Venous thromboembolism prophylaxis in the pediatric trauma population

doi:10.1016/j.jpedsurg.2013.02.059

Journal of Pediatric Surgery

Volume 48, Issue 6, June 2013, Pages 1413-1421

https://doi.org/10.1016/j.jpedsurg.2013.02.059 Get rights and content

Abstract

Background/Purpose

The aim of this study was to review evidence-based literature addressing pertinent questions about venous thromboembolism (VTE) after traumatic injury in children.

Methods

Data were obtained from English-language articles identified through Pubmed published from 1995 until November 2012, and from bibliographies of relevant articles. Studies were included if they contributed evidence to one of the following questions. In the pediatric traumatic injury population: (1) What is the overall incidence of VTE? (2) Is age (adolescence versus pre-adolescence) associated with higher VTE incidence? (3) Which risk factors are associated with higher VTE incidence? (4) Does mechanical and/or pharmacological prophylaxis impact outcomes?

Results

Eighteen articles were included in this systematic review. The evidence regarding each question was evaluated, graded by author consensus, and summarized.

Conclusions

The overall incidence of VTE is low. Older (> 13 years) and more severely injured patients are at higher VTE risk. Additional factors including injury type or presence of a central venous catheter also place a patient at higher VTE risk. Implementation of a risk-based clinical practice guideline for VTE prophylaxis has been associated with reduced symptomatic VTE at one institution. Randomized, prospective trials analyzing outcomes of VTE prophylaxis in pediatric trauma victims are needed.

Section snippets

Materials and methods

Our institution is an American College of Surgeons verified Level 1 Trauma Center and a South Carolina state verified Level 1 Pediatric Trauma Center and receives the majority of severely injured patients in the coastal region of South Carolina. Our institution had no guidelines for VTE prophylaxis in pediatric trauma victims. We identified a small workgroup consisting of a pediatric critical care pharmacist, two pediatric intensivists, our pediatric trauma program coordinator, and our

Results

Eighteen articles were included in the evidence review; most were Class 2 or 3 evidence. A summary of the evidence addressing each question is included below.

VTE incidence

The reported incidence of VTE in all pediatric trauma patients appears to be low (0.02%–0.33%); however, this may be an underestimation of the true incidence because retrospective database reviews have the inherent limitation that data may have been missing (Table 2). The incidence would likely be higher in patients prospectively screened for VTE; however, our review found only one study [16], in a PICU population, that prospectively screened asymptomatic patients with ultrasound or other

Conclusions

Randomized, prospective trials of VTE prophylaxis in pediatric trauma victims have not been published. Choosing which pediatric patients should receive pharmacological prophylaxis, with its inherent risks of adverse effects, is a challenge. The overall incidence of VTE is low. Older and more severely injured patients are at higher VTE risk. The patients at highest risk of developing VTE, and, thus, who stand the most to gain by receiving pharmacologic prophylaxis (if not contraindicated), are

