Enoxaparin DVT Prophylaxis in Trauma Patients
Although enoxaparin is more efficacious than many other deep vein thrombosis (DVT) prevention strategies after trauma, its routine use in trauma patients at low risk for venous thrombosis is unlikely to be cost-effective and may be deleterious if risk factors for bleeding are present. By way of consensus of opinion of trauma surgeons and pharmacists, enoxaparin DVT prophylaxis guidelines were developed, implemented, and evaluated. Fifty patients with major orthopedic or spinal trauma were followed throughout hospitalization. Enoxaparin use and frequency of DVT, pulmonary embolism (PE), thrombocytopenia, and enoxaparin-related major bleeding (overt bleeding associated with a hemoglobin decrease > 2 g/dl, need for > 2 units of packed red blood cells, or need for surgery) were recorded. All pharmacist interventions pertaining to enoxaparin prophylaxis were collected. Average patient age was 45.6 ± 19.5 years, average Injury Severity Score was 19.0 ± 11.2, and average length of hospitalization was 14.3 ± 10.0 days. Most injuries were related to motor vehicles (52%) and falls (30%). Sites of injury were femur or tibia (52%), pelvis or acetabulum (32%), hip (20%), and spinal cord (12%). Two-thirds (72%) of patients received enoxaparin during part of their hospital stay (on average, for 53% of the duration of hospitalization). Sequential compression devices and vena caval filters were used in 86% and 10% of patients, respectively. Duplex-proven DVT occurred in two patients, and angiography-proven PE developed in one patient. Enoxaparin-related major bleeding and thrombocytopenia occurred in three and one patient(s), respectively. Pharmacists recommended enoxaparin initiation in nine (18%) patients and discontinuation of the agent in seven (14%) patients (one for bleeding; six for lack of indication). Most recommendations (78%) were accepted. Data from the 50 patients in this study showed fewer thrombotic complications but more bleeding than the frequencies found in controlled studies. It is unclear whether the large number of days that patients did not receive enoxaparin was due to fears of enoxaparin-related bleeding or other factors.
Venous thrombosis after major trauma is associated with significant morbidity and mortality. One study revealed deep vein thrombosis (DVT) in 58% of trauma patients who were examined with contrast venography. Pulmonary embolism (PE) is the third most common cause of death in patients who survive the first 24 hours after trauma. Patients who develop venous thromboembolism usually require anticoagulation therapy, which can prolong hospitalization and increase the risk for adverse events such as bleeding. These patients are at risk for chronic sequelae such as postthrombotic phlebitis.
Provision of DVT prophylaxis after trauma has become a standard of practice. Pharmacologic DVT prophylaxis should be considered in all major trauma patients who are not bleeding or at high risk for a bleeding event. Level I evidence demonstrates the low-molecular-weight heparin (LMWH) enoxaparin to be more efficacious than low-dosage unfractionated heparin (UFH) in preventing thrombotic events after major trauma. Furthermore, enoxaparin was shown to be more cost-effective than low-dosage UFH, particularly in patients with lower extremity orthopedic injuries.
Although published guidelines recommend that all patients with major trauma be considered for DVT prophylaxis therapy with enoxaparin, trauma patients are extremely heterogeneous in their risk for developing venous thrombosis and their likelihood of experiencing unwanted bleeding related to antithrombotic prophylaxis. It was observed at our level 1 trauma center that enoxaparin prophylaxis was not uniformly prescribed. Trauma patients at greatest risk for venous thrombosis (e.g., orthopedic injuries) were sometimes not given enoxaparin, whereas patients at low risk for venous thrombosis (e.g., ambulatory) were sometimes inadvertently prescribed enoxaparin. In addition, we noticed that some patients were started on enoxaparin prophylaxis soon after surgery, creating undue risk for bleeding complications.
We developed, by way of consensus of opinion of trauma surgeons and clinical pharmacists, along with best literature evidence, detailed enoxaparin DVT prophylaxis guidelines for patients admitted with major trauma to our institution. We documented the role of clinical pharmacists in implementing these guidelines and evaluated the impact of the guidelines on enoxaparin use, frequency of DVT and PE, and enoxaparin-related adverse events such as bleeding and thrombocytopenia.
