Robert Madlinger, DO, MPH, FACS, FACOS, LTC, USAR, USARC
Chief of Trauma, Acute Care, and Critical Care Surgery
St. Joseph's University Medical Center; Mohawk Valley Health System, United States
Disclosure information not submitted.
Benjamin Rebein, DO, MBA, FACS
Chief of Trauma
St. Joseph Regional Medical Center, United States
Disclosure information not submitted.
Melissa Warta, MD, FACS
Assistant Trauma Medical Director and Director of Pediatric Trauma
Saint Joseph's University Medical Center, United States
Disclosure information not submitted.
Jamshed Zuberi, MD, MPH, FACS
Director of Research
St. Joseph's University Medical Center, United States
Disclosure information not submitted.
Title: Reduction of Venous Thromboembolism in Trauma Patients with Targeted Enoxaparin Dose Adjustment
Introduction/Hypothesis: The current standard venous thromboembolism (VTE) chemoprophylaxis dose for trauma patients is inadequate at providing sufficient protection against the formation of deep vein thrombosis and pulmonary embolism. Anti-factor Xa-guided enoxaparin dosing has successfully decreased the occurrence of VTE in trauma patients at several institutions. The purpose of this systematic review is to present the current literature on anti-factor Xa-guided enoxaparin dosing approaches for VTE chemoprophylaxis and also to present the association between anti-factor Xa levels with the occurrence of VTE in a concise and organized manner.
Methods: Four electronic databases, PubMed, EMBASE, JAMA network, and CINAHL Complete, were searched for articles regarding anti-factor Xa-guided enoxaparin dosing approaches and VTE chemoprophylaxis in the trauma patient population. The study was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The quality of evidence was assessed using the GRADE Working Group criteria.
Results: One-thousand nine-hundred forty-four articles resulted from our initial search criteria. After screening for relevance and inclusion and exclusion criteria, 22 studies with 7,144 patients were included in our analysis. Seventeen studies evaluated anti-factor Xa peak concentrations as a surrogate marker for enoxaparin activity and nine studies evaluated anti-factor Xa trough levels. Four studies assessed both peak and trough anti-factor Xa values. There was a decreased incidence of VTE in patients who achieved appropriate anti-factor Xa levels compared to those receiving the standard trauma fixed dose regimen.
Conclusions: Anti-factor Xa-guided enoxaparin dosing may be superior to standard dose enoxaparin (i.e., enoxaparin 30 mg BID with no dose adjustments) in reducing the occurrence of VTE events in trauma patients. Additionally, titrating enoxaparin to prophylactic anti-factor Xa trough levels may be superior to targeting prophylactic anti-factor Xa peak levels in achieving goal anti-factor Xa levels and reducing the occurrence of VTE in trauma patients. Further investigation via randomized controlled trials in multi-center studies is warranted.