Characterizing the delays in adequate thromboprophylaxis after TBI

A collaborative multidisciplinary trauma program improvement team improves VTE chemoprophylaxis guideline compliance in non-operative stable TBI

BACKGROUND

Delays in initiating venous thromboembolism (VTE) prophylaxis in patients suffering from traumatic brain injury (TBI) persist despite guidelines recommending early initiation. We hypothesized that the expansion of a Trauma Program Performance Improvement (PI) team will improve compliance of early (24-48 hours) initiation of VTE prophylaxis and will decrease VTE events in TBI patients.

METHODS

We performed a single-center retrospective review of all TBI patients admitted to a Level I trauma center before (2015-2016,) and after (2019-2020,) the expansion of the Trauma Performance Improvement and Patient Safety (PIPS) team and the creation of trauma process and outcome dashboards. Exclusion criteria included discharge or death within 48 hours of admission, expanding intracranial hemorrhage on CT scan, and a neurosurgical intervention (craniotomy, pressure monitor, or drains) prior to chemoprophylaxis initiation.

RESULTS

A total of 1,112 patients met the inclusion criteria, of which 54% (n = 604) were admitted after Trauma PIPS expansion. Following the addition of a dedicated PIPS nurse in the trauma program and creation of process dashboards, the time from stable CT to VTE prophylaxis initiation decreased (52 hours to 35 hours; p < 0.001) and more patients received chemoprophylaxis at 24 hours to 48 hours (59% from 36%, p < 0.001) after stable head CT. There was no significant difference in time from first head CT to stable CT (9 vs. 9 hours; p = 0.15). The Contemporary group had a lower rate of VTE events (1% vs. 4%; p < 0.001) with no increase in bleeding events (2% vs. 2%; p = 0.97). On multivariable analysis, being in the Early cohort was an independent predictor of VTE events (adjusted odds ratio, 3.74; 95% confidence interval, 1.45-6.16).

CONCLUSION

A collaborative multidisciplinary Trauma PIPS team improves guideline compliance. Initiation of VTE chemoprophylaxis within 24 hours to 48 hours of stable head CT is safe and effective.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study

BACKGROUND

In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI.

METHODS

Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest.

RESULTS

984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant.

CONCLUSION

In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH.

LEVEL OF EVIDENCE

Level III, Therapeutic Care Management.

Creatinine clearance predicts the goal enoxaparin dose in traumatic brain injury

BACKGROUND

Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism (VTE). Recent guidelines recommend starting TBI patients on enoxaparin 30 mg twice daily and then considering weight-based dosing. Creatinine clearance may be better than weight for patients when considering high and low enoxaparin dose requirements. We hypothesize that creatinine clearance (CrCl) predicts goal enoxaparin dose better than weight-based dosing.

METHODS

A retrospective review was conducted on patients admitted to an urban, academic Level I trauma center from August 2017 to February 2020. Patients were included if greater than 18 years, admitted longer than 48 hours, and head and neck AIS ≥ 3. Patients were excluded if they did not have TBI, if they received deep vein thrombosis prophylaxis other than enoxaparin 12-hour dosing, if no anti-Xa levels were drawn, or if the goal anti-Xa level was not reached. Patients were grouped into dosing cohorts based on dose of enoxaparin required to reach goal. Pearson's correlation was used to compare mean CrCl and mean weight across dosing cohorts.

RESULTS

A total of 120 patients met inclusion and exclusion criteria, mean age was 47 years and 68% of patients were male. The mean hospital length of stay was 24 days. There were 5 (4.2%) deep vein thrombosis, no pulmonary embolism, and 5 (4.2%) patients died. Mean CrCl increased significantly with increased dosing of enoxaparin, Pearson's correlation coefficient of 0.484 ( p < 0.001). Weight on admission also increased with increasing enoxaparin dose requirements, with Pearson's correlation coefficient of 0.411 ( p < 0.001).

CONCLUSION

Creatine clearance predicts goal enoxaparin dose in TBI better than a weight-based dosing strategy. Further research with a larger patient population is required to validate CrCl values to guide enoxaparin dosing.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Creatinine Clearance May Predict Goal Enoxaparin Dose in Trauma

BACKGROUND

Guidelines for enoxaparin dosing after trauma recommend an initial dose of 40 mg twice daily for most patients and then adjusting by anti-Xa levels. Previous studies indicated higher enoxaparin doses are necessary with higher levels of creatinine clearance (CrCl). We sought to determine if the goal enoxaparin dose correlates with the admission CrCl to reduce the reliance on measuring anti-Xa levels.

STUDY DESIGN

A retrospective review was conducted of patients admitted to an urban, academic Level 1 trauma center from April 2017 to February 2020. Patients started on enoxaparin who reached goal anti-Xa trough levels were included, and patients were excluded if they did not reach goal anti-Xa levels. Data collection included patient demographics, injury characteristics, admission CrCl, and final enoxaparin dose. CrCl was then correlated with the final enoxaparin dose.

RESULTS

Of 421 patients included, the mean age was 46.6 years and 73% were male. The median goal enoxaparin dose was 40 mg twice daily. The mean CrCl significantly increased with increasing twice-daily doses of enoxaparin (20 mg: 69.2 mL/min; 30 mg: 89 mL/min; 40 mg: 112.8 mL/min; 50 mg: 140.5mL/min; 60 mg: 147.4 mL/min; and 70 mg: 140 mL/min; p < 0.01).

