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Invited Commentary
April 2014

Order and Execution of DVT Prophylaxis: “The Best-Laid Plans of Mice and Men”

Author Affiliations
  • 1Division of Trauma and Emergency Surgery, Davis Medical Center, University of California, Sacramento
JAMA Surg. 2014;149(4):370-371. doi:10.1001/jamasurg.2013.4002

Robert Burns wrote, “The best-laid plans of mice and men/Often go awry….” In keeping with this theme, Louis and colleagues in “Correlation of Missed Doses of Enoxaparin With Increased Incidence of Deep Vein Thrombosis in Trauma and General Surgery Patients”1 examined whether their intentions to provide deep vein thrombosis (DVT) prophylaxis to surgery patients were being fulfilled. The authors prospectively collected data on 202 trauma and emergency surgery patients who were started on a regimen of enoxaparin sodium between 2007 and 2012. Duplex ultrasonography of the upper and lower extremities and neck veins revealed a DVT in 15.8%. Fifty-nine percent of the patients with DVT had missed a dose of enoxaparin, with most missing 1 to 4 doses. In 4 patients who developed DVT with uninterrupted enoxaparin therapy, 3 cases were associated with indwelling catheters in the neck and upper extremities. Multivariate analysis, accounting for appropriate risk factors, showed that only age 50 years or older and a missed dose of enoxaparin were associated with an increased risk for DVT. Although documentation was poor, common reasons for missed doses were pending procedures, the absence of the patient from the room, and epidural catheter use; however, many patients had no reason documented.

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