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Fan X, Yang Z, Liu Y, Wei Z, Zhao C, Pang C, Wang Z, Yang H. Analysis of High-Risk Factors and Construction of a Nomogram Predictive Model for Deep Venous Thrombosis in Pelvic and Acetabular Fracture Patients Treated Conservatively. Cureus 2024; 16:e56091. [PMID: 38618471 PMCID: PMC11011238 DOI: 10.7759/cureus.56091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 04/16/2024] Open
Abstract
PURPOSE This study aims to develop a predictive nomogram model to assist physicians in making evidence-based decisions and potentially reduce the incidence of deep venous thrombosis (DVT). METHODS We conducted a retrospective study, including patients admitted to the hospital from January 2014 to January 2022 with a closed, single pelvic or acetabular fracture. Comprehensive data were collected for each patient, encompassing demographics, injury characteristics, comorbidities, and results from laboratory tests and lower extremity ultrasounds. Potential risk factors were identified by univariate and multivariate logistic regression analyses. The predictive model was constructed and then internally validated. Calibration accuracy was assessed using a calibration slope and the Hosmer-Lemeshow goodness-of-fit test. The discrimination of the nomogram model was evaluated using the C-statistic. RESULTS Out of 232 individuals who underwent conservative treatment, 57 (24.6%) were classified into the DVT group and 175 (75.4%) into the non-DVT group based on lower extremity ultrasound findings. Predominantly, patients were aged between 41 and 65 in both groups. Body mass index (BMI) comparison showed that 54.29% (95/175) of the non-DVT group fell within the healthy weight range, while 45.61% (26/57) in the DVT group were overweight. Notably, the proportion of obesity in the DVT group was more than double that in the non-DVT group, indicating a higher DVT risk with increasing BMI (P=0.0215). Lower red blood cell (RBC) counts were observed in DVT patients compared to non-DVT ones (P<0.001). A similar pattern emerged for D-dimer, a marker for blood clot formation and dissolution, with significant differences noted (P=0.029). Multivariable analysis identified age, BMI, associated organ injury (AOI), American Society of Anesthesiologists score, hemoglobin (HGB), RBC, and D-dimer as candidate predictors. Significant variables included age (OR, 3.04; 95% CI, 1.76-5.26; P<0.001), BMI (OR, 1.97; 95% CI, 1.22-3.18; P=0.006), AOI (OR, 2.05; 95% CI, 1.07-3.95; P=0.031), and HGB (HR, 0.59; 95% CI, 0.39-0.88; P=0.010). The discrimination was 0.787, with a corrected c-index of 0.753. Calibration plots and the Hosmer-Lemeshow test indicated a good fit (P=0.7729). Decision curve analysis revealed a superior net clinical benefit when the predicted probability threshold ranged from 0.05 to 0.95. CONCLUSIONS We developed a nomogram predictive model, and it could act as a practical tool in clinical workflows to assist physicians in making favorable medical decisions, which potentially reduces the incidence of DVT in those patients with pelvic and acetabular fractures treated conservatively.
