromboprophylaxis. Dosage was adjusted to a prophylactic peak anti-Xa level of 0.2-0.4 IU/ml. Subgroup analysis was performed on high-risk patients (RAP score ≥ 10) who received lower extremity duplex ultrasound surveillance for deep vein thrombosis (DVT). Data are expressed as mean ± standard deviation. Significance was assessed at p<0.05. RESULTS: 131 patients received anti-Xa-guided enoxaparin thromboprophylaxis. Four patients were excluded for age or acute VTE on admission. 56 patients with RAP score ≥ 10 and surveillance duplex evaluations were included in the subgroup analysis with mean age 43±20 years, injury severity score 25±10, and RAP score 16±4. Prophylactic anti-Xa levels were initially achieved in 34.6% of patients. An additional 25.2% required 40-60mg BID to reach prophylactic levels. 39.4% never reached prophylactic levels. Weight, BMI, ISS, and RAP score were significantly higher with sub-prophylactic anti-Xa levels. One patient developed bleeding complications (0.8%). No patient developed intra-cerebral bleeding or heparin-induced thrombocytopenia.Nine VTE occurred in the high-risk subgroup, including four DVT (7.1%), all asymptomatic, and five pulmonary emboli (8.9%). The historical rate of DVT in similar patients (ISS 31±12 and RAP score 16±5) was 20.5%, a significant decrease [p=0.031]. Mean chest AIS scores were significantly higher for patients developing pulmonary emboli than DVT, 3.0±1.1 vs 0.0 [p<0.001]. CONCLUSIONS: Mean chest AIS was higher in patients developing PE. Increased weight, BMI, ISS, and RAP score are associated with sub-prophylactic anti-Xa levels. Anti-Xa-guided enoxaparin dosing reduced the rate of DVT from 20.5% to 7.1% in high-risk trauma patients. LEVEL OF EVIDENCE: Retrospective study using historical controls, level IV.

Original languageEnglish (US)
JournalJournal of Trauma and Acute Care Surgery
DOIs
StateAccepted/In press - Aug 3 2016

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Enoxaparin
Venous Thromboembolism
Wounds and Injuries
Venous Thrombosis
Embolism
Thorax
Retrospective Studies
Hemorrhage
Weights and Measures
Lung
Injury Severity Score
Thrombocytopenia

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery

Cite this

@article{dc21c256b29d47c195a7cc097591477f,
title = "Anti-Xa Guided Enoxaparin Thromboprophylaxis Reduces Rate Of Deep Venous Thromboembolism In High-Risk Trauma Patients",
abstract = "BACKGROUND: Appropriate prophylaxis against venous thromboembolism (VTE) remains undefined. This study evaluated an anti-Xa-guided enoxaparin thromboprophylaxis protocol on the incidence of VTE in high-risk trauma patients based upon Greenfield’s Risk Assessment Profile (RAP) score. METHODS: This is a retrospective observational study of patients admitted to a trauma ICU over a 12-month period. Patients were included if they received anti-Xa-guided enoxaparin thromboprophylaxis. Dosage was adjusted to a prophylactic peak anti-Xa level of 0.2-0.4 IU/ml. Subgroup analysis was performed on high-risk patients (RAP score ≥ 10) who received lower extremity duplex ultrasound surveillance for deep vein thrombosis (DVT). Data are expressed as mean ± standard deviation. Significance was assessed at p<0.05. RESULTS: 131 patients received anti-Xa-guided enoxaparin thromboprophylaxis. Four patients were excluded for age or acute VTE on admission. 56 patients with RAP score ≥ 10 and surveillance duplex evaluations were included in the subgroup analysis with mean age 43±20 years, injury severity score 25±10, and RAP score 16±4. Prophylactic anti-Xa levels were initially achieved in 34.6{\%} of patients. An additional 25.2{\%} required 40-60mg BID to reach prophylactic levels. 39.4{\%} never reached prophylactic levels. Weight, BMI, ISS, and RAP score were significantly higher with sub-prophylactic anti-Xa levels. One patient developed bleeding complications (0.8{\%}). No patient developed intra-cerebral bleeding or heparin-induced thrombocytopenia.Nine VTE occurred in the high-risk subgroup, including four DVT (7.1{\%}), all asymptomatic, and five pulmonary emboli (8.9{\%}). The historical rate of DVT in similar patients (ISS 31±12 and RAP score 16±5) was 20.5{\%}, a significant decrease [p=0.031]. Mean chest AIS scores were significantly higher for patients developing pulmonary emboli than DVT, 3.0±1.1 vs 0.0 [p<0.001]. CONCLUSIONS: Mean chest AIS was higher in patients developing PE. Increased weight, BMI, ISS, and RAP score are associated with sub-prophylactic anti-Xa levels. Anti-Xa-guided enoxaparin dosing reduced the rate of DVT from 20.5{\%} to 7.1{\%} in high-risk trauma patients. LEVEL OF EVIDENCE: Retrospective study using historical controls, level IV.",
author = "Singer, {George A.} and Gina Riggi and Karcutskie, {Charles A.} and Vaghaiwalla, {Tanaz M.} and Lieberman, {Howard M} and Enrique Ginzburg and Nicholas Namias and Edward Lineen",
year = "2016",
month = "8",
day = "3",
doi = "10.1097/TA.0000000000001193",
language = "English (US)",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
publisher = "Lippincott Williams and Wilkins",

}

TY - JOUR

T1 - Anti-Xa Guided Enoxaparin Thromboprophylaxis Reduces Rate Of Deep Venous Thromboembolism In High-Risk Trauma Patients

AU - Singer, George A.

