Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry

Sarah Lombardo¹, Marta McCrum¹, M Margaret Knudson², Ernest E Moore³, Lucy Kornblith², Scott Brakenridge⁴, Brandon Bruns⁵, Mark D Cipolle⁶, Todd W Costantini², Bruce Crookes⁷, Elliott R Haut⁸, Andrew J Kerwin⁹, Laszlo N Kiraly¹⁰, Lisa Marie Knowlton¹¹, Matthew J Martin¹², Michelle K McNutt¹³, David J Milia¹⁴, Alicia Mohr⁹, Frederick Rogers¹⁵, Thomas Scalea¹⁶, Sherry Sixta¹⁷, David Spain¹⁸, Charles E Wade¹³, George C Velmahos¹⁹, Ram Nirula²⁰, Jade Nunez¹

Affiliations

¹ Surgery, University of Utah, Salt Lake City, Utah, USA.
² Surgery, University of California San Francisco, San Francisco, California, USA.
³ Denver Health Medical Center, Denver, Colorado, USA.
⁴ Department of Surgery, University of Washington, Seattle, Washington, USA.
⁵ Department of Surgery, UT Southwestern Medical School, Dallas, Texas, USA.
⁶ Lehigh Valley Health Network, Allentown, Pennsylvania, USA.
⁷ Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
⁸ Surgery, Johns Hopkins University, Baltimore, Maryland, USA.
⁹ Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA.
¹⁰ Oregon Health & Science University, Portland, Oregon, USA.
¹¹ General Surgery, Stanford University, Stanford, California, USA.
¹² Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, Los Angeles, California, USA.
¹³ Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA.
¹⁴ Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
¹⁵ Lancaster General Health, Lancaster, Pennsylvania, USA.
¹⁶ University of Maryland School of Medicine, Baltimore, Maryland, USA.
¹⁷ St Anthony Hospital & Medical Campus, Lakewood, Colorado, USA.
¹⁸ Surgery, Stanford University, Stanford, California, USA.
¹⁹ Massachusetts General Hospital, Boston, Massachusetts, USA.
²⁰ University of Utah School of Medicine, Salt Lake City, Utah, USA.

PMID: 38420604
PMCID: PMC10900334
DOI: 10.1136/tsaco-2023-001230

Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry

Sarah Lombardo et al. Trauma Surg Acute Care Open. 2024.

. 2024 Feb 26;9(1):e001230.

doi: 10.1136/tsaco-2023-001230. eCollection 2024.

Authors

Affiliations

¹ Surgery, University of Utah, Salt Lake City, Utah, USA.
² Surgery, University of California San Francisco, San Francisco, California, USA.
³ Denver Health Medical Center, Denver, Colorado, USA.
⁴ Department of Surgery, University of Washington, Seattle, Washington, USA.
⁵ Department of Surgery, UT Southwestern Medical School, Dallas, Texas, USA.
⁶ Lehigh Valley Health Network, Allentown, Pennsylvania, USA.
⁷ Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
⁸ Surgery, Johns Hopkins University, Baltimore, Maryland, USA.
⁹ Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA.
¹⁰ Oregon Health & Science University, Portland, Oregon, USA.
¹¹ General Surgery, Stanford University, Stanford, California, USA.
¹² Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, Los Angeles, California, USA.
¹³ Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA.
¹⁴ Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
¹⁵ Lancaster General Health, Lancaster, Pennsylvania, USA.
¹⁶ University of Maryland School of Medicine, Baltimore, Maryland, USA.
¹⁷ St Anthony Hospital & Medical Campus, Lakewood, Colorado, USA.
¹⁸ Surgery, Stanford University, Stanford, California, USA.
¹⁹ Massachusetts General Hospital, Boston, Massachusetts, USA.
²⁰ University of Utah School of Medicine, Salt Lake City, Utah, USA.