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Affiliation(s)
- Xiaobo Fan
- Department of Orthopedic Surgery, The First Hospital of Handan, Handan, CHN
| | - Zongyou Yang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, CHN
| | - Yuan Liu
- Department of Orthopedic Surgery, The First Hospital of Handan, Handan, CHN
| | - Zhikun Wei
- Department of Orthopedic Surgery, The First Hospital of Handan, Handan, CHN
| | - Chenyang Zhao
- Department of Orthopedic Surgery, The First Hospital of Handan, Handan, CHN
| | - Chaojian Pang
- Department of Orthopedic Surgery, The First Hospital of Handan, Handan, CHN
| | - Zhihong Wang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, CHN
| | - Hongcheng Yang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, CHN
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Tischler EH, Tsai SHL, Wolfert AJ, von Keudell A, Roudnitsky V, Gross J, Suneja N. Is There a Role for Anti-factor Xa Activity Assay in Venous Thromboembolism Prophylaxis Management Among Orthopaedic Trauma Patients? Systematic Review and Meta-analysis. J Orthop Trauma 2023; 37:e368-e376. [PMID: 37053117 DOI: 10.1097/bot.0000000000002611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVES To determine the effect of anti-factor Xa assay dosing of low-molecular-weight heparin (LMWH) on rates of venous thromboembolism (VTE), deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, and mortality among orthopaedic trauma patients. DATA SOURCES PubMed/MEDLINE, Embase, Ovid, Cochrane Central Register of Controlled Trials (CENTRAL), clinicaltrials.gov , and Scopus were systematically searched from inception of the database to 2021. STUDY SELECTION Prospective, retrospective, and randomized controlled trial studies were included if they compared rates of VTE, DVT, PE, bleeding, and/or mortality between orthopaedic trauma patients receiving anti-factor Xa-based LMWH dosing and those receiving standard dosing. DATA EXTRACTION Two independent reviewers screened titles and abstracts for eligibility. Study characteristics including study design, inclusion criteria, and intervention were extracted. DATA SYNTHESIS Meta-analysis was performed using pooled proportion of events (effect size) with 95% confidence intervals. A random-effects model was used. Heterogeneity was quantified by Higgins I 2 . Heterogeneity and variability between subgroups indicated differences in the pooled estimate represented by a P -value. RESULTS Six hundred eighty-five studies were identified, and 10 studies including 2870 patients were included. In total, 30.3% and 69.7% received an adjusted and nonadjusted dose of LMWH, respectively. The rate of VTE and DVT were significantly lower in the anti-factor Xa-adjusted cohort, whereas there was no statistically significant difference in rates of PE, bleeding, or mortality between the cohorts. CONCLUSIONS This systematic review and meta-analysis demonstrates that anti-factor Xa activity assay dosing of LMWH among orthopaedic trauma patients leads to a reduction in overall DVT rates, although not PE rates, without an increased risk of bleeding events. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Eric H Tischler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, NY
| | - Sung Huang Laurent Tsai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Adam J Wolfert
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, NY
| | - Arvind von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Valery Roudnitsky
- Department of General Surgery, The State University of New York Downstate Health Sciences University, Brooklyn, NY; and
| | - Jonathan Gross
- Department of Orthopaedic Surgery, Staten Island University Hospital, Northwell Health Staten Island, Staten Island, NY
| | - Nishant Suneja
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, NY
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
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Al Tannir AH, Biesboer EA, Pokrzywa CJ, Figueroa J, Harding E, de Moya MA, Morris RS, Murphy PB. The efficacy of various Enoxaparin dosing regimens in general surgery patients: A systematic review. Surgery 2023:S0039-6060(23)00208-8. [PMID: 37198037 DOI: 10.1016/j.surg.2023.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Patients undergoing surgical procedures are at an increased risk of venous thromboembolism events. A fixed Enoxaparin dosing regimen is the standard of care for chemoprophylaxis in most institutions; however, breakthrough venous thromboembolism events are still reported. We aimed to systematically review the literature to determine the ability of various Enoxaparin dosing regimens to achieve adequate prophylactic anti-Xa levels for venous thromboembolism prevention in hospitalized general surgery patients. Additionally, we aimed to assess the correlation between subprophylactic anti-Xa levels and the development of clinically significant venous thromboembolism events. METHODS A systematic review was conducted using major databases from January 1, 1993, to February 17, 2023. Two independent researchers screened titles and abstracts, followed by a full-text review. Articles were included if Enoxaparin dosing regimens were evaluated by anti-Xa levels. Exclusion criteria included systematic reviews, pediatric population, nongeneral surgery (defined as trauma, orthopedics, plastics, and neurosurgery), and non-Enoxaparin chemoprophylaxis. The primary outcome was peak Anti-Xa level measured at steady state concentration. The risk of bias was assessed using the Risk of Bias in Nonrandomized studies-of Intervention tool. RESULTS A total of 6,760 articles were extracted, of which 19 were included in the scoping review. Nine studies included bariatric patients, whereas 5 studies explored abdominal surgical oncology patients. Three studies assessed thoracic surgery patients, and 2 studies included patients undergoing "general surgery" procedures. A total of 1,502 patients were included. The mean age was 47 years, and 38% were males. The percentages of patients reaching adequate prophylactic anti-Xa levels were 39%, 61%, 15%, 50%, and 78% across the 40 mg daily, 40 mg twice daily, 30 mg twice daily, and weight-tiered, and body mass index-based groups, respectively. The overall risk of bias was low to moderate. CONCLUSION Fixed Enoxaparin dosing regimens are not correlated with adequate anti-Xa levels in general surgery patients. Additional research is warranted to assess the efficacy of dosing regimens based on novel physiologic parameters (such as estimated blood volume).
