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Pharmacologic Venous Thromboembolism Prophylaxis in Patients with Nontraumatic Subarachnoid Hemorrhage Requiring an External Ventricular Drain

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Abstract

Background

Optimal pharmacologic thromboprophylaxis dosing is not well described in patients with subarachnoid hemorrhage (SAH) with an external ventricular drain (EVD). Our patients with SAH with an EVD who receive prophylactic enoxaparin are routinely monitored using timed anti-Xa levels. Our primary study goal was to determine the frequency of venous thromboembolism (VTE) and secondary intracranial hemorrhage (ICH) for this population of patients who received pharmacologic prophylaxis with enoxaparin or unfractionated heparin (UFH).

Methods

A retrospective chart review was performed for all patients with SAH admitted to the neurocritical care unit at Emory University Hospital between 2012 and 2017. All patients with SAH who required an EVD were included.

Results

Of 1,351 patients screened, 868 required an EVD. Of these 868 patients, 627 received enoxaparin, 114 received UFH, and 127 did not receive pharmacologic prophylaxis. VTE occurred in 7.5% of patients in the enoxaparin group, 4.4% in the UFH group (p = 0.32), and 3.2% in the no VTE prophylaxis group (p = 0.08). Secondary ICH occurred in 3.83% of patients in the enoxaparin group, 3.51% in the UFH group (p = 1), and 3.94% in the no VTE prophylaxis group (p = 0.53). As steady-state anti-Xa levels increased from 0.1 units/mL to > 0.3 units/mL, there was a trend toward a lower incidence of VTE. However, no correlation was noted between rising anti-Xa levels and an increased incidence of secondary ICH. When compared, neither enoxaparin nor UFH use was associated with a significantly reduced incidence of VTE or an increased incidence of ICH.

Conclusions

In this retrospective study of patients with nontraumatic SAH with an EVD who received enoxaparin or UFH VTE prophylaxis or no VTE prophylaxis, there was no statistically significant difference in the incidence of VTE or secondary ICH. For patients receiving prophylactic enoxaparin, achieving higher steady-state target anti-Xa levels may be associated with a lower incidence of VTE without increasing the risk of secondary ICH.

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Funding

There were no funding sources provided for this study.

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Authors and Affiliations

  1. Department of Clinical Pharmacy, Emory Healthcare, Atlanta, GA, USA

    Chidozie Ukpabi, Justin Joy & William Asbury

  2. Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA

    Ofer Sadan & Owen Samuels

  3. H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA

    Yuyang Shi & Yajun Mei

  4. Department of Pharmacy, Emory University Hospital Midtown, Atlanta, GA, USA

    Kristy N. Greene

  5. University of Nebraska Medical Center, Omaha, NE, USA

    Subin Mathew

Authors
  1. Chidozie Ukpabi
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  2. Ofer Sadan
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  3. Yuyang Shi
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  4. Kristy N. Greene
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  5. Owen Samuels
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  6. Subin Mathew
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  7. Justin Joy
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  8. Yajun Mei
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  9. William Asbury
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Contributions

CU: study design, data collection, data analysis, manuscript writing; OS: study design, data analysis, manuscript writing; YS: data analysis, manuscript writing; KNG: study design, manuscript final review; O. Samuels: study design, manuscript final review; SM: data collection, data analysis, manuscript editing; JJ: data collection, manuscript review; YM: study design, study analysis, final manuscript review; WA: study design, data analysis, manuscript writing and final manuscript editing.

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Correspondence to Chidozie Ukpabi.

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Ukpabi, C., Sadan, O., Shi, Y. et al. Pharmacologic Venous Thromboembolism Prophylaxis in Patients with Nontraumatic Subarachnoid Hemorrhage Requiring an External Ventricular Drain. Neurocrit Care (2024). https://doi.org/10.1007/s12028-024-01993-5

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