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Bounes F, Ferrandis R, Frere C, Helms J, Llau JV. European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 4: Prophylaxis in critical care patients. Eur J Anaesthesiol 2024; 41:582-588. [PMID: 38957023 DOI: 10.1097/eja.0000000000002011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Fanny Bounes
- From the CHU Toulouse, Université Paul Sabatier Toulouse III, Pôle Anesthésie-Réanimation, Toulouse, France (FB), Anesthesiology and Critical Care Department, Hospital Universitari i Politècnic La Fe, Universitat de València, Spain (RF), Sorbonne Université, Pitié-Salpêtrière Hospital, Paris (CF), Université de Strasbourg (UNISTRA), Faculté de Médecine; Hôpitaux universitaires de Strasbourg, Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Strasbourg, France (JH) and Anesthesiology and Critical Care Department, Hospital Universitari Doctor Peset, Universitat de València, Spain (JVL)
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Jonmarker S, Litorell J, Alarcon F, Al-Abani K, Björkman S, Farm M, Grip J, Söderberg M, Hollenberg J, Wahlin RR, Kander T, Rimling L, Mårtensson J, Joelsson-Alm E, Dahlberg M, Cronhjort M. A retrospective multicenter cohort study of the association between anti-Factor Xa values and death, thromboembolism, and bleeding in patients with critical COVID-19. Thromb J 2023; 21:101. [PMID: 37784131 PMCID: PMC10544466 DOI: 10.1186/s12959-023-00541-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/05/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Patients with critical COVID-19 have a high risk of thromboembolism, but intensified thromboprophylaxis has not been proven beneficial. The activity of low-molecular-weight heparins can be monitored by measuring anti-Factor Xa. We aimed to study the association between anti-Factor Xa values and death, thromboembolism, and bleeding in patients with critical COVID-19. METHOD This retrospective cohort study included adult patients with critical COVID-19 admitted to an intensive care unit at three Swedish hospitals between March 2020 and May 2021 with at least one valid peak and/or trough anti-Factor Xa value. Within the peak and trough categories, patients' minimum, median, and maximum values were determined. Logistic regressions with splines were used to assess associations. RESULTS In total, 408 patients had at least one valid peak and/or trough anti-Factor Xa measurement, resulting in 153 patients with peak values and 300 patients with trough values. Lower peak values were associated with thromboembolism for patients' minimum (p = 0.01), median (p = 0.005) and maximum (p = 0.001) values. No association was seen between peak values and death or bleeding. Higher trough values were associated with death for median (p = 0.03) and maximum (p = 0.002) values and with both bleeding (p = 0.01) and major bleeding (p = 0.02) for maximum values, but there were no associations with thromboembolism. CONCLUSIONS Measuring anti-Factor Xa activity may be relevant for administrating low-molecular-weight heparin to patients with critical COVID-19. Lower peak values were associated with an increased risk of thromboembolism, and higher trough values were associated with an increased risk of death and bleeding. Prospective studies are needed to confirm the results. TRIAL REGISTRATION The study was retrospectively registered at Clinicaltrials.gov, NCT05256524, February 24, 2022.
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Affiliation(s)
- Sandra Jonmarker
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden.
