Correlation of Missed Doses of Enoxaparin With Increased Incidence of Deep Vein Thrombosis in Trauma and General Surgery Patients | Peripheral Arterial Disease | JAMA Surgery | JAMA Network
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Guyatt  GH, Akl  EA, Crowther  M, Schünemann  HJ, Gutterman  DD, Zelman Lewis  S; American College of Chest Physicians.  Introduction to the ninth edition: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2) (suppl):48S-52S. PubMed
Cook  DJ, Crowther  MA, Meade  MO, Douketis  J; VTE in the ICU Workshop Participants.  Prevalence, incidence, and risk factors for venous thromboembolism in medical-surgical intensive care unit patients.  J Crit Care. 2005;20(4):309-313.PubMedGoogle ScholarCrossref
Shorr  AF, Ramage  AS.  Enoxaparin for thromboprophylaxis after major trauma: potential cost implications.  Crit Care Med. 2001;29(9):1659-1665.PubMedGoogle ScholarCrossref
O’Malley  KF, Ross  SE.  Pulmonary embolism in major trauma patients.  J Trauma. 1990;30(6):748-750.PubMedGoogle ScholarCrossref
Geerts  WH, Bergqvist  D, Pineo  GF,  et al; American College of Chest Physicians.  Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th Edition).  Chest. 2008;133(6)(suppl):381S-453S.PubMedGoogle ScholarCrossref
Geerts  WH, Code  KI, Jay  RM, Chen  E, Szalai  JP.  A prospective study of venous thromboembolism after major trauma.  N Engl J Med. 1994;331(24):1601-1606.PubMedGoogle ScholarCrossref
O’Brien  JA, Caro  JJ.  Direct medical cost of managing deep vein thrombosis according to the occurrence of complications.  Pharmacoeconomics. 2002;20(9):603-615.PubMedGoogle ScholarCrossref
Rasmussen  MS, Jørgensen  LN, Wille-Jørgensen  P. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery.  Cochrane Database Syst Rev. 2009;(1):CD004318. PubMedGoogle Scholar
Gould  MK, Garcia  DA, Wren  SM,  et al; American College of Chest Physicians.  Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines [published correction appears in Chest. 2012;141(5):1369].  Chest. 2012;141(2)(suppl):e227S-e277S. doi:10.1378/chest.11-2297. PubMedGoogle Scholar
Kanaan  AO, Silva  MA, Donovan  JL, Roy  T, Al-Homsi  AS.  Meta-analysis of venous thromboembolism prophylaxis in medically ill patients.  Clin Ther. 2007;29(11):2395-2405.PubMedGoogle ScholarCrossref
Salottolo  K, Offner  P, Levy  AS, Mains  CW, Slone  DS, Bar-Or  D.  Interrupted pharmacologic thromboprophylaxis increases venous thromboembolism in traumatic brain injury.  J Trauma. 2011;70(1):19-24. PubMedGoogle ScholarCrossref
Hess  JR, Brohi  K, Dutton  RP,  et al.  The coagulopathy of trauma: a review of mechanisms.  J Trauma. 2008;65(4):748-754. PubMedGoogle ScholarCrossref
Schols  SE, Lancé  MD, Feijge  MA,  et al.  Impaired thrombin generation and fibrin clot formation in patients with dilutional coagulopathy during major surgery.  Thromb Haemost. 2010;103(2):318-328.PubMedGoogle ScholarCrossref
Lustenberger  T, Relja  B, Puttkammer  B,  et al.  Activated thrombin-activatable fibrinolysis inhibitor (TAFIa) levels are decreased in patients with trauma-induced coagulopathy.  Thromb Res. 2013;131(1):e26-e30. doi:10.1016/j.thromres.2012.11.005.PubMedGoogle ScholarCrossref
Knudson  MM, Morabito  D, Paiement  GD, Shackleford  S.  Use of low molecular weight heparin in preventing thromboembolism in trauma patients.  J Trauma. 1996;41(3):446-459.PubMedGoogle ScholarCrossref
Goldhaber  SZ, Bounameaux  H.  Pulmonary embolism and deep vein thrombosis.  Lancet. 2012;379(9828):1835-1846.PubMedGoogle ScholarCrossref
Reitsma  PH, Versteeg  HH, Middeldorp  S.  Mechanistic view of risk factors for venous thromboembolism.  Arterioscler Thromb Vasc Biol. 2012;32(3):563-568.PubMedGoogle ScholarCrossref
Allman-Farinelli  MA.  Obesity and venous thrombosis: a review.  Semin Thromb Hemost. 2011;37(8):903-907.PubMedGoogle ScholarCrossref
Haut  ER, Chang  DC, Pierce  CA,  et al.  Predictors of posttraumatic deep vein thrombosis (DVT): hospital practice versus patient factors: an analysis of the National Trauma Data Bank (NTDB).  J Trauma. 2009;66(4):994-1001.PubMedGoogle ScholarCrossref
Original Investigation
Pacific Coast Surgical Association
April 2014

Correlation of Missed Doses of Enoxaparin With Increased Incidence of Deep Vein Thrombosis in Trauma and General Surgery Patients

Author Affiliations
  • 1Trauma Research Institute of Oregon, Oregon Health & Science University, Portland
JAMA Surg. 2014;149(4):365-370. doi:10.1001/jamasurg.2013.3963

Importance  Enoxaparin sodium is widely used for deep vein thrombosis (DVT) prophylaxis, yet DVT rates remain high in the trauma and general surgery populations. Missed doses during hospitalization are common.

Objective  To determine if missed doses of enoxaparin correlate with DVT formation.

Design, Setting, and Participants  Data were prospectively collected among 202 trauma and general surgery patients admitted to a level I trauma center.

Main Outcomes and Measures  Deep vein thrombosis screening was performed using a rigorous standardized protocol.

Results  The overall incidence of DVT was 15.8%. In total, 58.9% of patients missed at least 1 dose of enoxaparin. The DVTs occurred in 23.5% of patients who missed at least 1 dose and in 4.8% of patients who did not (P < .01). On univariate analysis, the need for mechanical ventilation (71.8% vs 44.1%), the performance of more than 1 operation (59.3% vs 40.0%), and male sex (75% vs 56%) were associated with DVT formation (P < .05 for all). A bivariate logistic regression was then performed, which revealed age 50 years or older and interrupted enoxaparin therapy as the only independent risk factors for DVT formation. The DVT rate did not differ between trauma and general surgery populations or in patients receiving once-daily vs twice-daily dosing regimens.

Conclusions and Relevance  Interrupted enoxaparin therapy and age 50 years or older are associated with DVT formation among trauma and general surgery patients. Missed doses occur commonly and are the only identified risk factor for DVT that can be ameliorated by physicians. Efforts to minimize interrupted enoxaparin prophylaxis in patients at risk for DVT should be optimized.