OBJECTIVESVenous thromboembolism (VTE) is a common nosocomial condition, developing frequently in overweight and obese patients. VTE prophylaxis with weight-based enoxaparin dosing may be more effective than the standard dosing regimen for overweight and obese patients; however, weight-based dosing is not practiced routinely. In this pilot study we sought to evaluate prophylactic anticoagulation regimens used for VTE prevention in overweight and obese patients on the Orthopedic-Medical Trauma (OMT) service to inform the need for modification of dosing practices.METHODSThis prospective, observational study evaluated the adequacy of current VTE prophylaxis practice at an academic tertiary center, including overweight and obese patients admitted during 2017-2018 to an OMT comanagement service. It included patients hospitalized for at least 3 days with a body mass index (BMI) of ≥25 and prescribed enoxaparin. Steady-state antifactor Xa trough and peak levels were monitored after three doses. Frequency of in prophylactic range (0.2-0.44) antifactor Xa levels and VTE events were compared by BMI groups and enoxaparin dosing using the χ² test.RESULTSThere were 404 inpatients included: 41.1% were overweight (BMI 25-29), 43.4% were obese (BMI 30-39), and 15.6% were morbidly obese (BMI ≥40). A total of 351 patients (86.9%) received standard dose enoxaparin 30 mg 2 times per day (BID), and 53 patients received enoxaparin 40 mg BID or more. A number of patients (213; 52.7%) did not achieve prophylactic range antifactor Xa levels. A significantly higher number of patients in the overweight group achieved prophylactic range antifactor Xa compared with obese and morbidly obese groups (58.4% vs 41.7% and 33%, P = 0.002 and 0.0007, respectively). Morbidly obese patients treated with enoxaparin 40 mg BID or higher versus enoxaparin 30 mg BID had fewer VTE events (4% vs 10.8%, P = 0.18).CONCLUSIONSThe current practice of VTE enoxaparin prophylaxis may not be adequate for overweight and obese OMT patients. Further guidelines are needed to implement weight-based VTE prophylaxis in overweight and obese hospitalized patients.

01 Aug 2022·Hospital Pharmacy

Evaluation of Unfractionated Heparin Dosing by Antifactor Xa During Targeted Temperature Management Post Cardiac Arrest

Article

Author: Modrykamien, Ariel ; Kataria, Vivek ; Ryman, Klayton M ; Mora, Adan ; Wang, Xuan ; Moon, Joon Yong ; Belcher, Carrigan

Purpose: To evaluate unfractionated heparin (UFH) dosing guided by antifactor Xa levels during targeted temperature management (TTM) post-cardiac arrest. Methods: Single-center, retrospective, observational study between January 1, 2014 and September 1, 2020. Patients initiated on TTM post-cardiac arrest and UFH were evaluated for inclusion. Patients included were ≥18 years of age and received weight-based UFH for ≥6 hours with 2 antifactor Xa levels drawn at target temperature. Excluded patients had no available temperature readings, received extracorporeal membrane oxygenation (ECMO) or factor Xa inhibitor (within 72 hours), or had hypertriglyceridemia or hyperbilirubinemia. The primary endpoint was to evaluate the proportion of patients that achieved a therapeutic antifactor Xa level between 0.3 and 0.7 IU/mL at steady state during TTM. Secondary endpoints included average UFH dose and average time to therapeutic antifactor Xa level at steady state; percent of first and total antifactor Xa levels subtherapeutic, therapeutic, and supratherapeutic during TTM. Results: A total of 73 patients met inclusion criteria. Of these, 21 patients achieved steady-state therapeutic antifactor Xa levels during TTM. The average time and dose to steady-state therapeutic antifactor Xa levels were 8.1 ± 4.5 hours and 9.9 ± 3.2 units/kg/hour. Overall, 61.7% of first and 47.4% of all antifactor Xa levels were supratherapeutic during TTM. Three (4.1%) patients experienced a major bleeding event. Conclusions: Guideline recommended UFH dosing, 12 or 18 units/kg/hour, during TTM resulted in more supratherapeutic antifactor Xa levels. Reduction of UFH infusion dose to 10 units/kg/hour may be required during TTM to maintain therapeutic antifactor Xa levels.

01 Sep 2021·Journal of Trauma and Acute Care SurgeryQ2 · MEDICINE

A tale of two centers: Is low-molecular-weight heparin really superior for prevention of posttraumatic venous thromboembolism?

Q2 · MEDICINE

Article

Author: Badiee, Jayraan ; Wessels, Lyndsey E. ; Prieto, James M. ; Berndtson, Allison E. ; Sise, Michael J. ; Calvo, Richard Y. ; Bansal, Vishal ; Martin, Matthew J. ; Checchi, Kyle D. ; Costantini, Todd W. ; Sise, C. Beth ; Rooney, Alexandra S.

BACKGROUNDLow-molecular-weight heparin (LMWH) is widely used for venous thromboembolism chemoprophylaxis following injury. However, unfractionated heparin (UFH) is a less expensive option. We compared LMWH and UFH for prevention of posttraumatic deep venous thrombosis (DVT) and pulmonary embolism (PE).METHODSTrauma patients 15 years or older with at least one administration of venous thromboembolism chemoprophylaxis at two level I trauma centers with similar DVT-screening protocols were identified. Center 1 administered UFH every 8 hours for chemoprophylaxis, and center 2 used twice-daily antifactor Xa-adjusted LMWH. Clinical characteristics and primary chemoprophylaxis agent were evaluated in a two-level logistic regression model. Primary outcome was incidence of DVT and PE.RESULTSThere were 3,654 patients: 1,155 at center 1 and 2,499 at center 2. The unadjusted DVT rate at center 1 was lower than at center 2 (3.5% vs. 5.0%; p = 0.04); PE rates did not significantly differ (0.4% vs. 0.6%; p = 0.64). Patients at center 2 were older (mean, 50.3 vs. 47.3 years; p < 0.001) and had higher Injury Severity Scores (median, 10 vs. 9; p < 0.001), longer stays in the hospital (mean, 9.4 vs. 7.0 days; p < 0.001) and intensive care unit (mean, 3.0 vs. 1.3 days; p < 0.001), and a higher mortality rate (1.6% vs. 0.6%, p = 0.02) than patients at center 1. Center 1’s patients received their first dose of chemoprophylaxis earlier than patients at center 2 (median, 1.0 vs. 1.7 days; p < 0.001). After risk adjustment and accounting for center effects, primary chemoprophylaxis agent was not associated with risk of DVT (odds ratio, 1.01; 95% confidence interval, 0.69–1.48; p = 0.949). Cost calculations showed that UFH was less expensive than LMWH.CONCLUSIONPrimary utilization of UFH is not inferior to LMWH for posttraumatic DVT chemoprophylaxis and rates of PE are similar. Given that UFH is lower in cost, the choice of this chemoprophylaxis agent may have major economic implications.LEVEL OF EVIDENCEPrognostic and epidemiological, level II; Therapeutic, level III.

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