Journal of Trauma and Injury

The Korean Society of Traumatology (대한외상학회)
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Evaluating chemical venous thromboembolism prophylaxis in trauma patients at a single Australian center

  • Received : 2024.04.03
  • Accepted : 2024.08.29
  • Published : 2024.09.30
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Abstract

Purpose: Trauma patients are at an elevated risk of developing venous thromboembolism (VTE), with the subsequent mortality in patients requiring intensive care unit admission ranging from 25% to 38%. There remains significant variability in clinical practice related to VTE prophylaxis in trauma patients due to the frequent presence of contraindications impacting the timing and consistency of application. This study aimed to assess the effectiveness of the current practice of chemical VTE prophylaxis in trauma patients at a single Australian center. Methods: A prospective review was conducted on patients admitted to the ACT Trauma Service (Canberra, Australia) from July to November 2022. The included patients were 18 years or older, without a direct contraindication to anticoagulation, who received chemical VTE prophylaxis with low-molecular-weight heparin (enoxaparin) for at least three doses and underwent subsequent testing of anti-factor Xa (aFXa) levels. Results: During the study period, 187 patients were admitted, of whom 63 were included in the study. Of these, 47 patients achieved therapeutic levels of anticoagulation as determined by their aFXa levels, while 16 were subtherapeutic. The only statistically significant difference between the two groups was in weight, with patients in the subtherapeutic group weighing an average of 91.9 kg compared to 79.1 kg in the therapeutic group (P<0.05). Conclusions: A fixed-dose enoxaparin regimen was utilized, with limited individualization based on patient factors, such as injuries, comorbidities, and other biological factors. Sixteen patients (25%) had subtherapeutic VTE prophylaxis, as measured by aFXa levels. Higher weight was significantly correlated with inadequate VTE prophylaxis dosing. While age, sex, and smoking status might play important roles in clinical decision-making, weight-based dosing of low-molecular-weight heparin may be more effective in achieving adequate VTE prophylaxis.

Keywords

Acknowledgement

Data collection for this research was supported by the ACT Trauma Service.

References

  1. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994;331:1601-6.  https://doi.org/10.1056/NEJM199412153312401
  2. Bendinelli C, Balogh Z. Postinjury thromboprophylaxis. Curr Opin Crit Care 2008;14:673-8.  https://doi.org/10.1097/MCC.0b013e3283196538
  3. Selby R, Geerts W, Ofosu FA, et al. Hypercoagulability after trauma: hemostatic changes and relationship to venous thromboembolism. Thromb Res 2009;124:281-7.  https://doi.org/10.1016/j.thromres.2008.10.002
  4. Meissner MH, Chandler WL, Elliott JS. Venous thromboembolism in trauma: a local manifestation of systemic hypercoagulability? J Trauma 2003;54:224-31.  https://doi.org/10.1097/01.TA.0000046253.33495.70
  5. Pottier P, Hardouin JB, Lejeune S, Jolliet P, Gillet B, Planchon B. Immobilization and the risk of venous thromboembolism: a meta-analysis on epidemiological studies. Thromb Res 2009;124:468-76.  https://doi.org/10.1016/j.thromres.2009.05.006
  6. Van Haren RM, Valle EJ, Thorson CM, et al. Hypercoagulability and other risk factors in trauma intensive care unit patients with venous thromboembolism. J Trauma Acute Care Surg 2014;76:443-9. https://doi.org/10.1097/TA.0b013e3182a9d11d
  7. Gao X, Zeng L, Wang H, et al. Prevalence of venous thromboembolism in intensive care units: a meta-analysis. J Clin Med 2022;11:6691. 
  8. Bahloul M, Chaari A, Dammak H, et al. Post-traumatic pulmonary embolism in the intensive care unit. Ann Thorac Med 2011;6:199-206.  https://doi.org/10.4103/1817-1737.84773
  9. Paffrath T, Wafaisade A, Lefering R, et al. Venous thromboembolism after severe trauma: incidence, risk factors and outcome. Injury 2010;41:97-101.  https://doi.org/10.1016/j.injury.2009.06.010
  10. Nathens AB, McMurray MK, Cuschieri J, et al. The practice of venous thromboembolism prophylaxis in the major trauma patient. J Trauma 2007;62:557-63.  https://doi.org/10.1097/TA.0b013e318031b5f5
  11. Rappold JF, Sheppard FR, Carmichael Ii SP, et al. Venous thromboembolism prophylaxis in the trauma intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2021;6:e000643. 
  12. Yorkgitis BK, Berndtson AE, Cross A, et al. American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma. J Trauma Acute Care Surg 2022;92:597-604.  https://doi.org/10.1097/TA.0000000000003475
  13. Rostas JW, Brevard SB, Ahmed N, et al. Standard dosing of enoxaparin for venous thromboembolism prophylaxis is not sufficient for most patients within a trauma intensive care unit. Am Surg 2015;81:889-92.  https://doi.org/10.1177/000313481508100923
  14. Ko A, Harada MY, Barmparas G, et al. Association between enoxaparin dosage adjusted by anti-factor Xa trough level and clinically evident venous thromboembolism after trauma. JAMA Surg 2016;151:1006-13.  https://doi.org/10.1001/jamasurg.2016.1662
  15. Walker CK, Sandmann EA, Horyna TJ, Gales MA. Increased enoxaparin dosing for venous thromboembolism prophylaxis in general trauma patients. Ann Pharmacother 2017;51:323-31.  https://doi.org/10.1177/1060028016683970
  16. Rakhra S, Martin EL, Fitzgerald M, Udy A. The ATLANTIC study: anti-Xa level assessment in trauma intensive care. Injury 2020;51:10-4.  https://doi.org/10.1016/j.injury.2019.10.066
  17. Taylor A, Huang E, Waller J, White C, Martinez-Quinones P, Robinson T. Achievement of goal anti-Xa activity with weight-based enoxaparin dosing for venous thromboembolism prophylaxis in trauma patients. Pharmacotherapy 2021;41:508-14.  https://doi.org/10.1002/phar.2526
  18. Garthe E, States JD, Mango NK. Abbreviated Injury Scale unification: the case for a unified injury system for global use. J Trauma 1999;47:309-23.  https://doi.org/10.1097/00005373-199908000-00016
  19. Loftis KL, Price J, Gillich PJ. Evolution of the Abbreviated Injury Scale: 1990-2015. Traffic Inj Prev 2018;19(sup2):S109-13.  https://doi.org/10.1080/15389588.2018.1512747
  20. Nunez JM, Becher RD, Rebo GJ, et al. Prospective evaluation of weight-based prophylactic enoxaparin dosing in critically ill trauma patients: adequacy of antiXa levels is improved. Am Surg 2015;81:605-9. https://doi.org/10.1177/000313481508100625