| | - Jacob Litorell
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Felix Alarcon
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Kais Al-Abani
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Sofia Björkman
- Department of Clinical Science, Anaesthesiology and Intensive Care, Lund University, Skåne University Hospital, Lund, Sweden
| | - Maria Farm
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Jonathan Grip
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Mårten Söderberg
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Centre for Resuscitation Science, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Thomas Kander
- Department of Clinical Science, Anaesthesiology and Intensive Care, Lund University, Skåne University Hospital, Lund, Sweden
| | - Liivi Rimling
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Johan Mårtensson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Eva Joelsson-Alm
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Martin Dahlberg
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Maria Cronhjort
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
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De Schryver N, Serck N, Eeckhoudt S, Laterre PF, Wittebole X, Gérard L. Pharmacokinetic profiles of intravenous versus subcutaneous administration of low molecular weight heparin for thromboprophylaxis in critically ill patients: A randomized controlled trial. J Crit Care 2022; 70:154029. [DOI: 10.1016/j.jcrc.2022.154029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
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The challenge of pharmacological thromboprophylaxis in ICU patients: anti-FXa activity does not constitute a simple solution. Intensive Care Med 2022; 48:1116-1117. [PMID: 35614321 DOI: 10.1007/s00134-022-06744-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/14/2022] [Indexed: 11/05/2022]
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Dibiasi C, Gratz J, Wiegele M, Baierl A, Schaden E. Anti-factor Xa Activity Is Not Associated With Venous Thromboembolism in Critically Ill Patients Receiving Enoxaparin for Thromboprophylaxis: A Retrospective Observational Study. Front Med (Lausanne) 2022; 9:888451. [PMID: 35573015 PMCID: PMC9103187 DOI: 10.3389/fmed.2022.888451] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background Anti-factor Xa activity has been suggested as a surrogate parameter for judging the effectiveness of pharmacological thromboprophylaxis with low molecular weight heparins in critically ill patients. However, this practice is not supported by evidence associating low anti-factor Xa activity with venous thromboembolism. Methods We performed a retrospective observational study including 1,352 critically ill patients admitted to 6 intensive care units of the Medical University of Vienna, Austria between 01/2015 and 12/2018. Included patients received prophylactically dosed enoxaparin (≤100 IU/kg body weight per day). We analyzed median peak, 12-h trough and 24-h trough anti-factor Xa activity per patient and compared anti-factor Xa activity between patients without vs. with venous thromboembolic events. Results 19 patients (1.4%) developed a total of 22 venous thromboembolic events. We did not observe a difference of median (IQR) anti-factor Xa activity between patients without venous thromboembolism [peak 0.22 IU/mL (0.14–0.32); 12-h trough 0.1 IU/mL (<0.1–0.17), 24-h trough < 0.1 IU/mL (<0.1– <0.1)] vs. patients with venous thromboembolism [peak 0.33 IU/mL (0.14–0.34); 12-h trough 0.12 IU/mL (<0.1–0.26); 24-h trough < 0.1 IU/mL (<0.1–<0.1)]. Conclusion Patients who developed venous thromboembolism had anti-factor Xa activities comparable to those who did not suffer from venous thromboembolism.
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Affiliation(s)
- Christoph Dibiasi
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Vienna, Austria
| | - Johannes Gratz
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Marion Wiegele
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Andreas Baierl
- Department of Statistic and Operations Research, University of Vienna, Vienna, Austria
| | - Eva Schaden
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Vienna, Austria
- *Correspondence: Eva Schaden,
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Xiao S, Luo Y, Guo L, Zhang J, Mu L, Ye Z. Comparison of doses of heparin for venous thromboembolism and bleeding in pregnant women. J Investig Med 2021; 70:773-779. [PMID: 34921124 DOI: 10.1136/jim-2021-002050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 11/04/2022]
Abstract
The evaluation criteria for dosage of low-molecular-weight heparin (LMWH) for pregnant women at high risk of venous thromboembolism (VTE) remain unclear. A retrospective study was performed to investigate the relative appropriate LMWH administration strategy and dosage for pregnant women at risk of VTE. 219 pregnant women with perinatal and postpartum VTE were reviewed and divided into group A (fixed dose group: n=73, 5000 IU dalteparin daily for all women), group B (weight group: n=73, 2500 IU dalteparin daily for women less than 50 kg; 5000 IU dalteparin daily for women more than 50 kg), and group C (anti-factor Xa (FXa) + weight group: n=73, 5000 IU once daily for women less than 50 kg; 7500 IU once daily for women weighing 50-80 kg; 10,000 IU once daily for women weighing over 80 kg). Further dose administration was adjusted according to peak anti-FXa level, maintaining the peak at the 0.5-1.0 IU/mL range. Women in group C presented lower incidence of VTE and other pregnancy complications than group A and group B. Adjusting the dosage of LMWH according to both weight and anti-FXa level of pregnant women not only prevented VTE but also reduced the risk of postpartum hemorrhage induced by LMWH administration. In addition, adjusting the dose of LMWH according to anti-FXa level and body weight also affected the recurrence of VTE and the occurrence of postpartum hemorrhage in pregnant women.