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Affiliation(s)
- Abdul Hafiz Al Tannir
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Elise A Biesboer
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Courtney J Pokrzywa
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Juan Figueroa
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Eric Harding
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Marc A de Moya
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Rachel S Morris
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Patrick B Murphy
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
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Administration of Prophylactic Enoxaparin on the Morning of Surgery Does Not Increase Risk of Blood Transfusion or Wound Drainage Following Internal Fixation of Geriatric Femur Fractures. J Am Acad Orthop Surg 2023; 31:305-311. [PMID: 36520993 DOI: 10.5435/jaaos-d-22-00233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 10/23/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Despite standard use of chemoprophylaxis, 30-day incidence of venous thromboembolism after geriatric, those older than 60 years, femur fracture surgery is reported to be up to 10%. Missing one dose of enoxaparin has been proven to increase the risk of developing venous thromboembolism. It is commonplace to hold preoperative chemoprophylaxis the morning of surgery because of concern for intraoperative bleeding or wound drainage. We sought to determine whether administration of prophylactic enoxaparin the morning of surgery resulted in an increased rate of blood transfusion or wound drainage in geriatric patients undergoing femur fracture treatment. METHODS We retrospectively reviewed patients older than 60 years who underwent internal fixation of an isolated femur fracture, including femoral neck, intertrochanteric, subtrochanteric, femoral shaft, and distal femur fractures, at a Level 1 trauma center. Medical records, hospital billing data, and radiographs were reviewed to determine patient characteristics such as Charlson Comorbidity Index, enoxaparin dosing, packed red blood cell transfusion, and persistent wound drainage, defined as any drainage requiring utilization of closed incision negative pressure wound therapy. Thirty-day mortality served as the secondary outcome measure. RESULTS Five hundred seven patients were included. One hundred sixty-four (32%) received enoxaparin on the morning of surgery, whereas 343 (68%) did not. 27% of patients received PRBC transfusion, and this did not differ between groups (27% vs. 28%, P = 0.72). Subgroup analysis of fixation strategies revealed no difference in the frequency of blood transfusion for any fixation type as related to the timing of enoxaparin dosage. Utilization of closed incision negative pressure wound therapy for the treatment of postoperative wound drainage did not differ between dosing groups. No difference was observed in thirty-day mortality between groups (2.4% vs. 2.7%, P = 0.9). DISCUSSION Administration of a prophylactic dose of enoxaparin on the morning of surgery does not seem to increase the rate of postoperative blood transfusion or wound drainage after fixation of geriatric femur fracture. LEVEL OF EVIDENCE Level III, therapeutic.
