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

Sarah Lombardo; Marta McCrum; M Margaret Knudson; Ernest E Moore; Lucy Kornblith; Scott Brakenridge; Brandon Bruns; Mark D Cipolle; Todd W Costantini; Bruce Crookes; Elliott R Haut; Andrew J Kerwin; Laszlo N Kiraly; Lisa Marie Knowlton; Matthew J Martin; Michelle K McNutt; David J Milia; Alicia Mohr; Frederick Rogers; Thomas Scalea; Sherry Sixta; David Spain; Charles E Wade; George C Velmahos; Ram Nirula; Jade Nunez

doi:10.1136/tsaco-2023-001230

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

Trauma Surg Acute Care Open. 2024 Feb 26;9(1):e001230. doi: 10.1136/tsaco-2023-001230. eCollection 2024.

Authors

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.

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.