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Derivation and Validation of a Machine Learning Algorithm for Predicting Venous Thromboembolism in Injured Children
2023, Journal of Pediatric Surgery
Venous thromboembolism (VTE) causes significant morbidity in pediatric trauma patients. We applied machine learning algorithms to the Trauma Quality Improvement Program (TQIP) database to develop and validate a risk prediction model for VTE in injured children.
Patients ≤18 years were identified from TQIP (2017–2019, n = 383,814). Those administered VTE prophylaxis ≤24 h and missing the outcome (VTE) were removed (n = 347,576). Feature selection identified 15 predictors: intubation, need for supplemental oxygen, spinal injury, pelvic fractures, multiple long bone fractures, major surgery (neurosurgery, thoracic, orthopedic, vascular), age, transfusion requirement, intracranial pressure monitor or external ventricular drain placement, and low Glasgow Coma Scale score. Data was split into training (n = 251,409) and testing (n = 118,175) subsets. Machine learning algorithms were trained, tested, and compared.
Low-risk prediction: For the testing subset, all models outperformed the baseline rate of VTE (0.15%) with a predicted rate of 0.01–0.02% (p < 2.2e⁻¹⁶). 88.4–89.4% of patients were classified as low risk by the models.
All models outperformed baseline with a predicted rate of VTE ranging from 1.13 to 1.32% (p < 2.2e⁻¹⁶). The performance of the 3 models was not significantly different.
We developed a predictive model that differentiates injured children for development of VTE with high discrimination and can guide prophylaxis use.
Prognostic, Level II.
Retrospective, Cross-sectional.
Venous thromboembolism research priorities: A scientific statement from the American Heart Association and the International Society on Thrombosis and Haemostasis
2020, Research and Practice in Thrombosis and Haemostasis
Venous thromboembolism (VTE) is a major cause of morbidity and mortality. The impact of the Surgeon General’s Call to Action in 2008 has been lower than expected given the public health impact of this disease. This scientific statement highlights future research priorities in VTE, developed by experts and a crowdsourcing survey across 16 scientific organizations. At the fundamental research level (T0), researchers need to identify pathobiologic causative mechanisms for the 50% of patients with unprovoked VTE and better understand mechanisms that differentiate hemostasis from thrombosis. At the human level (T1), new methods for diagnosing, treating, and preventing VTE will allow tailoring of diagnostic and therapeutic approaches to individuals. At the patient level (T2), research efforts are required to understand how foundational evidence impacts care of patients (eg, biomarkers). New treatments, such as catheter‐based therapies, require further testing to identify which patients are most likely to experience benefit. At the practice level (T3), translating evidence into practice remains challenging. Areas of overuse and underuse will require evidence‐based tools to improve care delivery. At the community and population level (T4), public awareness campaigns need thorough impact assessment. Large population‐based cohort studies can elucidate the biologic and environmental underpinings of VTE and its complications. To achieve these goals, funding agencies and training programs must support a new generation of scientists and clinicians who work in multidisciplinary teams to solve the pressing public health problem of VTE.
Spinal Cord Injury
2020, Braddom's Physical Medicine and Rehabilitation
Spinal cord injury (SCI) is a catastrophic event that results in physical disability and impaired function of various organ systems. The field of SCI has grown at an unprecedented rate. Great progress has occurred in the management of SCI and its associated conditions. Because of advances in clinical practice, people with SCI have increased life expectancy. Morbidity is reduced as well, as reflected in reduced hospital length of stay following SCI and fewer rehospitalizations during follow-up years. Spasticity can be effectively managed, and male fertility is much improved. Application of modern technology has enhanced the function and quality of life of many persons with SCI. The International Standards for Neurological and Functional Classification of SCI have been adapted worldwide as the preferred assessment instrument of persons with SCI seeking clinical care and for those participating in research studies. Current wheelchair designs and seating systems are far superior to older models and permit increased mobility. People with disability now use computers, tablets, and smartphones in their daily lives for recreational, education, and vocational purposes with great success. Advances in technology and engineering have made it possible to develop systems for standing and stepping with exoskeletal walking devices, allowing many individuals with SCI to ambulate whereas previously they would not have been able to do so.
Pediatric deep venous thrombosis
2019, Journal of Vascular Surgery: Venous and Lymphatic Disorders
Deep venous thrombosis (DVT) in the pediatric population is rare, occurring in about 10 to 14 out of 10,000 pediatric admissions annually, but with serious consequences such as pulmonary embolism and/or post-thrombotic syndrome. There is a dearth of surgical literature regarding this entity, its pathophysiology, its treatment and its long-term sequelae.
An extensive search of available surgical and medical literature in Medline, PubMed was obtained by searching terms synonymous with pediatric DVT. Case reports and opinion articles were excluded. Ongoing clinical trials were culled from clinicaltrial.gov by searching for pediatric DVT studies. Institutional guidelines, where available, were included in this summary.
