What is the recommended prophylaxis for Deep Vein Thrombosis (DVT) in a 28-year-old patient with a hip fracture?

DVT Prophylaxis for Hip Fracture

Enoxaparin (LMWH) is the recommended prophylaxis for DVT in a 28-year-old patient with a hip fracture. 1, 2

Rationale for LMWH (Enoxaparin) Selection

Low Molecular Weight Heparin (LMWH) is superior to other options for several important reasons:

• Enoxaparin has demonstrated superior efficacy compared to unfractionated heparin in preventing DVT after hip surgery with:

  • Better bioavailability
  • Longer half-life
  • More predictable anticoagulation effect
  • Lower risk of bleeding
  • Reduced risk of heparin-induced thrombocytopenia 1

• LMWH is associated with lower incidence of DVT and PE compared to unfractionated heparin (UFH), with fewer bleeding complications, transfusions, and lower rates of myocardial infarction, cardiac arrest, severe sepsis, and mortality 1, 2

Dosing and Administration

• Standard dosing: 30-40 mg subcutaneously once or twice daily 1
• Timing: Begin 12-24 hours after surgery 1
• Duration: 10-14 days standard, with extended prophylaxis up to 35 days recommended for optimal outcomes 1

Why Not the Other Options?

1. Unfractionated Heparin (Option B): While effective, it has been shown to be less effective than LMWH with higher bleeding risk and more frequent dosing requirements 2, 1

2. Warfarin (Option C): Requires frequent monitoring, has delayed onset of action, and has been shown to be less effective than LMWH in preventing DVT after hip surgery 2, 1

3. IVC Filter (Option D): Not recommended as primary prophylaxis for DVT. IVC filters are invasive devices reserved for patients with contraindications to anticoagulation or those who have failed anticoagulation therapy 1

Special Considerations

• Risk Assessment: The patient's risk for VTE should be evaluated using established scoring systems. Hip fracture surgery places this patient in a high-risk category 2

• Mechanical Prophylaxis: Should be used in conjunction with pharmacological prophylaxis (intermittent pneumatic compression devices or elastic stockings) 1

• Renal Function: If the patient has severe renal impairment (CrCl <30 mL/min), consider reducing the dose of enoxaparin to 30 mg once daily or using unfractionated heparin as an alternative 1

• Extended Prophylaxis: Evidence supports extending prophylaxis beyond hospital discharge (up to 35 days) to significantly reduce the risk of late-occurring DVT 1

Potential Pitfalls and Caveats

• When neuraxial anesthesia (spinal or epidural) is used, do not administer enoxaparin earlier than 12 hours after the block was performed, and wait at least 4 hours after catheter removal before administering the first postoperative dose 1

• Patients receiving the first dose of enoxaparin 10 hours or more postoperatively have significantly fewer bleeding complications 3

• Monitor for signs of bleeding complications, which occur in approximately 4.7% of patients receiving enoxaparin for hip fracture surgery 4

In summary, enoxaparin is the optimal choice for DVT prophylaxis in this 28-year-old patient with a hip fracture based on the most current evidence showing superior efficacy and safety compared to other options.