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Affiliation(s)
- Sha Xiao
- Department of Obstetrics and Gynecology, Tianjin First Central Hospital, Tianjin, China
| | - Yuancai Luo
- Department of Obstetrics and Gynecology, Tianjin First Central Hospital, Tianjin, China
| | - Lu Guo
- Department of Obstetrics and Gynecology, Tianjin First Central Hospital, Tianjin, China
| | - Jing Zhang
- Department of Obstetrics and Gynecology, Tianjin First Central Hospital, Tianjin, China
| | - Liping Mu
- Department of Obstetrics and Gynecology, Tianjin First Central Hospital, Tianjin, China
| | - Zhao Ye
- Department of Obstetrics and Gynecology, Tianjin First Central Hospital, Tianjin, China
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Wiegele M, Adelmann D, Dibiasi C, Pausch A, Baierl A, Schaden E. Monitoring of Enoxaparin during Hemodialysis Covered by Regional Citrate Anticoagulation in Acute Kidney Injury: A Prospective Cohort Study. J Clin Med 2021; 10:jcm10194491. [PMID: 34640507 PMCID: PMC8509597 DOI: 10.3390/jcm10194491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Current guidelines recommend the monitoring of anti-factor Xa (anti-Xa) levels to avoid an accumulation of low-molecular-weight heparins in patients with acute kidney injury, but there is no evidence on how to proceed with such monitoring during continuous renal replacement therapy. Against this background, we investigated the potential accumulation of enoxaparin administered subcutaneously for venous thromboembolism prophylaxis in critically ill patients during continuous renal replacement therapy covered by regional citrate anticoagulation. Methods: Anti-Xa levels were measured at baseline (≤12 h before renal replacement therapy) and on three consecutive days (A to C) when enoxaparin had reached trough levels. Supplementary testing included modified assays of rotational thromboelastometry known to be highly sensitive for low-molecular-weight heparins. Results: The 16 men and 13 women included were adults comparable in age, body mass index, thromboembolism risk assessment, and clinical severity of the disease. Throughout the four examinations, the median trough levels of anti-Xa remained below the detection limit of the test (<0.1 IU mL−1), with interquartile ranges of <0.1 to 0.14 IU mL−1 at baseline and <0.1 to 0.16 IU mL−1 on days A/B/C. All rotational thromboelastometry parameters of clot initiation and clot formation dynamics did not significantly change from baseline to day C. Conclusions: Neither anti-Xa levels nor modified assays of rotational thromboelastometry revealed any accumulation of enoxaparin administered for thromboprophylaxis during continuous renal replacement therapy covered by regional citrate anticoagulation. Although generally recommended in patients with acute kidney injury, monitoring of anti-Xa levels should be questioned in this defined setting.
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Affiliation(s)
- Marion Wiegele
- Department of Anesthesia, Critical Care and Pain Medicine, Division of General Anesthesia and Intensive Care Medicine, Medical University of Vienna, 1090 Vienna, Austria; (M.W.); (C.D.); (A.P.)
| | - Dieter Adelmann
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, CA 94143, USA;
| | - Christoph Dibiasi
- Department of Anesthesia, Critical Care and Pain Medicine, Division of General Anesthesia and Intensive Care Medicine, Medical University of Vienna, 1090 Vienna, Austria; (M.W.); (C.D.); (A.P.)
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, 1090 Vienna, Austria
| | - Andrè Pausch
- Department of Anesthesia, Critical Care and Pain Medicine, Division of General Anesthesia and Intensive Care Medicine, Medical University of Vienna, 1090 Vienna, Austria; (M.W.); (C.D.); (A.P.)
| | - Andreas Baierl
- Department of Statistic and Operations Research, University of Vienna, 1090 Vienna, Austria;
| | - Eva Schaden
- Department of Anesthesia, Critical Care and Pain Medicine, Division of General Anesthesia and Intensive Care Medicine, Medical University of Vienna, 1090 Vienna, Austria; (M.W.); (C.D.); (A.P.)
