Pharmacist recommendations for prophylactic enoxaparin monitoring and dose adjustment in trauma patients admitted to a surgical intensive care unit
Background: There is limited information describing pharmacist participation in prophylactic enoxaparin monitoring in the surgical intensive care unit (SICU).
Objective: Our study sought to: 1) characterize pharmacist recommendations for enoxaparin monitoring in trauma patients admitted to the SICU, 2) describe the frequency that medical providers accept pharmacist recommendations for enoxaparin monitoring in trauma patients admitted to the SICU, and 3) illustrate the frequency that trauma patients admitted to our SICU service achieve anti-factor Xa trough concentrations (AFXa-TRs) of 0.11 - 0.20 IU/mL following pharmacist recommendation to adjust prophylactic enoxaparin dosing.
Methods: Adult patients who had an AFXa-TR drawn after at least three consecutive prophylactic enoxaparin doses between June 1, 2017 and March 1, 2018 were identified through chart review and included in this study. Patients were excluded based on the following criteria: 1) age less than 18 years, 2) anti-factor Xa (AFXa) level not representative of a trough concentration, 3) AFXa-TR not representative of steady state concentration, and 4) non-trauma based prophylactic enoxaparin dosing. This study was exempt from IRB review.
Results: The final analysis consisted of 42 patients. A pharmacist provided at least one recommendation in 97.6% (41/42) of trauma patients with enoxaparin monitoring during their SICU stay. In total, a pharmacist made 170 recommendations, mean of 4.2 (SD 1.8) recommendations per patient. Recommendations were: 1) obtain an AFXa-TR, n=90; 2) adjust enoxaparin dose based on AFXa-TR, n=58; and 3) maintain enoxaparin dose based on AFXa-TR, n=22. Medical providers accepted 89.4% (152/170) of pharmacist recommendations for enoxaparin monitoring. Dose adjustments were made in 33 patients following pharmacist recommendation; of these, 27 had a repeat AFXa-TR following at least one dose adjustment. Target AFXa-TRs were achieved in 19/27 patients, indicating 70.4% had recommended AFXa concentrations.
Conclusions: Pharmacists provided recommendations for prophylactic enoxaparin monitoring and dose adjustment in trauma patients admitted to the SICU. Medical providers regularly accepted pharmacist recommendations and trauma patients commonly achieved target AFXa-TR following pharmacist recommendation for dose adjustment. Further research is required to identify the optimal enoxaparin dose for VTE prophylaxis in trauma patients.
Bandle J, Shackford SR, Sise CB, Knudson MM; CLOTT Study Group. Variability is the standard: the management of venous thromboembolic disease following trauma. J Trauma Acute Care Surg. 2014;76(1):213-216. https://doi.org/10.1097/TA.0b013e3182aa2fa9
Rogers FB, Cipolle MD, Velmahos G, Rozycki G, Luchette FA. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group. J Trauma. 2002;53(1):142-164. https://doi.org/10.1097/00005373-200207000-00032
Bush S, LeClaire A, Hampp C, Lottenberg L. Review of a large clinical series: once- versus twice-daily enoxaparin for venous thromboembolism prophylaxis in high-risk trauma patients. J Intensive Care Med. 2011;26(2):111-115. https://doi.org/10.1177/0885066610384462
Arnold JD, Dart BW, Barker DE, Maxwell RA, Burkholder HC, Mejia VA, Smith PW, Longley JM. Unfractionated heparin three times a day versus enoxaparin in prevention of deep vein thrombosis in trauma patients. Am Surg. 2010;76(6):563-570.
Malinoski D, Jafari F, Ewing T, Ardary C, Conniff H, Baje M, Kong A, Lekawa ME, Dolich MO, Cinat ME, Barrios C, Hoyt DB. Standard prophylactic enoxaparin dosing leads to inadequate anti-Xa levels and increased deep vein venous thrombosis rates in critically ill trauma and surgical patients. J Trauma. 2010;68(4):874-880. https://doi.org/10.1097/TA.0b013e3181d32271
Ko A, Harada MY, Barmparas G, Chung K, Mason R, Yim DA, Dhillon N, Margulies DR, Gewertz BL, Ley EJ. Association between enoxaparin dosage adjusted by anti–factor Xa trough level and clinically evident venous thromboembolism after trauma. JAMA Surg. 2016;151(11):1006-1013. https://doi.org/10.1001/jamasurg.2016.1662
Dhillon NK, Smith EJT, Gillette E, Mason R, Barmparas G, Gewertz BL, Ley EJ. Trauma patients with lower extremity and pelvic fractures: Should anti-factor Xa trough level guide prophylactic enoxaparin dose? Int J Surg. 2018;51:128-132. https://doi.org/10.1016/j.ijsu.2018.01.023
Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31-41. https://doi.org/10.1159/000180580
Levine MN, Planes A, Hirsh J, Goodyear M, Vochelle N, Gent M. The relationship between anti-factor Xa level and clinical outcome in patients receiving enoxaparine low molecular weight heparin to prevent deep vein thrombosis after hip replacement. Thromb Haemost. 1989;62(3):940-944.
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults--The Evidence Report. National Institutes of Health. Obes Res. 1998;6(Suppl 2):51S-209S. https://doi.org/10.1002/j.1550-8528.1998.tb00690.x
Anderegg SV, Demik DE, Carter BL, Dawson JD, Farris K, Shelsky C, Kaboli P. Acceptance of recommendations by inpatient pharmacy case managers: unintended consequences of hospitalist and specialist care. Pharmacotherapy. 2013;33(1):11-21. https://doi.org/10.1002/phar.1164
Shanika LGT, Wijekoon CN, Jayamanne S, Coombes J, Coombes I, Mamunuwa N, Dawson AH, De Silva HA. Acceptance and attitudes of healthcare staff towards the introduction of clinical pharmacy service: a descriptive cross-sectional study from a tertiary care hospital in Sri Lanka. BMC Health Serv Res. 2017;17(1):46. https://doi.org/10.1186/s12913-017-2001-1
Devlin, JW, Tyburski, JG, Moed, B. Implementation and evaluation of guidelines for use of enoxaparin as deep vein thrombosis prophylaxis after major trauma. Pharmacotherapy. 2001;21(6):740-747. https://doi.org/10.1592/phco.21.7.740.34578
Walker CK, Sandmann EA, Horyna TJ, Gales MA. Increased enoxaparin dosing for venous thromboembolism prophylaxis in general trauma patients. Ann Pharmacother. 2017;51(4):323-331. https://doi.org/10.1177/1060028016683970
Khalafallah AA, Kirkby BE, Wong S, Foong YC, Ranjan N, Luttrell J, Mathew R, Chilvers CM, Mauldon E, Sharp C, Hannan T. Venous thromboembolism in medical patients during hospitalization and 3 months after hospitalization: a prospective observation study. BMJ Open. 2016;6(8):e012346. https://doi.org/10.1136/bmjopen-2016-012346
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