Standard prophylactic enoxaparin dosing leads to inadequate anti-Xa levels and increased deep venous thrombosis rates in critically Ill trauma and surgical patients

Darren Malinoski, Fariba Jafari, Tyler Ewing, Chris Ardary, Heather Conniff, Mark Baje, Allen Kong, Michael E. Lekawa, Matthew O. Dolich, Marianne E. Cinat, Cristobal Barrios, David B. Hoyt

Research output: Contribution to journalArticle

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Abstract

BACKGROUND: Deep venous thromboses (DVT) continue to cause significant morbidity in critically ill patients. Standard prophylaxis for high risk patients includes twice-daily dosing with 30 mg enoxaparin. Despite prophylaxis, DVT rates still exceed 10% to 15%. Anti-Xa levels are used to measure the activity of enoxaparin and 12-hour trough levels ≤0.1 IU/mL have been associated with higher rates of DVT in orthopedic patients. We hypothesized that low Anti-Xa levels would be found in critically ill trauma and surgical patients and that low levels would be associated with higher rates of DVT. METHODS:: All patients on the surgical intensive care unit (ICU) service were prospectively followed. In the absence of contraindications, patients were given prophylactic enoxaparin and anti-Xa levels were drawn after the third dose. Trough levels ≤0.1 IU/mL were considered low. Screening duplex exams were obtained within 48 hours of admission and then weekly. Patients were excluded if they did not receive a duplex, if they had a prior DVT, or if they lacked correctly timed anti-Xa levels. DVT rates and demographic data were compared between patients with low and normal anti-Xa levels. RESULTS:: Data were complete for 54 patients. Eighty-five percent suffered trauma (Injury Severity Score of 25 ± 12) and 74% were male. Overall, 27 patients (50%) had low anti-Xa levels. Patients with low anti-Xa levels had significantly more DVTs than those with normal levels (37% vs. 11%, p = 0.026), despite similar age, body mass index, Injury Severity Score, creatinine clearance, high risk injuries, and ICU/ventilator days. CONCLUSION:: Standard dosing of enoxaparin leads to low anti-Xa levels in half of surgical ICU patients. Low levels are associated with a significant increase in the risk of DVT. These data support future studies using adjusted-dose enoxaparin.

Original languageEnglish (US)
Pages (from-to)874-879
Number of pages6
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume68
Issue number4
DOIs
StatePublished - Apr 1 2010
Externally publishedYes

Fingerprint

Enoxaparin
Critical Illness
Venous Thrombosis
Wounds and Injuries
Intensive Care Units
Injury Severity Score
Critical Care
Mechanical Ventilators
Orthopedics
Creatinine
Body Mass Index

Keywords

  • Anti-Xa levels
  • Critical care
  • Low-molecular weight heparin
  • Venous thrombosis

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Standard prophylactic enoxaparin dosing leads to inadequate anti-Xa levels and increased deep venous thrombosis rates in critically Ill trauma and surgical patients. / Malinoski, Darren; Jafari, Fariba; Ewing, Tyler; Ardary, Chris; Conniff, Heather; Baje, Mark; Kong, Allen; Lekawa, Michael E.; Dolich, Matthew O.; Cinat, Marianne E.; Barrios, Cristobal; Hoyt, David B.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 68, No. 4, 01.04.2010, p. 874-879.

Research output: Contribution to journalArticle

Malinoski, Darren ; Jafari, Fariba ; Ewing, Tyler ; Ardary, Chris ; Conniff, Heather ; Baje, Mark ; Kong, Allen ; Lekawa, Michael E. ; Dolich, Matthew O. ; Cinat, Marianne E. ; Barrios, Cristobal ; Hoyt, David B. / Standard prophylactic enoxaparin dosing leads to inadequate anti-Xa levels and increased deep venous thrombosis rates in critically Ill trauma and surgical patients. In: Journal of Trauma - Injury, Infection and Critical Care. 2010 ; Vol. 68, No. 4. pp. 874-879.
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abstract = "BACKGROUND: Deep venous thromboses (DVT) continue to cause significant morbidity in critically ill patients. Standard prophylaxis for high risk patients includes twice-daily dosing with 30 mg enoxaparin. Despite prophylaxis, DVT rates still exceed 10{\%} to 15{\%}. Anti-Xa levels are used to measure the activity of enoxaparin and 12-hour trough levels ≤0.1 IU/mL have been associated with higher rates of DVT in orthopedic patients. We hypothesized that low Anti-Xa levels would be found in critically ill trauma and surgical patients and that low levels would be associated with higher rates of DVT. METHODS:: All patients on the surgical intensive care unit (ICU) service were prospectively followed. In the absence of contraindications, patients were given prophylactic enoxaparin and anti-Xa levels were drawn after the third dose. Trough levels ≤0.1 IU/mL were considered low. Screening duplex exams were obtained within 48 hours of admission and then weekly. Patients were excluded if they did not receive a duplex, if they had a prior DVT, or if they lacked correctly timed anti-Xa levels. DVT rates and demographic data were compared between patients with low and normal anti-Xa levels. RESULTS:: Data were complete for 54 patients. Eighty-five percent suffered trauma (Injury Severity Score of 25 ± 12) and 74{\%} were male. Overall, 27 patients (50{\%}) had low anti-Xa levels. Patients with low anti-Xa levels had significantly more DVTs than those with normal levels (37{\%} vs. 11{\%}, p = 0.026), despite similar age, body mass index, Injury Severity Score, creatinine clearance, high risk injuries, and ICU/ventilator days. CONCLUSION:: Standard dosing of enoxaparin leads to low anti-Xa levels in half of surgical ICU patients. Low levels are associated with a significant increase in the risk of DVT. These data support future studies using adjusted-dose enoxaparin.",
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author = "Darren Malinoski and Fariba Jafari and Tyler Ewing and Chris Ardary and Heather Conniff and Mark Baje and Allen Kong and Lekawa, {Michael E.} and Dolich, {Matthew O.} and Cinat, {Marianne E.} and Cristobal Barrios and Hoyt, {David B.}",
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T1 - Standard prophylactic enoxaparin dosing leads to inadequate anti-Xa levels and increased deep venous thrombosis rates in critically Ill trauma and surgical patients