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, 1090 Vienna, Austria
- Correspondence: ; Tel.: +43-1-40400-41020
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Marshall AM, Trussell TM, Yee AM, Malone MP. Anti-Xa levels in critically ill children receiving enoxaparin for venothromboembolism prophylaxis. Thromb Res 2021; 203:117-120. [PMID: 33992874 DOI: 10.1016/j.thromres.2021.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/16/2022]
Abstract
Venothrombolism (VTE) prophylaxis is increasingly utilized in pediatric intensive care units (PICUs). Enoxaparin, a low-molecular weight heparin, is frequently used for this purpose. Enoxaparin can also be used for therapeutic anticoagulation in cases of known thrombus. In such cases, monitoring involves obtaining serum anti- Xa levels with a target value of 0.5-1 units/mL. No monitoring recommendations currently exist for enoxaparin when intended for pediatric VTE prophylaxis. We hypothesize that a clinically important number of patients on VTE prophylaxis with enoxaparin have serum anti-Xa levels consistent with values targeted for therapeutic anticoagulation. We found that over 20% of patients on VTE prophylaxis with enoxaparin had serum anti-Xa levels consistent with true therapeutic anticoagulation (anti-Xa level 0.5-1 units/mL) during their enoxaparin course and 5% achieved values of supratherapeutic anticoagulation (anti-Xa level >1 units/mL). Serum anti-Xa level did not correlate with once versus twice daily dosing, body mass index (BMI), or creatinine level. Blood urea nitrogen (BUN) was found to have a positive odds ratio for an anti-Xa level ≥ 0.5 units/mL. We believe that this incidence of unintended therapeutic anticoagulation indicates a clinically significant number and therefore routine anti-Xa evaluation while on VTE prophylaxis is warranted within our population.
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Affiliation(s)
- Amanda M Marshall
- Children's Hospital & Medical Center/University of Nebraska Medicine Center, United States of America.
| | | | - Addison M Yee
- The University of Arkansas for Medical Sciences/Arkansas Children's Hospital, United States of America
| | - Mathew P Malone
- The University of Arkansas for Medical Sciences/Arkansas Children's Hospital, United States of America
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Andersen NG, Mowinckel MC, Sunde K, Sandset PM, Beitland S. Utility of coagulation analyses to assess thromboprophylaxis with dalteparin in intensive care unit patients. Acta Anaesthesiol Scand 2021; 65:489-498. [PMID: 33205407 DOI: 10.1111/aas.13748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/19/2020] [Accepted: 11/08/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the utility of coagulation analyses to assess thromboprophylaxis with dalteparin in intensive care unit (ICU) patients. METHODS Prospective observational study of ICU patients receiving dalteparin prophylaxis at Oslo University Hospital in Norway. Trough and peak antithrombin, protein C, anti-factor Xa activity (aFXa), d-dimer, thromboelastography, calibrated automated thrombogram and microparticles were analysed. Levels were compared in patients with and without venous thromboembolism (VTE), major bleeding, acute kidney injury (AKI) with use of renal replacement therapy (RRT) and variable dalteparin dose. RESULTS Among 50 included patients (76% male, mean age 62 years) five (10%) developed VTE and eight (16%) major bleeding. Median through aFXa level was 0.03 (0.02-0.05) IU/mL, and 48 (96%) of patients were within and two (4%) above target range. Peak aFXa level was 0.21 (0.13-0.29) IU/mL, the number of patients below, within and above prophylactic range were 21 (42%), 25 (50%) and four (8%). Peak aFXa levels were similar in patients with and without VTE (0.18 vs 0.21 IU/L, P = .72), major bleeding (0.22 vs 0.21 IU/mL, P = .38) and AKI with RRT (0.18 vs 0.24, P = .13), but lower in patients receiving dalteparin 5000 IU od compared to 7500 IU od (0.19 vs 0.30 IU/mL, P < .01). CONCLUSIONS Intensive care unit patients receiving dalteparin prophylaxis had half of patients within prophylactic peak aFXa target range. Peak aFXa levels was affected by administered dalteparin dose, but not presence of VTE, major bleeding or AKI with RRT.
