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Heim C, Bruder N, Davenport R, Duranteau J, Gaarder C. European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 11: Trauma. Eur J Anaesthesiol 2024; 41:612-617. [PMID: 38957029 DOI: 10.1097/eja.0000000000002017] [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)
- Catherine Heim
- From the Department of Anesthesiology, CHUV - University Hospital Lausanne, Switzerland (CH), Aix-Marseille University, APHM, Marseille, France (NB), Centre for Trauma Sciences, Blizard Insitute, Queen Mary University of London, UK (RD), Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France (JD) and Department of Traumatology, Oslo University Hospital, Oslo, Norway (CG)
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Lombardo S, McCrum M, Knudson MM, Moore EE, Kornblith L, Brakenridge S, Bruns B, Cipolle MD, Costantini TW, Crookes B, Haut ER, Kerwin AJ, Kiraly LN, Knowlton LM, Martin MJ, McNutt MK, Milia DJ, Mohr A, Rogers F, Scalea T, Sixta S, Spain D, Wade CE, Velmahos GC, Nirula R, Nunez J. Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry. Trauma Surg Acute Care Open 2024; 9:e001230. [PMID: 38420604 PMCID: PMC10900334 DOI: 10.1136/tsaco-2023-001230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/26/2023] [Indexed: 03/02/2024] Open
Abstract
Introduction Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD). Methods Patients from the prospective, observational CLOTT-1 registry receiving prophylactic enoxaparin (n=5539) were categorized as WB (0.45-0.55 mg/kg two times per day) or SFD (30 mg two times per day, 40 mg once a day). Multivariate logistic regression was used to generate a predicted probability of VTE for WB and SFD patients. Results Of 4360 patients analyzed, 1065 (24.4%) were WB and 3295 (75.6%) were SFD. WB patients were younger, female, more severely injured, and underwent major operation or major venous repair at a higher rate than individuals in the SFD group. Obesity was more common among the SFD group. Unadjusted VTE rates were comparable (WB 3.1% vs. SFD 3.9%; p=0.221). Early prophylaxis was associated with lower VTE rate (1.4% vs. 5.0%; p=0.001) and deep vein thrombosis (0.9% vs. 4.4%; p<0.001), but not pulmonary embolism (0.7% vs. 1.4%; p=0.259). After adjustment, VTE incidence did not differ by dosing strategy (adjusted OR (aOR) 0.75, 95% CI 0.38 to 1.48); however, early administration was associated with a significant reduction in VTE (aOR 0.47, 95% CI 0.30 to 0.74). Conclusion In young trauma patients, WB prophylaxis is not associated with reduced VTE rate when compared with SFD. The timing of the initiation of chemoprophylaxis may be more important than the dosing strategy. Further studies need to evaluate these findings across a wider age and comorbidity spectrum. Level of evidence Level IV, therapeutic/care management.
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Affiliation(s)
| | - Marta McCrum
- Surgery, University of Utah, Salt Lake City, Utah, USA
| | - M Margaret Knudson
- Surgery, University of California San Francisco, San Francisco, California, USA
| | | | - Lucy Kornblith
- Surgery, University of California San Francisco, San Francisco, California, USA
| | - Scott Brakenridge
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Brandon Bruns
- Department of Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Mark D Cipolle
- Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Todd W Costantini
- Surgery, University of California San Francisco, San Francisco, California, USA
| | - Bruce Crookes
- Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Elliott R Haut
- Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Andrew J Kerwin
- Surgery, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida, USA
| | | | | | - Matthew J Martin
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, Los Angeles, California, USA
| | - Michelle K McNutt
- Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David J Milia
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Alicia Mohr
- Surgery, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida, USA
| | | | - Thomas Scalea
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sherry Sixta
- St Anthony Hospital & Medical Campus, Lakewood, Colorado, USA
| | - David Spain
- Surgery, Stanford University, Stanford, California, USA
| | - Charles E Wade
- Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | | | - Ram Nirula
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jade Nunez
- Surgery, University of Utah, Salt Lake City, Utah, USA
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Owodunni OP, Lau BD, Wang J, Shaffer DL, Kraus PS, Holzmueller CG, Aboagye JK, Hobson DB, Varasteh Kia M, Armocida S, Streiff MB, Haut ER. Effectiveness of a Patient Education Bundle on Venous Thromboembolism Prophylaxis Administration by Sex. J Surg Res 2022; 280:151-162. [PMID: 35969933 DOI: 10.1016/j.jss.2022.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 07/14/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a frequent cause of preventable harm among hospitalized patients. Many prescribed prophylaxis doses are not administered despite supporting evidence. We previously demonstrated a patient-centered education bundle improved VTE prophylaxis administration broadly; however, patient-specific factors driving nonadministration are unclear. We examine the effects of the education bundle on missed doses of VTE prophylaxis by sex. METHODS We performed a post-hoc analysis of a nonrandomized controlled trial to evaluate the differences in missed doses by sex. Pre-intervention and intervention periods for patients admitted to 16 surgical and medical floors between 10/2014-03/2015 (pre-intervention) and 04/2015-12/2015 (intervention) were compared. We examined the conditional odds of (1) overall missed doses, (2) missed doses due to patient refusal, and (3) missed doses for other reasons. RESULTS Overall, 16,865 patients were included (pre-intervention 6853, intervention 10,012), with 2350 male and 2460 female patients (intervention), and 6373 male and 5682 female patients (control). Any missed dose significantly reduced on the intervention floors among male (odds ratio OR 0.55; 95% confidence interval CI, 0.44-0.70, P < 0.001) and female (OR 0.59; 95% CI, 0.47-0.73, P < 0.001) patients. Similar significant reductions ensued for missed doses due to patient refusal (P < 0.001). Overall, there were no sex-specific differences (P-interaction >0.05). CONCLUSIONS Our intervention increased VTE prophylaxis administration for both female and male patients, driven by decreased patient refusal. Patient education should be applicable to a wide range of patient demographics representative of the target group. To improve future interventions, quality improvement efforts should be evaluated based on patient demographics and drivers of differences in care.
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Affiliation(s)
- Oluwafemi P Owodunni
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland; Department of Health Policy and Management, The Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Jiangxia Wang
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Dauryne L Shaffer
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christine G Holzmueller
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland
| | - Jonathan K Aboagye
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah B Hobson
- The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland; Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Mujan Varasteh Kia
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephanie Armocida
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael B Streiff
- The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland; Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland; Department of Health Policy and Management, The Johns Hopkins University School of Public Health, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Johns Hopkins Surgery Center for Outcomes Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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