AU - Riggi, Gina

AU - Karcutskie, Charles A.

AU - Vaghaiwalla, Tanaz M.

AU - Lieberman, Howard M

AU - Ginzburg, Enrique

AU - Namias, Nicholas

AU - Lineen, Edward

PY - 2016/8/3

Y1 - 2016/8/3

N2 - BACKGROUND: Appropriate prophylaxis against venous thromboembolism (VTE) remains undefined. This study evaluated an anti-Xa-guided enoxaparin thromboprophylaxis protocol on the incidence of VTE in high-risk trauma patients based upon Greenfield’s Risk Assessment Profile (RAP) score. METHODS: This is a retrospective observational study of patients admitted to a trauma ICU over a 12-month period. Patients were included if they received anti-Xa-guided enoxaparin thromboprophylaxis. Dosage was adjusted to a prophylactic peak anti-Xa level of 0.2-0.4 IU/ml. Subgroup analysis was performed on high-risk patients (RAP score ≥ 10) who received lower extremity duplex ultrasound surveillance for deep vein thrombosis (DVT). Data are expressed as mean ± standard deviation. Significance was assessed at p<0.05. RESULTS: 131 patients received anti-Xa-guided enoxaparin thromboprophylaxis. Four patients were excluded for age or acute VTE on admission. 56 patients with RAP score ≥ 10 and surveillance duplex evaluations were included in the subgroup analysis with mean age 43±20 years, injury severity score 25±10, and RAP score 16±4. Prophylactic anti-Xa levels were initially achieved in 34.6% of patients. An additional 25.2% required 40-60mg BID to reach prophylactic levels. 39.4% never reached prophylactic levels. Weight, BMI, ISS, and RAP score were significantly higher with sub-prophylactic anti-Xa levels. One patient developed bleeding complications (0.8%). No patient developed intra-cerebral bleeding or heparin-induced thrombocytopenia.Nine VTE occurred in the high-risk subgroup, including four DVT (7.1%), all asymptomatic, and five pulmonary emboli (8.9%). The historical rate of DVT in similar patients (ISS 31±12 and RAP score 16±5) was 20.5%, a significant decrease [p=0.031]. Mean chest AIS scores were significantly higher for patients developing pulmonary emboli than DVT, 3.0±1.1 vs 0.0 [p<0.001]. CONCLUSIONS: Mean chest AIS was higher in patients developing PE. Increased weight, BMI, ISS, and RAP score are associated with sub-prophylactic anti-Xa levels. Anti-Xa-guided enoxaparin dosing reduced the rate of DVT from 20.5% to 7.1% in high-risk trauma patients. LEVEL OF EVIDENCE: Retrospective study using historical controls, level IV.

AB - BACKGROUND: Appropriate prophylaxis against venous thromboembolism (VTE) remains undefined. This study evaluated an anti-Xa-guided enoxaparin thromboprophylaxis protocol on the incidence of VTE in high-risk trauma patients based upon Greenfield’s Risk Assessment Profile (RAP) score. METHODS: This is a retrospective observational study of patients admitted to a trauma ICU over a 12-month period. Patients were included if they received anti-Xa-guided enoxaparin thromboprophylaxis. Dosage was adjusted to a prophylactic peak anti-Xa level of 0.2-0.4 IU/ml. Subgroup analysis was performed on high-risk patients (RAP score ≥ 10) who received lower extremity duplex ultrasound surveillance for deep vein thrombosis (DVT). Data are expressed as mean ± standard deviation. Significance was assessed at p<0.05. RESULTS: 131 patients received anti-Xa-guided enoxaparin thromboprophylaxis. Four patients were excluded for age or acute VTE on admission. 56 patients with RAP score ≥ 10 and surveillance duplex evaluations were included in the subgroup analysis with mean age 43±20 years, injury severity score 25±10, and RAP score 16±4. Prophylactic anti-Xa levels were initially achieved in 34.6% of patients. An additional 25.2% required 40-60mg BID to reach prophylactic levels. 39.4% never reached prophylactic levels. Weight, BMI, ISS, and RAP score were significantly higher with sub-prophylactic anti-Xa levels. One patient developed bleeding complications (0.8%). No patient developed intra-cerebral bleeding or heparin-induced thrombocytopenia.Nine VTE occurred in the high-risk subgroup, including four DVT (7.1%), all asymptomatic, and five pulmonary emboli (8.9%). The historical rate of DVT in similar patients (ISS 31±12 and RAP score 16±5) was 20.5%, a significant decrease [p=0.031]. Mean chest AIS scores were significantly higher for patients developing pulmonary emboli than DVT, 3.0±1.1 vs 0.0 [p<0.001]. CONCLUSIONS: Mean chest AIS was higher in patients developing PE. Increased weight, BMI, ISS, and RAP score are associated with sub-prophylactic anti-Xa levels. Anti-Xa-guided enoxaparin dosing reduced the rate of DVT from 20.5% to 7.1% in high-risk trauma patients. LEVEL OF EVIDENCE: Retrospective study using historical controls, level IV.

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U2 - 10.1097/TA.0000000000001193

DO - 10.1097/TA.0000000000001193

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C2 - 27488490

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JO - Journal of Trauma and Acute Care Surgery

JF - Journal of Trauma and Acute Care Surgery

SN - 2163-0755

ER -