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Affiliation(s)
| | - Marie-Christine Mowinckel
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Kjetil Sunde
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Universitetet i Oslo, Oslo, Norway
| | - Per Morten Sandset
- Department of Haematology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Universitetet i Oslo, Oslo, Norway
| | - Sigrid Beitland
- Renal Research Group Ullevål, Faculty of Medicine, University of Oslo, Oslo, Norway
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Vahtera A, Szanto T, Lassila R, Valkonen M, Sivula M, Huhtala H, Pettilä V, Kuitunen A. Continuous intravenous infusion of enoxaparin controls thrombin formation more than standard subcutaneous administration in critically ill patients. A sub-study of the ENOKSI thromboprophylaxis RCT. Acta Anaesthesiol Scand 2021; 65:109-115. [PMID: 32888192 DOI: 10.1111/aas.13697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/22/2020] [Accepted: 08/18/2020] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Standard subcutaneous low-molecular-weight heparin (LMWH) thromboprophylaxis yields low anti-factor Xa activity in patients in the intensive care unit (ICU). The aim of the study was to assess coagulation status in ICU patients randomized to receive enoxaparin thromboprophylaxis either as a standard subcutaneous bolus (SCB) or continuous intravenous infusion (CII) for 3 consecutive days after the initiation of LMWH thromboprophylaxis. MATERIALS AND METHODS Thirty-eight patients were studied by conventional coagulation variables: prothrombin fragment F 1+2 (F 1+2) representing FXa inhibition and antithrombin (AT). Additionally, 18 patients were analyzed by the thrombin generation assay-calibrated automated thrombogram (TGA-CAT). Blood samples were collected before the initiation of the LMWH thromboprophylaxis (ie, baseline), at 51 h, and at 72 h. RESULTS At beginning, no differences in coagulation biomarkers were observed. The levels of F 1+2 were significantly lower at 51 and 72 h in the CII group than in the SCB group. AT levels increased during the follow-up in the CII group, unlike in the SCB group. TGA-CAT was poor in some patients overall. In a subset of patients at 51 h lag time (4.3 vs 7.5 min, respectively, P < 0.05) and time to peak (7.7 vs 14.3 min, respectively, P < 0.05) were prolonged in the SCB group. At 72 h, however, peak thrombin was lower in the CII than in the SCB group: 271 vs 356 nM, respectively (P < 0.05). CONCLUSIONS Enoxaparin thromboprophylaxis administered by CII inhibited more prominently FXa and preserved better the AT level, compared with standard subcutaneous care.
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Affiliation(s)
- Annukka Vahtera
- Department of Intensive Care Medicine Tampere University Hospital PO Box 2000 Tampere 33521 Finland
| | - Timea Szanto
- Coagulation Disorders Unit Department of Clinical Chemistry HUSLAB Laboratory Services Helsinki University Hospital Helsinki Finland
| | - Riitta Lassila
- Coagulation Disorders Unit Department of Clinical Chemistry HUSLAB Laboratory Services Helsinki University Hospital Helsinki Finland
| | - Miia Valkonen
- Division of Intensive Care Medicine Department of Anesthesiology Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Mirka Sivula
- Division of Intensive Care Medicine Department of Anesthesiology Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Heini Huhtala
- Faculty of Social Sciences University of Tampere Tampere 33014 Finland
| | - Ville Pettilä
- Division of Intensive Care Medicine Department of Anesthesiology Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Anne Kuitunen
- Department of Intensive Care Medicine Tampere University Hospital PO Box 2000 Tampere 33521 Finland
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Venous thromboembolism in burns patients: Are we underestimating the risk and underdosing our prophylaxis? J Plast Reconstr Aesthet Surg 2020; 74:1814-1823. [PMID: 33414092 DOI: 10.1016/j.bjps.2020.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 09/23/2020] [Accepted: 12/02/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Burns patients exhibit all factors of Virchow's triad and are thus at high theoretical risk of venous thromboembolism (VTE). At our tertiary referral burns unit, a standard dose of low molecular weight heparin, which acts primarily by inhibiting Factor Xa, is given for thromboprophylaxis. However, the pharmacokinetics of enoxaparin are altered following a burn injury, and thus burns patients are likely underdosed on their thromboprophylaxis. The objectives of this study were to determine the incidence and risk factors for VTE among burns patients at the Victorian Adult Burns Service (VABS) and to determine the adequacy of the current enoxaparin thromboprophylaxis