AU - Malinoski, Darren

AU - Jafari, Fariba

AU - Ewing, Tyler

AU - Ardary, Chris

AU - Conniff, Heather

AU - Baje, Mark

AU - Kong, Allen

AU - Lekawa, Michael E.

AU - Dolich, Matthew O.

AU - Cinat, Marianne E.

AU - Barrios, Cristobal

AU - Hoyt, David B.

PY - 2010/4/1

Y1 - 2010/4/1

N2 - BACKGROUND: Deep venous thromboses (DVT) continue to cause significant morbidity in critically ill patients. Standard prophylaxis for high risk patients includes twice-daily dosing with 30 mg enoxaparin. Despite prophylaxis, DVT rates still exceed 10% to 15%. Anti-Xa levels are used to measure the activity of enoxaparin and 12-hour trough levels ≤0.1 IU/mL have been associated with higher rates of DVT in orthopedic patients. We hypothesized that low Anti-Xa levels would be found in critically ill trauma and surgical patients and that low levels would be associated with higher rates of DVT. METHODS:: All patients on the surgical intensive care unit (ICU) service were prospectively followed. In the absence of contraindications, patients were given prophylactic enoxaparin and anti-Xa levels were drawn after the third dose. Trough levels ≤0.1 IU/mL were considered low. Screening duplex exams were obtained within 48 hours of admission and then weekly. Patients were excluded if they did not receive a duplex, if they had a prior DVT, or if they lacked correctly timed anti-Xa levels. DVT rates and demographic data were compared between patients with low and normal anti-Xa levels. RESULTS:: Data were complete for 54 patients. Eighty-five percent suffered trauma (Injury Severity Score of 25 ± 12) and 74% were male. Overall, 27 patients (50%) had low anti-Xa levels. Patients with low anti-Xa levels had significantly more DVTs than those with normal levels (37% vs. 11%, p = 0.026), despite similar age, body mass index, Injury Severity Score, creatinine clearance, high risk injuries, and ICU/ventilator days. CONCLUSION:: Standard dosing of enoxaparin leads to low anti-Xa levels in half of surgical ICU patients. Low levels are associated with a significant increase in the risk of DVT. These data support future studies using adjusted-dose enoxaparin.

AB - BACKGROUND: Deep venous thromboses (DVT) continue to cause significant morbidity in critically ill patients. Standard prophylaxis for high risk patients includes twice-daily dosing with 30 mg enoxaparin. Despite prophylaxis, DVT rates still exceed 10% to 15%. Anti-Xa levels are used to measure the activity of enoxaparin and 12-hour trough levels ≤0.1 IU/mL have been associated with higher rates of DVT in orthopedic patients. We hypothesized that low Anti-Xa levels would be found in critically ill trauma and surgical patients and that low levels would be associated with higher rates of DVT. METHODS:: All patients on the surgical intensive care unit (ICU) service were prospectively followed. In the absence of contraindications, patients were given prophylactic enoxaparin and anti-Xa levels were drawn after the third dose. Trough levels ≤0.1 IU/mL were considered low. Screening duplex exams were obtained within 48 hours of admission and then weekly. Patients were excluded if they did not receive a duplex, if they had a prior DVT, or if they lacked correctly timed anti-Xa levels. DVT rates and demographic data were compared between patients with low and normal anti-Xa levels. RESULTS:: Data were complete for 54 patients. Eighty-five percent suffered trauma (Injury Severity Score of 25 ± 12) and 74% were male. Overall, 27 patients (50%) had low anti-Xa levels. Patients with low anti-Xa levels had significantly more DVTs than those with normal levels (37% vs. 11%, p = 0.026), despite similar age, body mass index, Injury Severity Score, creatinine clearance, high risk injuries, and ICU/ventilator days. CONCLUSION:: Standard dosing of enoxaparin leads to low anti-Xa levels in half of surgical ICU patients. Low levels are associated with a significant increase in the risk of DVT. These data support future studies using adjusted-dose enoxaparin.

KW - Anti-Xa levels

KW - Critical care

KW - Low-molecular weight heparin

KW - Venous thrombosis

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