Abstract and Introduction
Abstract
Although enoxaparin is more efficacious than many other deep vein thrombosis (DVT) prevention strategies after trauma, its routine use in trauma patients at low risk for venous thrombosis is unlikely to be cost-effective and may be deleterious if risk factors for bleeding are present. By way of consensus of opinion of trauma surgeons and pharmacists, enoxaparin DVT prophylaxis guidelines were developed, implemented, and evaluated. Fifty patients with major orthopedic or spinal trauma were followed throughout hospitalization. Enoxaparin use and frequency of DVT, pulmonary embolism (PE), thrombocytopenia, and enoxaparin-related major bleeding (overt bleeding associated with a hemoglobin decrease > 2 g/dl, need for > 2 units of packed red blood cells, or need for surgery) were recorded. All pharmacist interventions pertaining to enoxaparin prophylaxis were collected. Average patient age was 45.6 ± 19.5 years, average Injury Severity Score was 19.0 ± 11.2, and average length of hospitalization was 14.3 ± 10.0 days. Most injuries were related to motor vehicles (52%) and falls (30%). Sites of injury were femur or tibia (52%), pelvis or acetabulum (32%), hip (20%), and spinal cord (12%). Two-thirds (72%) of patients received enoxaparin during part of their hospital stay (on average, for 53% of the duration of hospitalization). Sequential compression devices and vena caval filters were used in 86% and 10% of patients, respectively. Duplex-proven DVT occurred in two patients, and angiography-proven PE developed in one patient. Enoxaparin-related major bleeding and thrombocytopenia occurred in three and one patient(s), respectively. Pharmacists recommended enoxaparin initiation in nine (18%) patients and discontinuation of the agent in seven (14%) patients (one for bleeding; six for lack of indication). Most recommendations (78%) were accepted. Data from the 50 patients in this study showed fewer thrombotic complications but more bleeding than the frequencies found in controlled studies. It is unclear whether the large number of days that patients did not receive enoxaparin was due to fears of enoxaparin-related bleeding or other factors.
Introduction
Venous thrombosis after major trauma is associated with significant morbidity and mortality. One study revealed deep vein thrombosis (DVT) in 58% of trauma patients who were examined with contrast venography. Pulmonary embolism (PE) is the third most common cause of death in patients who survive the first 24 hours after trauma. Patients who develop venous thromboembolism usually require anticoagulation therapy, which can prolong hospitalization and increase the risk for adverse events such as bleeding. These patients are at risk for chronic sequelae such as postthrombotic phlebitis.
Provision of DVT prophylaxis after trauma has become a standard of practice. Pharmacologic DVT prophylaxis should be considered in all major trauma patients who are not bleeding or at high risk for a bleeding event. Level I evidence demonstrates the low-molecular-weight heparin (LMWH) enoxaparin to be more efficacious than low-dosage unfractionated heparin (UFH) in preventing thrombotic events after major trauma. Furthermore, enoxaparin was shown to be more cost-effective than low-dosage UFH, particularly in patients with lower extremity orthopedic injuries.
Although published guidelines recommend that all patients with major trauma be considered for DVT prophylaxis therapy with enoxaparin, trauma patients are extremely heterogeneous in their risk for developing venous thrombosis and their likelihood of experiencing unwanted bleeding related to antithrombotic prophylaxis. It was observed at our level 1 trauma center that enoxaparin prophylaxis was not uniformly prescribed. Trauma patients at greatest risk for venous thrombosis (e.g., orthopedic injuries) were sometimes not given enoxaparin, whereas patients at low risk for venous thrombosis (e.g., ambulatory) were sometimes inadvertently prescribed enoxaparin. In addition, we noticed that some patients were started on enoxaparin prophylaxis soon after surgery, creating undue risk for bleeding complications.
We developed, by way of consensus of opinion of trauma surgeons and clinical pharmacists, along with best literature evidence, detailed enoxaparin DVT prophylaxis guidelines for patients admitted with major trauma to our institution. We documented the role of clinical pharmacists in implementing these guidelines and evaluated the impact of the guidelines on enoxaparin use, frequency of DVT and PE, and enoxaparin-related adverse events such as bleeding and thrombocytopenia.
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