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Studying Ways to Prevent VTEs in Trauma Patients

By Russell Mason, PharmD, BCPS

As a critical care pharmacist, I collaborate with the teams involved in patient care in the Surgical Intensive Care Unit (SICU). My role is to meticulously evaluate medication regimens for efficacy, drug and disease state interactions, appropriate dosing and potential for adverse events.

I round daily with the SICU team and bring a pharmacist's unique perspective when assessing patients and their progress towards therapeutic goals, conveying my recommendations regarding medication regimens. In addition, I mentor pharmacy students and residents who are on rotation in the SICU. One of my personal goals is to reduce the incidence of venous thromboembolism (VTE) for our patients in the SICU.

Trauma patients are especially at increased risk of VTE due to the nuances of Virchow's triad, namely endothelial injury, hypercoagulability and stasis. Enoxaparin is the drug of choice for the prevention of VTE in trauma patients who do not have a contraindication to its use.

Cedars-Sinai researchers have previously demonstrated, by measuring trough anti-Xa levels, that the conventional prophylactic dose of 30 mg SQ q 12 hours may be inadequate for the prevention of VTE. Those trauma patients with levels less than 0.1 are at increased risk of VTE.

However, no studies evaluated whether adjusting enoxaparin dose to maintain adequate trough levels reduces VTE. So, in our most recent study, we evaluated whether adjusting enoxaparin to reach a goal anti-Xa trough level reduced VTE in trauma patients. We determined that a high percentage of patients (83.9 percent) had anti-Xa levels below goal and required dose adjustments to reach goal levels.

Furthermore, our study demonstrated a significant decrease in clinically diagnosed VTE rates when those patients with enoxaparin adjusted by anti-Xa were compared to those who were not (1.1 percent vs 7.6 percent, p=0.046). Bleeding, hematocrit or transfusion rates were comparable between groups, and the majority of the patients required enoxaparin 40 mg SQ q 12 hours for VTE prophylaxis.

Based on the results of this study, we now initiate VTE prophylactic dosing at 40 mg SQ q 12 hours in most trauma patients with normal renal function.

I continue to work with the SICU team to collect steady-state trough anti-Xa levels to be certain the enoxaparin is in the appropriate range, and I monitor trough anti-Xa levels weekly. In addition, the Department of Pharmacy Services is working with the trauma service to develop a pharmacist-driven protocol to ensure that enoxaparin is appropriately dosed by anti-Xa levels in trauma patients.

We are excited to collaborate with physicians to develop this protocol so that patients will receive appropriate medication dosing and monitoring. If you are interested in this project or other collaborations, please stop by the SICU and say hello.