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Survey of pharmacologic thromboprophylaxis in critically ill children
Edward Vincent S Faustino1, Sonya Patel, Ravi R Thiagarajan
1Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA. vince.faustino@yale.edu
Insights
Pediatric intensive care units show varied practices for prescribing thromboprophylaxis, with adolescents receiving it more often than younger children, though less than adult guidelines suggest. This highlights the need for evidence-based trials in pediatric populations.
Area of Science:
- Pediatric critical care medicine
- Pharmacology
- Thrombosis and hemostasis
Background:
- Evidence guiding thromboprophylaxis in pediatric intensive care units (PICUs) is limited.
- Current prescribing practices for pharmacologic thromboprophylaxis in critically ill children are not well-defined.
Purpose of the Study:
- To assess the current prescribing practices for pharmacologic thromboprophylaxis in critically ill children within PICUs.
- To identify factors influencing thromboprophylaxis decisions in pediatric intensive care.
Main Methods:
- A cross-sectional survey was administered to pediatric intensivists in US and Canadian PICUs (at least 10 beds).
- The survey included scenarios involving adolescents, children, and infants to evaluate prescribing habits.
- Pediatric intensive care unit clinical directors or section heads were the target participants.
Main Results:
- Physician leaders from 97 PICUs responded (64.2% response rate).
- Thromboprophylaxis was prescribed more frequently for mechanically ventilated adolescents (42.3%) compared to children (1.0%) or infants (1.1%).
- Factors increasing prophylaxis likelihood included hypercoagulability, prior deep venous thrombosis, or cavopulmonary anastomosis; major bleeding or anticipated invasive procedures decreased likelihood. Low-molecular-weight heparin was the preferred agent.
Conclusions:
- PICU physician leaders were more likely to prescribe thromboprophylaxis to adolescents than younger children, but less frequently than recommended for adults.
- Significant heterogeneity in prescribing practices was observed across different age groups.
- The documented practice variations emphasize the urgent need for randomized controlled trials to establish evidence-based guidelines for thromboprophylaxis in critically ill children and adolescents.
Objective:
There is lack of evidence to guide thromboprophylaxis in the pediatric intensive care unit. We aimed to assess current prescribing practice for pharmacologic thromboprophylaxis in critically ill children.
Setting:
Pediatric intensive care units in the United States and Canada with at least ten beds.
Design:
Cross-sectional self-administered survey of pediatric intensivists using adolescent, child, and infant scenarios.
Participants:
Pediatric intensive care unit clinical directors or section heads.
Interventions:
None.
Measurements And Main Results:
Physician leaders from 97 of 151 (64.2%) pediatric intensive care units or their designees responded to the survey. In mechanically ventilated children, 42.3% of the respondents would usually or always prescribe thromboprophylaxis for the adolescent but only 1.0% would prescribe it for the child and 1.1% for the infant. Considering all pediatric intensive care unit patients, 3.1%, 32.0%, and 44.2% of respondents would never prescribe thromboprophylaxis for the adolescent, child, and infant scenarios, respectively. These findings were significant (p < .001 for the adolescent vs. child and infant; p = .002 for child vs. infant). Other patient factors that increased the likelihood of prescribing prophylaxis to a critically ill child for all three scenarios were the presence of hypercoagulability, prior deep venous thrombosis, or a cavopulmonary anastomosis. Prophylaxis was less likely to be prescribed to patients with major bleeding or an anticipated invasive intervention. Low-molecular-weight heparin was the most commonly prescribed drug.
Conclusions:
In these scenarios, physician leaders in pediatric intensive care units were more likely to prescribe thromboprophylaxis to adolescents compared with children or infants, but they prescribed it less often in adolescents than is recommended by evidence-based guidelines for adults. The heterogeneity in practice we documented underscores the need for rigorous randomized trials to determine the need for thromboprophylaxis in critically ill adolescents and children.
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