Creatinine clearance predicts the goal enoxaparin dose in traumatic brain injury.

BACKGROUND: Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism (VTE). Recent guidelines recommend starting TBI patients on enoxaparin 30 mg twice daily and then considering weight-based dosing. Creatinine clearance may be better than weight for patients when considering high and low enoxaparin dose requirements. We hypothesize that creatinine clearance (CrCl) predicts goal enoxaparin dose better than weight-based dosing. METHODS: A retrospective review was conducted on patients admitted to an urban, academic Level I trauma center from August 2017 to February 2020. Patients were included if greater than 18 years, admitted longer than 48 hours, and head and neck AIS ≥ 3. Patients were excluded if they did not have TBI, if they received deep vein thrombosis prophylaxis other than enoxaparin 12-hour dosing, if no anti-Xa levels were drawn, or if the goal anti-Xa level was not reached. Patients were grouped into dosing cohorts based on dose of enoxaparin required to reach goal. Pearson's correlation was used to compare mean CrCl and mean weight across dosing cohorts. RESULTS: A total of 120 patients met inclusion and exclusion criteria, mean age was 47 years and 68% of patients were male. The mean hospital length of stay was 24 days. There were 5 (4.2%) deep vein thrombosis, no pulmonary embolism, and 5 (4.2%) patients died. Mean CrCl increased significantly with increased dosing of enoxaparin, Pearson's correlation coefficient of 0.484 ( p < 0.001). Weight on admission also increased with increasing enoxaparin dose requirements, with Pearson's correlation coefficient of 0.411 ( p < 0.001). CONCLUSION: Creatine clearance predicts goal enoxaparin dose in TBI better than a weight-based dosing strategy. Further research with a larger patient population is required to validate CrCl values to guide enoxaparin dosing. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

The futility of closed chest compressions after trauma: A multi-institutional study.

BACKGROUND: The desire to deliver appropriate care after trauma creates challenges when deciding to proceed if care appears futile. This study aimed to analyze survival rates for trauma patients who undergo closed chest compressions by decade of life. METHODS: A multicenter retrospective review of trauma patients with an Injury Severity Score ≥16 who underwent closed chest compressions from 2015 to 2020 at four large, urban, academic Level I trauma centers was conducted. Those with intraoperative arrest were excluded. The primary endpoint was survival to discharge. RESULTS: Of the 247 patients meeting inclusion criteria, 18% were 70 years or older, 78% were male, and 24% presented due to a penetrating mechanism of injury. Compressions occurred in the prehospital setting (56%), emergency department (21%), intensive care unit (19%), and on the floor (3%). On average, patients arrested on hospital day 2, and survived 1 day after arrest if return of spontaneous circulation was achieved. Overall mortality was 92%. Average hospital length of stay was lower in patients 70 years or older (3 days vs. 6 days, p < 0.01). Survival was highest in patients 60 years to 69 years (24%), and although patients 70 years or older presented with lower Injury Severity Scores (28 vs. 32, p = 0.04), no patient 70 years or older survived to hospital discharge (0% v 9%, p = 0.03). CONCLUSION: Closed chest compressions are associated with a high mortality rate after moderate to severe trauma with 100% mortality in patients older than 70 years. This information may assist with the decision to withhold chest compression, especially in older adults. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Creatinine Clearance May Predict Goal Enoxaparin Dose in Trauma.

BACKGROUND: Guidelines for enoxaparin dosing after trauma recommend an initial dose of 40 mg twice daily for most patients and then adjusting by anti-Xa levels. Previous studies indicated higher enoxaparin doses are necessary with higher levels of creatinine clearance (CrCl). We sought to determine if the goal enoxaparin dose correlates with the admission CrCl to reduce the reliance on measuring anti-Xa levels. STUDY DESIGN: A retrospective review was conducted of patients admitted to an urban, academic Level 1 trauma center from April 2017 to February 2020. Patients started on enoxaparin who reached goal anti-Xa trough levels were included, and patients were excluded if they did not reach goal anti-Xa levels. Data collection included patient demographics, injury characteristics, admission CrCl, and final enoxaparin dose. CrCl was then correlated with the final enoxaparin dose. RESULTS: Of 421 patients included, the mean age was 46.6 years and 73% were male. The median goal enoxaparin dose was 40 mg twice daily. The mean CrCl significantly increased with increasing twice-daily doses of enoxaparin (20 mg: 69.2 mL/min; 30 mg: 89 mL/min; 40 mg: 112.8 mL/min; 50 mg: 140.5mL/min; 60 mg: 147.4 mL/min; and 70 mg: 140 mL/min; p < 0.01). CONCLUSIONS: Admission CrCl may predict the enoxaparin dose required to achieve adequate anti-Xa levels. Our data indicate that CrCls of approximately 70, 90, 110, 140, and 150 mL/min may predict the twice-daily enoxaparin doses of 20, 30, 40, 50, and 60 mg, respectively. CrCl dosing guidance may reduce the time to goal anti-Xa levels and the frequency of anti-Xa measurements. Further research is necessary, and enoxaparin dosing should continue to be monitored by anti-Xa levels.