03-Prophylactic Anticoagulation Dosing in Aneurysmal Subarachnoid Hemorrhage Patients Requiring an EVD
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Neuroscience, Pharmacology, 2021
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The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Chidozie I. Ukpabi

Introduction/Hypothesis: Aneurysmal subarachnoid hemorrhage (aSAH) is commonly managed in neurocritical care units and is a significant cause of disability and mortality. Unfractionated heparin (UFH) is recommended to prevent venous thromboembolism (VTE) in this population following definitive aneurysm management. There is limited data validating the use of low molecular weight heparin (LMWH) in this population especially in patients requiring an external ventricular drain (EVD). Even while on prophylactic anticoagulation doses, patients with aSAH with EVDs have an increased risk of secondary intracranial hemorrhage (ICH). This study examined the rate of VTE and ICH retrospectively in aSAH patients in order to identify the safest and most effective anticoagulation dosing strategy.

Methods: Following IRB approval, all aSAH patients admitted to Emory University Hospital from 2012 - 2017 were screened. Patients with an EVD were analyzed for their VTE prophylactic regimen (LMWH ≤0.5mg/kg/day or UFH 5000 units q8 - 12h), VTE events based on ICD coding, and new ICH events based on imaging.

Results: Out of 1,351 patients screened, 862 required an EVD. 547 patients received prophylactic LMWH and 173 received UFH. VTE events occurred in 8.4% of patients receiving LMWH and 8.7% in those receiving UFH (p=0.9), while ICH occurred in 6.8% and 1.7% respectively (p<0.01). There was no difference in the dosing between the groups who developed VTE and those who did not. Using the prophylactic weight-based regimen, patients >70 kg had a statistically significant higher rate of VTE. In a regression analysis aiming at steady state anti-Xa levels between 0.1 - 0.3 units/mL, the risk of VTE is <9.6% and the risk of hemorrhage is <6.8% although this correlation did not achieve statistical significance.

Conclusions: This retrospective analysis of aSAH patients who required an EVD allows for an estimation of the efficacy and safety of a weight based VTE prophylactic regimen. LMWH demonstrated similar efficacy to UFH yet was associated with higher rates of EVD-related hemorrhage. Since patients weighing over 70 kg tend to develop VTE more frequently, using anti Xa levels could aid in adjusting the dose used while stratifying risk and benefit. Further prospective trials are required to optimize the care for this high-risk patient population.


Meta Tag
Content Type Presentation
Knowledge Area Neuroscience
Knowledge Area Pharmacology
Knowledge Level Advanced
Membership Level Select
Tag Subarachnoid Hemorrhage
Tag Anticoagulation
Year 2021
Prophylactic Anticoagulation Dosing
Subarachnoid Hemorrhage Patients
Unfractionated Heparin


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