Modi Rishi N, Borst Johanna M, Kirchberg Tyler N, Box Kevin, Smith Alan M, Godat Laura N, Doucet Jay J, Costantini Todd W, Berndtson Allison E
From the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (R.N.M., J.M.B., T.N.K., A.M.S., L.N.G., J.J.D., T.W.C., A.E.B.), and Department of Pharmacology (K.B.), University of California, San Diego, San Diego, California.
J Trauma Acute Care Surg. 2023 Jan 1;94(1):78-85. doi: 10.1097/TA.0000000000003738. Epub 2022 Jul 5.
The optimal enoxaparin dosing strategy to achieve venous thromboembolism (VTE) prophylaxis in trauma patients remains unclear. Current dosing guidelines often include weight, age, and renal function but still fail to achieve appropriate prophylactic anti-Xa levels in many patients. We hypothesized that additional patient factors influence anti-Xa response to enoxaparin in trauma patients.
This is a retrospective review of patients admitted to a Level 1 trauma center for ≥4 days from July 2015 to September 2020, who received enoxaparin VTE prophylaxis per protocol (50-59 kg, 30 mg/dose; 60-99 kg, 40 mg/dose; ≥100 kg, 50 mg/dose; all doses every 12 hours) and had an appropriately timed peak anti-Xa level. Multivariate regression was performed to identify independent predictors of prophylactic anti-Xa levels (0.2-0.4 IU/mL) upon first measurement.
The cohort (N = 1,435) was 76.4% male, with a mean ± SD age of 49.9 ± 20.0 years and a mean ± SD weight of 82.5 ± 20.2 kg (males, 85.2 kg; females, 73.7 kg; p <0.001). Overall, 68.6% of patients (n = 984) had a prophylactic anti-Xa level on first assessment (69.6% of males, 65.1% of females). Males were more likely to have a subprophylactic level than females (22.1% vs. 8.0%, p <0.001), whereas females were more likely to have supraprophylactic levels than males (26.9% vs. 8.3%, p < 0.001). When controlling for creatinine clearance, anti-Xa level was independently associated with dose-to-weight ratio (odds ratio, 0.191 for 0.5 mg/kg; p < 0.001; confidence interval, 0.151-0.230) and female sex (odds ratio, 0.060; p < 0.001; confidence interval, 0.047-0.072). Weight and age were not significant when controlling for the other factors.
Male patients have a decreased anti-Xa response to enoxaparin when compared with female patients, leading to a greater incidence of subprophylactic anti-Xa levels in male patients at all dose-to-weight ratios. To improve the accuracy of VTE chemoprophylaxis, sex should be considered as a variable in enoxaparin dosing models.
Therapeutic/Care Management; Level III.
在创伤患者中，实现静脉血栓栓塞（VTE）预防的最佳依诺肝素给药策略仍不明确。当前的给药指南通常包括体重、年龄和肾功能，但在许多患者中仍未能达到适当的预防性抗Xa水平。我们推测，其他患者因素会影响创伤患者对依诺肝素的抗Xa反应。
这是一项对2015年7月至2020年9月入住一级创伤中心≥4天的患者的回顾性研究，这些患者按照方案接受依诺肝素VTE预防（50 - 59 kg，30 mg/剂量；60 - 99 kg，40 mg/剂量；≥100 kg，50 mg/剂量；所有剂量均每12小时一次），且具有适时的抗Xa峰值水平。进行多变量回归以确定首次测量时预防性抗Xa水平（0.2 - 0.4 IU/mL）的独立预测因素。
该队列（N = 1435）中男性占76.4%，平均年龄±标准差为49.9 ± 20.0岁，平均体重±标准差为82.5 ± 20.2 kg（男性为85.2 kg，女性为73.7 kg；p <0.001）。总体而言，68.6%的患者（n = 984）在首次评估时有预防性抗Xa水平（男性为69.6%，女性为65.1%）。男性比女性更有可能处于预防不足水平（22.1%对8.0%，p <0.001），而女性比男性更有可能处于预防过度水平（26.9%对8.3%，p < 0.001）。在控制肌酐清除率后，抗Xa水平与剂量体重比（0.5 mg/kg时的比值比为0.191；p < 0.001；置信区间为0.151 - 0.230）和女性性别（比值比为0.060；p < 0.001；置信区间为0.047 - 0.072）独立相关。在控制其他因素时，体重和年龄无显著意义。
与女性患者相比，男性患者对依诺肝素的抗Xa反应降低，导致在所有剂量体重比下男性患者预防不足的抗Xa水平发生率更高。为提高VTE化学预防的准确性，应将性别作为依诺肝素给药模型中的一个变量。
治疗/护理管理；三级。