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Venous thromboembolism in patients with surgically treated ankle fractures. Arch Orthop Trauma Surg 2023; 143:1237-1242. [PMID: 34757461 DOI: 10.1007/s00402-021-04192-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/24/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES In patients with rotational ankle fracture, we compare the rate of venous thromboembolism development between patients who received chemoprophylaxis vs those patients that received none. DESIGN Retrospective cohort study. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Between 2014 and 2018, we identified 483 patients with rotational ankle fracture that had no VTE risk factors, were under 70 years of age, and had an isolated injury. INTERVENTION Chemoprophylaxis vs no chemoprophylaxis after open reduction internal fixation of a rotational ankle fracture. MAIN OUTCOME MEASUREMENTS Development of VTE was the primary outcome. Secondary outcomes included wound problems, infection, hematoma, or non-union. RESULTS There were 313 patients that received no prophylaxis and 170 patients that received chemoprophylaxis after operative fixation of an isolated ankle fracture. Demographics including age, gender, body mass index, and ASA class were similar between groups. The rate of DVT/PE was 3.5% in those without DVT prophylaxis, and 4.1% in those on DVT prophylaxis with no significant differences found (p = 0.8). There was no significant difference in wound complication (no VTE prophylaxis-3.7% vs VTE prophylaxis-2.5%, p = 0.7) or infection rates (no VTE prophylaxis-3.8% vs VTE prophylaxis 4.1%, p = 1.0) between groups. CONCLUSIONS No difference was detected in the rate of symptomatic DVT or PE in patients based on chemoprophylaxis. Our results support the conclusion that the use of chemoprophylaxis may remain surgeon preference and based on patient risk factors for VTE development. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Pannucci CJ, Fleming KI, Varghese TK, Stringham J, Huang LC, Pickron TB, Prazak AM, Bertolaccini C, Momeni A. Low Anti-Factor Xa Level Predicts 90-Day Symptomatic Venous Thromboembolism in Surgical Patients Receiving Enoxaparin Prophylaxis: A Pooled Analysis of Eight Clinical Trials. Ann Surg 2022; 276:e682-e690. [PMID: 33086312 PMCID: PMC8639105 DOI: 10.1097/sla.0000000000004589] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the relationship between enoxaparin dose adequacy, quantified with anti-Factor Xa (aFXa) levels, and 90-day symptomatic venous thromboembolism (VTE) and postoperative bleeding. SUMMARY BACKGROUND DATA Surgical patients often develop "breakthrough" VTE events-those which occur despite receiving chemical anticoagulation. We hypothesize that surgical patients with low aFXa levels will be more likely to develop 90-day VTE, and those with high aFXa will be more likely to bleed. METHODS Pooled analysis of eight clinical trials (N = 985) from a single institution over a 4 year period. Patients had peak steady state aFXa levels in response to a known initial enoxaparin dose, and were followed for 90 days. Survival analysis log-rank test examined associations between aFXa level category and 90-day symptomatic VTE and bleeding. RESULTS Among 985 patients, 2.3% (n = 23) had symptomatic 90-day VTE, 4.2% (n = 41) had 90-day clinically relevant bleeding, and 2.1% (n = 21) had major bleeding. Patients with initial low aFXa were significantly more likely to have 90-day VTE than patients with adequate or high aFXa (4.2% vs 1.3%, P = 0.007). In a stratified analysis, this relationship was significant for patients who received twice daily (6.2% vs 1.5%, P = 0.003), but not once daily (3.0% vs 0.7%, P = 0.10) enoxaparin. No association was seen between high aFXa and 90-day clinically relevant bleeding (4.8% vs 2.9%, P = 0.34) or major bleeding (3.6% vs 1.6%, P = 0.18). CONCLUSIONS This manuscript establishes inadequate enoxaparin dosing as a plausible mechanism for breakthrough VTE in surgical patients, and identifies anticoagulant dose adequacy as a novel target for process improvement measures.