We provide a clinically relevant summary with the aims of improving prevention, early identification and treatment of pediatric DVT.
Although rare and frequently with subtle presentations, pediatric DVT can be serious. Early identification and treatment can be instrumental in limiting sequelae and in improving outcomes for these patients.
Primary thromboprophylaxis in hospitalized children: A multi-center retrospective analysis
2019, Thrombosis Research
Citation Excerpt :
Additional barriers to SCD use include hospital cost and process implementation [19]. In addition, the most effective way to prevent hospital-acquired VTE in children remains unknown and this likely contributes to decreased use of thromboprophylaxis [20,21]. This study identified characteristics of patients receiving thromboprophylaxis.
Hospital acquired venous thromboembolism in children is associated with significant morbidity/mortality. Prevention strategies include sequential compression devices and prophylactic anticoagulation but these interventions carry risk and are poorly studied in children.
Objectives were to evaluate primary thromboprophylaxis use in hospitalized children over time and the associated bleeding risk.
Retrospective study of hospitalized patients aged 10–18 years within the Pediatric Health Information System administrative database from January 2008–September 2015. Factors associated with thromboprophylaxis receipt and bleeding were identified using generalized linear mixed effects models.
Of 1,075,383 hospitalizations, 10,544 (1%) received prophylactic enoxaparin and 58,768 (5%) received mechanical compression. Mechanical thromboprophylaxis increased slightly over time (4.3% in 2008, 6.2% in 2015), enoxaparin use did not (0.8% in 2008, 1.2% in 2015). Patients aged 16–18 were more likely than younger children (10−12) to receive pharmacologic (adjusted odds ratio [aOR] 3.1, 95% confidence interval [CI] 2.9–3.3) or mechanical thromboprophylaxis (aOR 2.9, 95% CI 2.9–3). Patients on rehabilitation medical service were more likely to receive prophylactic enoxaparin (aOR 53, 95% CI 44.1–64.5). 5.6% (589/10,544) of patients receiving enoxaparin prophylaxis had bleeding. Thromboprophylaxis use by hospital varied with a range of 0.25–3.3% for enoxaparin and 2–26.2% for mechanical compression.
Thromboprophylaxis is infrequently utilized in hospitalized children. Pharmacologic prophylaxis with enoxaparin remains low and has not substantially increased over time. Significant variability exists across hospitals and services in the administration of both mechanical and pharmacologic thromboprophylaxis highlighting the need for further evidence to standardize practice.
Venous thromboembolism following inpatient pediatric surgery: Analysis of 153,220 patients
2019, Journal of Pediatric Surgery
To evaluate venous thromboembolism (VTE) rates and risk factors following inpatient pediatric surgery.
153,220 inpatient pediatric surgical patients were selected from the 2012–2015 NSQIP-P database. Demographic and perioperative variables were documented. Primary outcome was VTE requiring treatment within 30 postoperative days. Secondary outcomes included length of stay (LOS) and 30-day mortality. Prediction models were generated using logistic regression. Mortality and time to VTE were assessed using Kaplan–Meier survival analysis.
305 patients (0.20%) developed 296 venous thromboses and 12 pulmonary emboli (3 cooccurrences). Median time to VTE was 9 days. Most VTEs (81%) occurred predischarge. Subspecialties with highest VTE rates were cardiothoracic (0.72%) and general surgery (0.28%). No differences were seen for elective vs. urgent/emergent procedures (p = 0.106). All-cause mortality VTE patients was 1.2% vs. 0.2% in patients without VTE (p < 0.001). After stratifying by American Society of Anesthesiologists (ASA) class, no mortality differences remained when ASA < 3. Preoperative, postoperative, and total LOSs were longer for patients with VTE (p < 0.001 for each). ASA ≥ 3, preoperative sepsis, ventilator dependence, enteral/parenteral feeding, steroid use, preoperative blood transfusion, gastrointestinal disease, hematologic disorders, operative time, and age were independent predictors (C-statistic = 0.83).
Pediatric postsurgical patients have unique risk factors for developing VTE.
Level II.

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^☆: Declaration of competing interests: The authors declare that they have no competing interests.

^☆☆: Presented in poster format at the Society of Critical Care Medicine Annual Congress in Houston, Texas on February 5, 2012.

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Independent Review ArticleVenous thromboembolism prophylaxis in the pediatric trauma population☆,☆☆

Abstract

Background/Purpose

Methods

Results

Conclusions

Section snippets

Materials and methods

Results

VTE incidence

Conclusions

Chest

Blood

Chest

J Pediatr Surg

J Pediatr Surg

Arch Phys Med Rehabil

J Pediatr Surg

Thromb Res

Chest

Outcome of pediatric thromboembolic disease: a report from the Canadian Childhood Thrombophilia Registry

Pediatr Res

Clinical course of postthrombotic syndrome in children with history of venous thromboembolism

Blood Coagul Fibrinolysis

Effect of injury severity on the incidence and utilization-related outcomes of venous thromboembolism in pediatric trauma inpatients

Pediatr Crit Care Med

Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group

J Trauma

Independent Review Article
Venous thromboembolism prophylaxis in the pediatric trauma population☆,☆☆