Olson, Logan M.

Abstract Optimal dosing of prophylactic enoxaparin for individuals ≥150 kg is unknown due to limited inclusion in previous studies. Estimate an optimal weight-based prophylactic enoxaparin dose for individuals ≥150 kg. This multicenter, retrospective study included ≥150 kg adult patients admitted to the hospital between January 2014 and April 2024, who received twice daily prophylactic enoxaparin (goal peak anti-Xa 0.2–0.4 IU/mL). At least one peak anti-Xa was required, obtained 3 to 5 hours after the 3rd consecutive dose. The primary outcome was the range of dosing that produced goal prophylactic peak anti-Xa following linear regression modeling. Secondary outcomes were hospital and intensive care unit (ICU)/progressive care unit (PCU) length of stay (LOS), in-hospital mortality, and VTE/bleed events within 72 hours after an eligible peak anti-Xa. A total of 311 encounters and 388 peak anti-Xa levels were assessed. Patients were 46 (37–55) years old, 53.1% were male, and weighed 183.3 kg (166.1–204.1) with a BMI of 61.3 kg/m2 (54.8–69.4). Creatinine clearance was 179.6 mL/min (126.5–228.2) and patients received 4 doses (4–6) before peak anti-Xa, with a time between of 249 minutes (227–271). Linear regression modeling revealed a statistically significant correlation (r2 = 0.27) between weight-based dose and peak anti-Xa (p < 0.0001). Enoxaparin 0.34 mg/kg (95% CI 0.33–0.36) twice daily was predicted to achieve a peak anti-Xa of 0.3 IU/mL. Hospital LOS was 8 days (4–15), ICU/PCU LOS was 8 days (4–14, n = 158), and only two patients (0.6%) died during hospitalization. One VTE event was observed. Our results suggest an appropriate empiric weight-based prophylactic enoxaparin dose for hospitalized patients ≥150 kg is 0.34 mg/kg twice daily.

Background: Post–cardiac surgery bleeding can have devastating consequences, and it is unknown if warfarin-induced rapid international normalized ratio (INR) rise during the immediate postoperative period increases bleed risk. Objective: To determine the impact of warfarin-induced rapid-rise INR on post–cardiac surgery bleeding. Methods: This was a single-center, retrospective chart review of post–cardiac surgery patients initiated on warfarin at Mayo Clinic Hospital, Rochester. Patients were grouped based on occurrence or absence of rapid-rise INR (increase ≥1.0 within 24 hours). The primary outcome compared bleed events between groups. Secondary outcomes assessed hospital length of stay (LOS) and identified risk factors associated with bleed events and rapid rise in INR. Results: During the study period, 2342 patients were included, and 56 bleed events were evaluated. Bleed events were similar between rapid-rise (n = 752) and non–rapid-rise (n = 1590) groups in both univariate (hazard ratio [HR] = 1.22; P = 0.594) and multivariable models (HR = 1.24; P = 0.561). Those with rapid-rise INR had longer LOS after warfarin administration (discharge HR = 0.84; P = 0.0002). The most common warfarin dose immediately prior to rapid rise was 5 mg. Risk factors for rapid-rise INR were low body mass index, female gender, and cross-clamp time. Conclusion and Relevance: This represents the first report to assess warfarin-related rapid-rise INR in post–cardiac surgery patients and found correlation to hospital LOS but not bleed events. Conservative warfarin dosing may be warranted until further research can be conducted.

AbstractBackgroundTrace‐element contamination of contemporary parenteral nutrition (PN) components exists in unknown quantities and, in combination with excessive amounts of certain trace elements provided in commercially available adult, pediatric, and neonatal multitrace‐element (MTE) products, could result in eventual accumulation and toxicity. This study aims to quantify trace‐element contamination in components used for PN compounding to further inform recommendations for MTE product reformulation and individualized trace‐element prescribing in PN.MethodsA total of 32 unique components (65 products) available for PN compounding were tested for manganese, chromium, selenium, zinc, and copper contamination, utilizing inductively coupled plasma mass spectrometry. Theoretical adult, pediatric, and neonatal PNs were formulated to assess the impact of macronutrient and micronutrient component doses on PN trace‐element contamination.ResultsTrace‐element contamination was detected in 24 (75%) components tested. Chromium and manganese were common, present in 65.6% and 51.5% of all components, respectively. Eight components did not contain detectable trace‐element contamination, most notably sterile water, concentrated dextrose, and lipid emulsion. Manganese contamination in theoretical adult, pediatric, and neonatal PN was 25.18, 9.92, and 1.37 µg, respectively. Chromium contamination was 4.85, 1.5, and 0.28 µg, respectively.ConclusionTrace‐element contamination was prevalent in components used to compound PN. Our findings support reformulation of adult, pediatric, and neonatal manufactured MTE products to eliminate chromium, decrease manganese, and supply full daily physiologic requirements of selenium, zinc, and copper. Future study is needed to assess the additional contamination that could occur through the compounding and storage processes.