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Affiliation(s)
| | - Kory I Fleming
- Division of Plastic Surgery, University of Utah, Salt Lake City, Utah
| | - Thomas K Varghese
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - John Stringham
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Lyen C Huang
- Division of General Surgery, University of Utah, Salt Lake City, Utah
| | - T Bartley Pickron
- Division of General Surgery, University of Utah, Salt Lake City, Utah
| | - Ann Marie Prazak
- Department of Pharmacy, University of Utah, Salt Lake City, Utah
| | | | - Arash Momeni
- Division of Plastic Surgery, Stanford University, Palo Alto, California
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Ambani SW, Bengur FB, Varelas LJ, Nguyen VT, Cruz CDL, Acarturk TO, Manders EK, Kubik MW, Sridharan S, Gimbel ML, Solari MG. Standard Fixed Enoxaparin Dosing for Venous Thromboembolism Prophylaxis Leads to Low Peak Anti-Factor Xa Levels in Both Head and Neck and Breast Free Flap Patients. J Reconstr Microsurg 2022; 38:749-756. [PMID: 35714620 DOI: 10.1055/s-0042-1749340] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a serious complication, particularly in cancer patients undergoing free flap reconstruction. Subcutaneous enoxaparin is the conventional prophylaxis for VTE prevention, and serum anti-factor Xa (afXa) levels are being increasingly used to monitor enoxaparin activity. In this study, free flap patients receiving standard enoxaparin prophylaxis were prospectively followed to investigate postoperative afXa levels and 90-day VTE and bleeding-related complications. METHODS Patients undergoing free tissue transfer during an 8-month period were identified and prospectively followed. Patients received standard fixed enoxaparin dosing at 30 mg twice daily in head and neck (H&N) and 40 mg daily in breast reconstructions. Target peak prophylactic afXa range was 0.2 to 0.5 IU/mL. The primary outcome was the occurrence of 90-day postoperative VTE- and bleeding-related events. Independent predictors of afXa level and VTE incidence were analyzed for patients that met the inclusion criteria. RESULTS Seventy-eight patients were prospectively followed. Four (5.1%) were diagnosed with VTE, and six (7.7%) experienced bleeding-related complications. The mean afXa levels in both VTE patients and bleeding patients were subprophylactic (0.13 ± 0.09 and 0.11 ± 0.07 IU/mL, respectively). Forty-six patients (21 breast, 25 H&N) had valid postoperative peak steady-state afXa levels. Among these, 15 (33%) patients achieved the target prophylactic range: 5 (33%) H&N and 10 (67%) breast patients. The mean afXa level for H&N patients was significantly lower than for breast patients (p = 0.0021). Patient total body weight was the sole negative predictor of afXa level (R 2 = 0.47, p < 0.0001). CONCLUSION Standard fixed enoxaparin dosing for postoperative VTE prophylaxis does not achieve target afXa levels for the majority of our free flap patients. H&N patients appear to be a particularly high-risk group that may require a more personalized and aggressive approach. Total body weight is the sole negative predictor of afXa level, supporting a role for weight-based enoxaparin dosing.
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Affiliation(s)
- Shoshana W Ambani
- Division of Plastic & Reconstructive Surgery, Henry Ford Jackson Health, Jackson, Michigan.,Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Fuat Baris Bengur
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lee J Varelas
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vu T Nguyen
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Carolyn De La Cruz
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tahsin Oguz Acarturk
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ernest K Manders
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark W Kubik
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shaum Sridharan
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael L Gimbel
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mario G Solari
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Chemoprophylaxis for venous thromboembolism in pelvic and/or acetabular fractures: A systematic review. Injury 2022; 53:1449-1454. [PMID: 35148902 DOI: 10.1016/j.injury.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is unclear which pharmacological agents, and at what dosage and timing, are most effective for venous thromboembolism (VTE) prophylaxis in patients with pelvic/acetabular fractures. METHODS We searched the Cochrane Database of Systematic Reviews, Embase, Web of Science, EBSCO, and PubMed on October 3, 2020, for English-language studies of VTE prophylaxis in patients with pelvic/acetabular fractures. We applied no date limits. We included studies that compared efficacy of pharmacological agents for VTE prophylaxis, timing of administration of such agents, and/or dosage of such agents. We recorded interventions, sample sizes, and VTE incidence, including deep vein thrombosis (DVT) and pulmonary embolism. RESULTS Two studies (3604 patients) compared pharmacological agents, reporting that patients