PMID: 38420604
PMCID: PMC10900334
DOI: 10.1136/tsaco-2023-001230

Abstract

Introduction: Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD).

Methods: Patients from the prospective, observational CLOTT-1 registry receiving prophylactic enoxaparin (n=5539) were categorized as WB (0.45-0.55 mg/kg two times per day) or SFD (30 mg two times per day, 40 mg once a day). Multivariate logistic regression was used to generate a predicted probability of VTE for WB and SFD patients.

Results: Of 4360 patients analyzed, 1065 (24.4%) were WB and 3295 (75.6%) were SFD. WB patients were younger, female, more severely injured, and underwent major operation or major venous repair at a higher rate than individuals in the SFD group. Obesity was more common among the SFD group. Unadjusted VTE rates were comparable (WB 3.1% vs. SFD 3.9%; p=0.221). Early prophylaxis was associated with lower VTE rate (1.4% vs. 5.0%; p=0.001) and deep vein thrombosis (0.9% vs. 4.4%; p<0.001), but not pulmonary embolism (0.7% vs. 1.4%; p=0.259). After adjustment, VTE incidence did not differ by dosing strategy (adjusted OR (aOR) 0.75, 95% CI 0.38 to 1.48); however, early administration was associated with a significant reduction in VTE (aOR 0.47, 95% CI 0.30 to 0.74).

Conclusion: In young trauma patients, WB prophylaxis is not associated with reduced VTE rate when compared with SFD. The timing of the initiation of chemoprophylaxis may be more important than the dosing strategy. Further studies need to evaluate these findings across a wider age and comorbidity spectrum.

Level of evidence: Level IV, therapeutic/care management.

Keywords: Multiple Trauma; Thromboembolism; Venous thromboembolism; observational study.

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Conflict of interest statement

Competing interests: SL reported receiving fees from Oakstone Publishing for completed work. LK reported receiving personal fees from Cerus SAB outside the submitted work. BB reported receiving grants from the US Department of Defense during the conduct of the study. MDC reported receiving grants from the US Army Medical Research Acquisition Activity during the conduct of the study. BC reported receiving grants from the National Trauma Institute during the conduct of the study. ERH reported receiving grants from the US Army Medical Research Acquisition Activity during the conduct of the study and grants from the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, the National Heart, Lung, and Blood Institute, and the Henry M Jackson Foundation for the Advancement of Military Medicine, and speaker fees from Vizient (paid speaker for the Vizient Hospital Improvement Innovation Network VTE Prevention Acceleration Network) outside the submitted work. AJK reported receiving grants from the US Army Medical Research Acquisition Activity during the conduct of the study. LNK reported receiving grants from the Coalition for National Trauma Research of the US Department of Defense during the conduct of the study. MJM reported receiving grants from the US Department of Defense during the conduct of the study. AM reported receiving grants from the National Trauma Institute during the conduct of the study. CEW reported having stock in Decisio and receiving grants from Grifols outside the submitted work. GCV reported receiving grants from the National Institutes of Health during the conduct of the study.

Figures

**Figure 1**
Study flow diagram. AIS, Abbreviated Injury Scale; BID, two times per day; DVT, deep vein thrombosis; HLOS, hospital length of stay; ISS, Injury Severity Score; IVC, inferior vena cava; SFD, standard fixed dosing; WB, weight based.

**Figure 2**
Unadjusted venous thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolism (PE) rates by cohort. Early prophylaxis was associated with significantly lower rates of VTE and DVT relative to delayed initiation of prophylaxis for both weight-based (WB) (▲) and standard fixed dosing (SFD) (♦) groups.

**Figure 3**
Kaplan-Meier curve of the full cohort showing time to positive venous duplex examination (deep vein thrombosis (DVT) positive) within 30 days of admission. Patients who died or discharged prior to 30 days were censored.

See this image and copyright information in PMC

References

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Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry

Affiliations

Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

Full Text Sources

Research Materials