Int J Angiol 2016; 25(05): e16-e18
DOI: 10.1055/s-0034-1396899
Case Report
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Ineffective Treatment of Low-Molecular-Weight Heparin in Obese Subject with Traumatic Fractures of the Leg

Egidio Imbalzano
1   Department of Internal Medicine and Medical Therapy, University of Messina, Messina, Sicily, Italy
,
Michele Creazzo
1   Department of Internal Medicine and Medical Therapy, University of Messina, Messina, Sicily, Italy
,
Giovanni Trapani
1   Department of Internal Medicine and Medical Therapy, University of Messina, Messina, Sicily, Italy
,
Giuseppina Lizio
1   Department of Internal Medicine and Medical Therapy, University of Messina, Messina, Sicily, Italy
,
Antonino Saitta
1   Department of Internal Medicine and Medical Therapy, University of Messina, Messina, Sicily, Italy
› Author Affiliations
Further Information

Publication History

Publication Date:
14 January 2015 (online)

Abstract

American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, 9th edition, 2012, suggest no prophylaxis rather than pharmacological thromboprophylaxis in management of venous thromboembolism (VTE) risk of isolated lower leg injuries distal to knee requiring leg immobilization. Low-molecular-weight heparin (LMWH) is a class of drugs commonly used as antithrombotics in surgery and in case of prolonged bed rest and hypomobility. A 35-year-old obese man with no history of health disease (height, 170 cm; weight, 95 kg; and body mass index, 32.9 kg/m2) was involved in a car accident, and as a result of the trauma he suffered the compound fracture of left tibia and fibula. Tibial intramedullary nailing was performed. The injury was near the knee, and the patient was advised long-term bed rest. For these reasons, he was treated with enoxaparin 40 mg once daily subcutaneously. On the 7th day of hospitalization, the leg became edematous and reddish. A Doppler ultrasonography evaluation was performed which showed a massive deep vein thrombosis of left leg and then a pulmonary angiotomography showed a massive pulmonary embolism. In this clinical case, there was a pharmacological treatment failure to prevent VTE after orthopedic surgery and related long-term rest using enoxaparin at prophylaxis dosage in a patient without history of health disease but at high risk of VTE for obesity, trauma, orthopedic surgery, and immobilization. Enoxaparin dosage to prevent VTE in patients with high risk should be reconsidered and especially in obese a weight-adjusted dosage can be better than a fixed dosage.

 
  • References

  • 1 Falck-Ytter Y, Francis CW, Johanson NA , et al. American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: american college of chest physicians evidence-based clinical practice guidelines. Chest 2012; 141 (2_suppl): e278S-e325S
  • 2 Testroote M, Stigter W, de Visser DC, Janzing H. Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilization. Cochrane Database Syst Rev 2008; Oct 8; (4) CD006681
  • 3 Testroote M, Morrenhof W, Janzing H. Prevention of venous thromboembolism in patients with below-knee immobilisation of the leg—survey of current practice in The Netherlands. Acta Chir Belg 2011; 111 (1) 32-35
  • 4 Nokes TJ, Keenan J. Thromboprophylaxis in patients with lower limb immobilisation - review of current status. Br J Haematol 2009; 146 (4) 361-368
  • 5 Freeman A, Horner T, Pendleton RC, Rondina MT. Prospective comparison of three enoxaparin dosing regimens to achieve target anti-factor Xa levels in hospitalized, medically ill patients with extreme obesity. Am J Hematol 2012; 87 (7) 740-743
  • 6 Costantini TW, Min E, Box K , et al. Dose adjusting enoxaparin is necessary to achieve adequate venous thromboembolism prophylaxis in trauma patients. J Trauma Acute Care Surg 2013; 74 (1) 128-133 , discussion 134–135
  • 7 Ludwig KP, Simons HJ, Mone M, Barton RG, Kimball EJ. Implementation of an enoxaparin protocol for venous thromboembolism prophylaxis in obese surgical intensive care unit patients. Ann Pharmacother 2011; 45 (11) 1356-1362
  • 8 Malinoski D, Jafari F, Ewing T , et al. Standard prophylactic enoxaparin dosing leads to inadequate anti-Xa levels and increased deep venous thrombosis rates in critically ill trauma and surgical patients. J Trauma 2010; 68 (4) 874-880
  • 9 Freeman AL, Pendleton RC, Rondina MT. Prevention of venous thromboembolism in obesity. Expert Rev Cardiovasc Ther 2010; Dec; 8 (12) 1711-1721