regimen through measurement of anti-factor Xa (AFXa) levels and comparison with established reference ranges. METHODS This study consisted of two parts. In part 1, the Burns Registry of Australia and New Zealand (BRANZ) was reviewed for cases of VTE in burns patients admitted to the VABS from 2013 - 2018. Part 2 was a prospective study that determined peak and trough AFXa levels in patients admitted to the VABS with >10% total body surface area (TBSA) burns. RESULTS Part 1. Totally, 1,475 patients were admitted to the VABS between 2013 - 2018. There were 20 cases of VTE (1.36%). Percent TBSA of burn (OR = 1.04, 95% CI: 1.03 - 1.06), full thickness burns (OR = 2.78, 95% CI: 1.15 - 6.73), ICU admission (OR = 15.08, 95% CI: 5.01 - 45.44), mechanical ventilation (OR = 10.62, 95% CI: 4.05 - 27.91), operative procedures (OR = 1.43, 95% CI: 1.29 - 1.59), and a longer hospital stay (OR = 1.05, 95% CI: 1.04 - 1.07) were all associated with an increased VTE risk. Part 2. A total of 20 participants with >10% TBSA burns were recruited to the prospective study. Peak anti Factor Xa (AFXa) levels were measured for all 20 participants with 15% recording an initial prophylactic peak AFXa level within reference range. Upon subsequent measurements, 50% of participants reached a prophylactic peak AFXa level. Trough AFXa levels were measured for 17 participants with no participant recording an initial or subsequent trough AFXa level at or above the prophylactic threshold. CONCLUSION Our study demonstrates a high incidence of VTE among burns patients at the VABS, especially among the major burns patients, and a thromboprophylaxis protocol that is ineffective in achieving prophylactic levels of AFXa level. The evidence suggests a need to evaluate different dosing protocols among burns patients in order to improve AFXa levels, with the aim of decreasing incidence of VTE in high-risk patients.
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12
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Blake M, Roadley-Battin R, Torlinski T. Prophylactic anti-coagulation after severe burn injury in critical care settings. Acta Med Litu 2019; 26:38-45. [PMID: 31281215 PMCID: PMC6586379 DOI: 10.6001/actamedica.v26i1.3954] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/26/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Severely burnt patients are at an increased risk of thromboembolic complications, hence sufficient prophylactic anticoagulation is of paramount importance. Local guidelines at the Burns Centre in the Queen Elizabeth Hospital, Birmingham therefore advise increasing the standard dose of low molecular weight heparin in these patients. An audit was carried out to assess the current practice in burns patients to ensure adequate anticoagulation and adherence to guidelines. MATERIALS AND METHODS Retrospective data was collected on all burns patients in the Burns Centre over a two-year period. The main objectives were to assess:anticoagulation regimes prescribed to severe burns patientsmonitoring of Anti-Factor Xa levelsadjustment of dosing based on the resultsThe locally produced trust guidelines were used as the comparator. RESULTS All burns patients were prescribed anticoagulation, but often the dose was not increased as suggested in the guidelines. Although most of the severely burnt patients were prescribed adjusted higher doses of anti-coagulation, only 60% of these patients were monitored with Anti-Factor Xa assays. Of these assays, 66% showed sub-prophylactic levels. The majority of results led to the adjustment of the dose of anticoagulant. However, often dose changes were made late. DISCUSSION AND CONCLUSIONS The audit confirmed the need for increased doses of prophylactic anticoagulation in severe burns. The better adherence to the guidelines can be achieved by additional training and implementation of decision support via electronic prescribing system.
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Affiliation(s)
- Megan Blake
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ruth Roadley-Battin
- Department of Anaesthetics and Intensive Care Medicine, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | - Tomasz Torlinski
- Department of Anaesthetics and Intensive Care Medicine, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
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Vahtera A, Valkonen M, Huhtala H, Pettilä V, Kuitunen A. Plasma anti-FXa concentration after continuous intravenous infusion and subcutaneous dosing of enoxaparin for thromboprophylaxis in critically ill patients. A randomized clinical trial. Thromb Res 2017; 158:71-75. [DOI: 10.1016/j.thromres.2017.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 07/28/2017] [Accepted: 08/22/2017] [Indexed: 10/19/2022]
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