William Peppard, PharmD, BCPS
Pharmacist
Froedtert & The Medical College of Wisconsin
Milwaukee, Wisconsin
Disclosure information not submitted.
David Herrmann, PharmD, BCCCP
Pharmacist
Froedtert & the Medical College of Wisconsin, United States
Disclosure information not submitted.
Allison Samuei, PharmD
Pharmacist
University of Wisconsin Hospital and Clinics, United States
Disclosure information not submitted.
Elizabeth Langenstroer, PharmD,
PGY2 Critical Care Pharmacy Resident
NewYork Presbyterian Hospital
New York, NY
Disclosure information not submitted.
Lisa Rein, ScM
Biostatistician
Medical College of Wisconsin, United States
Disclosure information not submitted.
David Milia, MD, FACS
Director, Division of Trauma
Froedtert & the Medical College of Wisconsin, United States
Disclosure information not submitted.
Thomas Carver, MD, FACS
Director, Surgical Intensive Care
Medical College of Wisconsin Froedtert Hospital, United States
Disclosure information not submitted.
Title: Novel Blood Volume-Based Guideline Versus Western Trauma Association Guideline for VTE Prophylaxis
Introduction: In 2020, a novel blood volume (BV)-based venous thromboembolism (VTE) prophylaxis dosing guideline for trauma patients was implemented. This change increased attainment of target anti-Xa levels to 81% compared to 64% with our historical control, a body mass index-based protocol (p=0.08). The Western Trauma Association (WTA) published a guideline recommending increased enoxaparin (ENOX) dosing based on age, mass, renal function, traumatic brain or spinal cord injury, and pregnancy. This study was designed to compare the dosing strategies of the BV and WTA guidelines.
Methods: We retrospectively reviewed the charts of all adult trauma inpatients receiving enoxaparin for VTE prophylaxis who underwent routine anti-Xa level monitoring over a 3-month period (Aug-Oct 2020) at an ACS-verified level 1 trauma center. The actual BV dose administered was compared to the theoretical dose according to the WTA guideline. The primary outcome was the frequency of patients receiving enoxaparin 40 mg BID. Secondary outcome was attainment of target anti-Xa levels (0.2-0.5 units/mL) after at least 3 doses of ENOX. Fisher’s exact and Kruskal-Wallis tests were used to analyze data.
Results: A total of 142 patients were included; 61% did not meet criteria to increase ENOX to 40 mg BID per WTA guideline. The BV guideline led to more patients receiving a higher ENOX dose when compared to WTA, with 58% vs 39% initially receiving ENOX 40 mg BID, and 1% vs 0% receiving ENOX 60 mg BID, respectively (p< 0.01). Compared to WTA the BV guideline under-dosed 22% of patients, 37% received the same dose, and 42% of patients received a higher dose. There was no difference in attainment of target anti-Xa levels for these 3 groups (84%, 85% and 75%, respectively, p=0.55); the anti-Xa levels did not differ between these 3 groups (p=0.18). VTE developed in 5 (3.5%) patients (2 at target, 3 below), and bleed developed in 3 (2.1%) patients (2 at target, 1 below).
Conclusions: Our BV-based guideline yielded more aggressive ENOX dosing compared to the theoretical WTA guideline, and dosing was discordant for most patients between the two strategies, but VTE and bleed rates did not change. These findings provide the basis for future prospective comparative studies to better define optimal ENOX dosing.