CONCLUSIONS

Admission CrCl may predict the enoxaparin dose required to achieve adequate anti-Xa levels. Our data indicate that CrCls of approximately 70, 90, 110, 140, and 150 mL/min may predict the twice-daily enoxaparin doses of 20, 30, 40, 50, and 60 mg, respectively. CrCl dosing guidance may reduce the time to goal anti-Xa levels and the frequency of anti-Xa measurements. Further research is necessary, and enoxaparin dosing should continue to be monitored by anti-Xa levels.

Rate of prophylactic anti-Xa achievement and impact on venous thromboembolism following oncologic hepato-pancreatico-biliary surgery: A prospective cohort study

BACKGROUND

Hepato-pancreatico-biliary (HPB) patients experience competing risk of venous thromboembolism (VTE) and bleeding. We sought to evaluate the effect of anti-Xa levels on VTE and bleeding, and to characterize factors associated with subprophylaxis.

METHODS

This prospective cohort study evaluated adult HPB surgical patients; cohorts were described by anti-Xa levels as subprophylactic (<0.2 IU/mL), prophylactic (0.2-0.5 IU/mL), and supraprophylactic (>0.5 IU/mL). Primary outcome evaluated bleeding and VTE complications. Secondary outcomes evaluated factors associated with subprophylaxis.

RESULTS

We included 157 patients: 68 (43.6%) attained prophylactic anti-Xa and 89 (56.7%) were subprophylactic. Subprophylactic patients experienced more VTE compared to prophylactic patients (6.9% vs 0%; p = 0.028) without differences in bleeding complications (14.6% vs 5.9%; p = 0.081). Factors associated with subprophylactic anti-Xa included female sex (OR 2.90, p = 0.008), and Caprini score (OR 1.30, p = 0.035). Enoxaparin was protective against subprophylaxis compared to tinzaparin (OR 0.43, p = 0.029).

CONCLUSIONS

Many HPB patients have subprophylactic anti-Xa levels, placing them at risk of VTE. Enoxaparin may be preferential, however, studies evaluating optimized prophylaxis are needed.

The efficacy of various Enoxaparin dosing regimens in general surgery patients: A systematic review

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).

Novel therapeutic medications for venous thromboembolism prevention in trauma patients: Findings from the Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma

ABSTRACT

Trauma patients are at high risk for venous thromboembolism (VTE). Despite evidence-based guidelines and concerted efforts in trauma centers to implement optimal chemoprophylaxis strategies, VTE remains a frequent diagnosis in trauma patients. Current chemoprophylaxis strategies largely focus on the subcutaneous injection of low-molecular-weight heparin, which is administered twice daily. Novel approaches to pharmacologic VTE prophylaxis have the potential to reduce VTE rates by improving patient compliance through oral administration or through their ability to target alternative pathways that mediate thrombosis. While novel pharmacologic VTE prophylaxis strategies have been studied in nontrauma patients, there is a paucity of literature in trauma patients where the risk of thrombosis versus hemorrhage must be carefully considered. As a component of the 2022 Consensus Conference to Implement Optimal VTE Prophylaxis in Trauma, this review provides an update of the novel chemoprophylaxis agents for potential use in trauma patients. Here, we will consider the relative risks and benefits related to the use of these drugs, evaluate the current literature in nontrauma patients, and consider future directions that could potentially improve posttrauma VTE prophylaxis.

Relationship Between Anti-Xa Level Achieved with Prophylactic Low-Molecular Weight Heparin and Venous Thromboembolism in Trauma Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Trauma patients have simultaneously high venous thromboembolism (VTE) and bleeding risk. Optimal chemoprophylaxis regimens remain unclear. This study aims to answer three questions for trauma patients. Is there any association between anti-Xa and VTE? Does dose adjustment improve prophylactic anti-Xa rates? Does dose adjustment improve anti-Xa adequacy and VTE compared to standard dosing?

METHODS

Systematic search of MEDLINE, Embase, Scopus, and Web of Science occurred in May 2021.Two author review included trauma studies that: evaluated low molecular weight heparin chemoprophylaxis, reported anti-Xa level, and evaluated ≥1 outcome. Data was dually extracted and estimated effects were calculated using RevMan 5.4 applying the Mantel-Haenszel method. Analysis #1 compared patients with peak anti-Xa ≥ 0.2 IU/ml or trough ≥0.1 IU/ml to those with lower anti-Xa using VTE as the primary outcome. Analysis #2 reported the effect of dose adjustment on anti-Xa. Analysis #3 compared standard dosing to dose adjustment with the primary outcome being anti-Xa adequacy; secondary outcomes were VTE, pulmonary embolism, and bleeding complications.

RESULTS

3401 studies were evaluated with 24 being included (19 retrospective studies, 5 prospective studies). In analysis #1, achieving adequate anti-Xa was associated with reduced odds of VTE (4.0% to 3.1%, OR 0.52, p = 0.03). Analysis #2 demonstrated that 768 (75.3%) patients achieved prophylactic anti-Xa with adjustment protocols.Analysis three suggested that dose adjusted chemoprophylaxis achieves prophylactic anti-Xa more frequently (OR 4.05, p = 0.007) but without VTE (OR 0.72, p = 0.15) or PE (OR 0.48, p = 0.10) differences. In subgroup analysis, anti-Xa dose adjustment also suggested no VTE reduction (OR 0.68, p = 0.08).

CONCLUSIONS

Patients with higher anti-Xa levels are less likely to experience VTE, and anti-Xa guided chemoprophylaxis increases anti-Xa adequacy. However, dose adjustment, including anti-Xa guided dosing, may not reduce VTE.

LEVEL OF EVIDENCE

Level IV; Systematic Review Meta-Analysis.