who received direct oral anticoagulants (DOACs) were less likely to develop DVT than those who received low molecular weight heparin (LMWH) (p < 0.01). Compared with unfractionated heparin (UH), LMWH was associated with lower odds of VTE (odds ratio [OR] = 0.37, 95% confidence interval [CI]: 0.22-0.63) and death (OR = 0.27, 95% CI: 0.10-0.72). Three studies (3107 patients) compared timing of VTE prophylaxis, reporting that late prophylaxis was associated with higher odds of VTE (OR = 1.9, 95% CI: 1.2-3.2) and death (OR = 4.0, 95% CI: 1.5-11) and higher rates of symptomatic DVT (9.2% vs. 2.5%, p = 0.03; and 22% vs. 3.1%, p = 0.01). One study (31 patients) investigated dosage of VTE prophylaxis, reporting that a higher proportion of patients with acetabular fractures were underdosed (23% of patients below range of anti-Factor Xa [aFXa] had acetabular fractures vs. 4.8% of patients within adequate range of aFXa, p<0.01). CONCLUSIONS Early VTE chemoprophylaxis (within 24 or 48 h after injury) was better than late administration in terms of VTE and death. Many patients with acetabular fractures are underdosed with LMWH, with inadequate aFXa levels. Compared with UH, LMWH was associated with lower odds of VTE and death. DOACs were associated with lower risk of DVT compared with LMWH. LEVEL OF EVIDENCE III, systematic review of retrospective cohort studies.
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Gates RS, Lollar DI, Collier BR, Smith J, Faulks ER, Gillen JR. Enoxaparin titrated by anti-Xa levels reduces venous thromboembolism in trauma patients. J Trauma Acute Care Surg 2022; 92:93-97. [PMID: 34561398 DOI: 10.1097/ta.0000000000003418] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND 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 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 deep vein thrombosis rate (p = 0.01) but no significant reduction in pulmonary embolism rate (p = 0.21) after implementation of the anti-Xa titration protocol. Risk-adjusted Trauma Quality Improvement Program data showed an improvement in rate of symptomatic pulmonary embolism from fifth decile to first decile. CONCLUSION 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 Therapeutic/care management, Level IV.
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Affiliation(s)
- Rebecca S Gates
- From the Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
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Pannucci CJ, Fleming KI, Bertolaccini C, Agarwal J, Rockwell WB, Mendenhall SD, Kwok A, Goodwin I, Gociman B, Momeni A. Optimal Dosing of Prophylactic Enoxaparin after Surgical Procedures: Results of the Double-Blind, Randomized, Controlled FIxed or Variable Enoxaparin (FIVE) Trial. Plast Reconstr Surg 2021; 147:947-958. [PMID: 33761517 DOI: 10.1097/prs.0000000000007780] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The accepted "one-size-fits-all" dose strategy for prophylactic enoxaparin may not optimize the medication's risks and benefits after surgical procedures. The authors hypothesized that weight-based administration might improve the pharmacokinetics of prophylactic enoxaparin when compared to fixed-dose administration. METHODS The FIxed or Variable Enoxaparin (FIVE) trial was a randomized, double-blind trial that compared the pharmacokinetic and clinical outcomes of patients assigned randomly to postoperative venous thromboembolism prophylaxis using enoxaparin 40 mg twice daily or enoxaparin 0.5 mg/kg twice daily. Patients were randomized after surgery and received the first enoxaparin dose at 8 hours after surgery. Primary hypotheses were (1) weight-based administration is noninferior to a fixed dose for avoiding underanticoagulation (anti-factor Xa <0.2 IU/ml) and (2) weight-based administration is superior to fixed-dose administration for avoiding overanticoagulation (anti-factor Xa >0.4 IU/ml). Secondary endpoints were 90-day venous thromboembolism and bleeding. RESULTS In total, 295 patients were randomized, with 151 assigned to fixed-dose and 144 to weight-based administration of enoxaparin. For avoidance of under anticoagulation, weight-based administration had a greater effectiveness (79.9 percent versus 76.6 percent); the 3.3 percent (95 percent CI, -7.5 to 12.5 percent) greater effectiveness achieved statistically significant noninferiority relative to the a priori specified -12 percent noninferiority margin (p = 0.004). For avoidance of overanticoagulation, weight-based enoxaparin administration was superior to fixed-dose administration (90.6 percent versus 82.2 percent); the 8.4 percent (95 percent CI, 0.1 to 16.6 percent) greater effectiveness showed significant safety superiority (p = 0.046). Ninety-day venous thromboembolism and major bleeding were not different between fixed-dose and weight-based cohorts (0.66 percent versus 0.69 percent, p = 0.98; 3.3 percent versus 4.2 percent, p = 0.72, respectively). CONCLUSION Weight-based administration showed superior pharmacokinetics for avoidance of underanticoagulation and overanticoagulation in postoperative patients receiving prophylactic enoxaparin. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, I.
