Timing and Dose of Pharmacological Thromboprophylaxis in Adult Trauma Patients: Perceptions, Barriers, and Experience of Saudi Arabia Practicing Physicians
Authors: Amer Marwa , Bawazeer Mohammed , Maghrabi Khalid , Amin Rashid , De Vol Edward , Hijazi Mohammed 
Published: January 2021

Background

Pharmacological venous thromboembolism prophylaxis (PVTE-Px) in trauma care is challenging and frequently delayed until post injury bleeding risk is perceived to be sufficiently low; yet data for optimal initiation time is lacking. This study assessed practice pattern of PVTE-Px initiation time and dose in traumatic brain injury (TBI), spinal cord injury (SCI), and non-operative (NOR) solid organ injuries.

Methods

Multicenter, cross sectional, observational, survey-based study involving intensivists, trauma surgeons, general surgeons, spine orthopedics, and neurosurgeons practicing in trauma centers. The data of demographics, PVTE-Px timing and dose, and five clinical case scenarios were obtained. Analyses were stratified by early initiators vs. late initiators and logistic regression models were used to identify factors associated with early initiation of PVTE-Px.

Results

Of 102 physicians (29 % response rate), most respondents were intensivists (63.7%) and surgeons (who are general and trauma surgeons) (22.5%); majority were consultants (58%), practicing at level 1 trauma centers (40.6%) or academic teaching hospitals (45.1%). A third of respondents (34.2%) indicated that decision to initiate PVTE-Px in TBI and SCI was made by a consensus between surgical, critical care, and neurosurgical services. For patients with NOR solid organ injuries, 34.2% of respondents indicated trauma surgeons initiated the decision on PVTE-Px timing. About 53.7% of the respondents considered their PVTE-Px practice as appropriate, half used combined mechanical and PVTE-Px (57.1%), 52% preferred enoxaparin (40 mg once daily), and only 6.5% used anti-Xa level to guide enoxaparin prophylactic dose. Responses to clinical cases varied. For TBI and TBI with intracranial pressure monitor, 40.3% and 45.6% of the respondents were early initiators with stable repeated head computed tomography [CT], respectively. For SCI, most respondents were early initiators without repeated CT spine (36.8%). With regards to NOR solid organ injuries [gunshot wound to the liver and grade IV splenic injuries], 49.1% and 36.4% of respondents were early initiators without a repeat CT abdomen.

Conclusions

Variations were observed in PVTE-Px initiation time influenced by trauma type. Our findings suggested enoxaparin is preferred in a standard prophylactic dose. More robust data from randomized trials are needed and the use of clinicians’ judgment is recommended.

Key Messages

Ideal time to initiate therapy, agent selection, dosing, and monitoring of pharmacological venous thromboembolism prophylaxis (PVTE-Px) for trauma patients is challenging.

Variations were observed in PVTE-Px initiation time influenced by trauma type.

Our study results are relatively in line with the recent evidence-based clinical literature

Our findings suggested limited awareness of augmented renal clearance (ARC) and utilization of serum anti-factor-Xa (anti-Xa) level.