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Published on: June 2, 2015
Evaluation of guidelines for injured children at high risk for venous thromboembolism: A prospective observational
Rachel M Landisch1, Sheila J Hanson, Laura D Cassidy
1From the Department of Surgery (R.M.L.), Division of Pediatric Surgery (K.B., D.M.G.), and the Department of Pediatrics (S.J.H., R.C.P.), Division of Critical Care and Division of Hematology/Oncology, The Children's Hospital of Wisconsin; and Institute for Health and Equity (L.D.C.), Medical College of Wisconsin, Milwaukee, Wisconsin.
Insights
Venous thromboembolism (VTE) risk in pediatric trauma patients can be predicted using specific clinical factors. These factors help identify children needing VTE prophylaxis, improving prevention strategies.
Area of Science:
- Pediatric critical care medicine
- Trauma surgery
- Vascular medicine
Background:
- Venous thromboembolism (VTE) prophylaxis is standard for adult trauma patients but not standardized for pediatric trauma.
- Identifying high-risk pediatric patients for VTE is crucial for effective prevention.
- This study aimed to validate VTE prophylaxis guidelines in critically injured children.
Purpose of the Study:
- To prospectively implement and assess the accuracy of VTE prophylaxis guidelines in injured pediatric patients.
- To identify specific clinical factors associated with a high risk of VTE in this population.
- To improve VTE risk stratification and prevention in pediatric trauma.
Main Methods:
- Prospective data collection on injured children (August 2010-August 2015).
- Implementation of VTE prophylaxis guidelines for high-risk patients, with screening ultrasounds for those also at high bleeding risk.
- Stepwise logistic regression and ROC curve analysis to assess predictive accuracy of risk factors for VTE.
Main Results:
- Of 588 ICU patients, 199 were identified as high risk for VTE; 10% of this group developed VTE.
- Significant VTE predictors included central venous catheter, inotropes, immobilization, and Glasgow Coma Scale <9.
- The predictive model demonstrated excellent accuracy with an area under the ROC curve of 0.92.
Conclusions:
- Specific clinical factors accurately predict VTE risk in critically injured children.
- Incorporating these factors into guidelines enhances risk stratification for VTE prophylaxis.
- Improved VTE prevention strategies can be developed for pediatric trauma patients.
Background:
Pharmacologic prophylaxis for venous thromboembolism (VTE) is a widely accepted practice in adult trauma patients to prevent associated morbidity and mortality. However, VTE prophylaxis has not been standardized in injured pediatric patients. Our institution identified factors potentially associated with a high risk of VTE in critically injured children that led to prospective implementation of VTE prophylaxis guidelines. We hypothesize that the guidelines are accurate in predicting children at risk for VTE.
Methods:
Data were prospectively collected on injured children from August 2010 to August 2015. Pharmacologic prophylaxis was indicated for patients identified by the guidelines as high risk for VTE. Prophylaxis was deferred and a screening ultrasound was performed if the high-risk VTE patients were also at high risk for bleeding. To assess the accuracy of predicting confirmed cases of VTE, stepwise logistic regression analysis was used to measure the association of individual risk factors with VTE controlling for age (≥13 years). A receiver operating characteristic curve measured the accuracy of the final model to predict a VTE.
Results:
Of 4,061 trauma patients, 588 were admitted to the ICU, with the guidelines identifying 199 as high risk for VTE. VTE occurred in 3.9% (23/588) of the ICU population and 10% (20/199) of the high risk group. The median age of VTE patients in the ICU was 9.7 years. Statistically significant predictors (p < 0.05) of VTE in the multivariate model included presence of a central venous catheter (OR = 5.2), inotropes (OR = 7.7), immobilization (OR = 5.5), and a Glasgow Coma Scale of <9 (OR = 1.3). The area under receiver operating characteristic curve of this model was 0.92, demonstrating its excellent predictive ability.
Conclusion:
Specific clinical factors in critically injured children are associated with a high risk for VTE. Incorporating these risk factors in VTE prophylaxis guidelines facilitates more accurate risk stratification and may allow for improved VTE prevention in pediatric trauma.
Level Of Evidence:
Prognostic study, level II.
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