Introduction Prior studies have demonstrated that patients presenting for elective surgery may have higher-than-expected residual anti-Xa level activity at or beyond 24 hours following their last treatment dose of enoxaparin. Given that 24 hours of abstinence is currently recommended by both European and American societies before the performance of neuraxial or deep anesthetic/analgesic procedures, determining the actual timeframe at which residual anti-Xa level activity reliably falls below 0.2 IU/mL, the lower limit of the target range for thromboprophylaxis, is critical.
Methods This was a prospective observational trial. Consenting patients on treatment-dose enoxaparin were randomized to either a 24-hour group (last dose at 07:00 the day prior to surgery) or a 36-hour group (last dose at 19:00 2 days prior to surgery). On arrival for surgery, blood samples were obtained to assess residual anti-Xa level activity and renal function. The primary outcome was residual anti-Xa level activity following the last treatment dose of enoxaparin. Incorporating all patients, linear regression modeling was performed to predict the timepoint at which the level of anti-Xa activity reliably fell below 0.2 IU/mL.
Results 103 patients were analyzed. Time from the last dose at which residual anti-Xa activity fell below 0.2 IU/mL, based on the upper bound of the 95% CI, was 31.5 hours. No correlation overall between age, renal function, or sex was found.
Conclusion Residual levels of anti-Xa activity do not reliably fall below 0.2 IU/mL 24 hours following discontinuation of treatment-dose enoxaparin. Therefore, current time-based guidelines are not conservative enough. Routine anti-Xa testing should be strongly considered, or current time-based guidelines should be reassessed.
Trial registration number NCT03296033.
- Diagnostic Techniques and Procedures
- Injections, Spinal
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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Contributors Guarantor: DSH. Study conception and design: DSH, CJE, SWD, DJ, JDT, JWR, RW. Data collection: DSH, CJE, SWD, DJ, JDT, JWR, RW. Analysis and interpretation of results: DSH, GRT, GR, RW. Manuscript preparation: DSH, CJE, SWD, DJ, JDT, JWR, GRT, GR, RW. All authors have approved the final manuscript.
Funding The study was funded by the Department of Anesthesiology at Atrium Wake Forest Baptist Hospital.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.