J Trauma Acute Care Surg. 2021 Sep 24. doi: 10.1097/TA.0000000000003418. Online ahead of print.
ABSTRACT
OBJECTIVES: Trauma is a major risk factor for the development of a venous thromboembolism (VTE). After observing higher than expected VTE rates within our center’s Trauma Quality Improvement Program (TQIP) data, we instituted a change in our VTE prophylaxis protocol, moving to enoxaparin dosing titrated by anti-Xa levels. We hypothesized that this intervention would lower our symptomatic VTE rates.
METHODS: Adult trauma patients at a single institution meeting National Trauma Data Standard criteria from April 2015 to September 2019 were examined with regards to VTE chemoprophylaxis regimen and VTE incidence. Two groups of patients were identified based on VTE protocol – those who received enoxaparin 30 mg twice daily without routine anti-Xa levels (“pre”) versus those who received enoxaparin 40 mg twice daily with dose titrated by serial anti-Xa levels (“post”). Univariate and multivariate analyses were performed to define statistically significant differences in VTE incidence between the two cohorts.
RESULTS: There were 1698 patients within the “pre” group and 1406 patients within the “post” group. The two groups were essentially the same in terms of demographics and risk factors for bleeding or thrombosis. There was a statistically significant reduction in VTE rate (p=0.01) and DVT rate (p=0.01) but no significant reduction in PE rate (p = 0.21) after implementation of the anti-Xa titration protocol. Risk-adjusted TQIP data showed an improvement in rate of symptomatic pulmonary embolism from 5th decile to 1st decile.
CONCLUSIONS: A protocol titrating prophylactic enoxaparin dose based on anti-Xa levels reduced VTE rates. Implementation of this type of protocol requires diligence from the physician and pharmacist team. Further research will investigate the impact of protocol compliance and time to appropriate anti-Xa level on incidence of VTE.
LEVEL OF EVIDENCE: IV, therapeutic/care management.
PMID:34561398 | DOI:10.1097/TA.0000000000003418