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Affiliation(s)
- Christopher J Pannucci
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Kory I Fleming
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Corinne Bertolaccini
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Jayant Agarwal
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - W Bradford Rockwell
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Shaun D Mendenhall
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Alvin Kwok
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Isak Goodwin
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Barbu Gociman
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Arash Momeni
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
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Sun H, Ma X, Li Z, Liu J, Wang W, Qi X. Release characteristics of enoxaparin sodium-loaded polymethylmethacrylate bone cement. J Orthop Surg Res 2021; 16:108. [PMID: 33541384 PMCID: PMC7860616 DOI: 10.1186/s13018-021-02223-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/11/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND This study aimed to prepare the polymethylmethacrylate (PMMA) bone cement release system with different concentrations of enoxaparin sodium (ES) and to investigate the release characteristics of ES after loading into the PMMA bone cement. METHODS In the experimental group, 40 g Palacos®R PMMA bone cement was loaded with various amount of ES 4000, 8000, 12,000, 16,000, 20,000, and 24,000 AXaIU, respectively. The control group was not loaded with ES. Scanning electron microscopy (SEM) was used to observe the surface microstructure of the bone cement in the two groups. In the experiment group, the mold was extracted continuously with pH7.4 Tris-HCL buffer for 10 days. The extract solution was collected every day and the anti-FXa potency was measured. The experiment design and statistical analysis were conducted using a quantitative response parallel line method. RESULTS Under the SEM, it was observed that ES was filled in the pores of PMMA bone cement polymer structure and released from the pores after extraction. There was a burst effect of the release. The release amount of ES on the first day was 0.415, 0.858, 1.110, 1.564, 1.952, and 2.513, respectively, from the six groups with various ES loading amount of 4000, 8000, 12,000, 16,000, 20,000, and 24,000 AXaIU, all reaching the peak of release on the first day. The release decreased rapidly on the next day and entered the plateau phase on the fourth day. CONCLUSION The prepared ES-PMMA bone cement has high application potential in orthopedic surgery. ES-PMMA bone cement shows good drug release characteristics. The released enoxaparin sodium has a local anti-coagulant effect within 24 h after application, but it will not be released for a long time, which is complementary to postoperative anti-coagulation therapy.
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Affiliation(s)
- Hui Sun
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xinzhe Ma
- Department of Orthopaedic Surgery, Shijiazhuang Third Hospital, Shijiazhuang, China
| | - Zhiyong Li
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jianning Liu
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wei Wang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiangbei Qi
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China.
- Tiemenguan District of the Third Hospital of Hebei Medical University, Tiemenguan City, China.
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Identification of "Never Events" After Orthopaedic Trauma. J Orthop Trauma 2020; 34:421-423. [PMID: 32427818 DOI: 10.1097/bot.0000000000001809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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