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Published on: February 10, 2023
Venous thromboembolic risk stratification in pediatric trauma: A Pediatric Trauma Society Research Committee
Daniel F Labuz1, Aaron Cunningham, Joseph Tobias
1From the Division of Pediatric Surgery, Department of Surgery (D.F.L., A.C., J.T., A.D., E.D., N.A.H., M.A.J.), Oregon Health and Science University, Portland, Oregon; Department of Surgery (C.W.M.), Madigan Army Medical Center; Department of Pediatric Surgery (M.A.E.), Mary Bridge Children's Hospital, Tacoma, Washington; Division of Pediatric Surgery, Department of Surgery (M.D.H., M.A.C.), University of Massachusetts Medical School, Worcester, Massachusetts; Division of Pediatric General and Thoracic Surgery (M.K., R.A.F.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Pediatric Surgery (S.C.F., B.N.-M.), Texas Children's Hospital, Houston, Texas; Division of Pediatric Surgery, Department of Surgery (T.M., D.B.K.), Mayo Clinic, Rochester, Minnesota; Division of Pediatric Surgery (A.S., A.C.), Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts; Division of Critical Care (A.O., A.Z.), Children's Hospital and Clinics of Minnesota, Minneapolis, Minnesota; Division of Pediatric Surgery, Department of Surgery (A.G., M.K.), University of Tennessee Health Sciences Center, Memphis, Tennessee; and Division of Pediatric Surgery (M.A.J.), Randall Children's Hospital at Legacy Emanuel, Portland, Oregon.
Insights
A validated algorithm accurately predicts venous thromboembolism (VTE) risk in pediatric trauma patients, even with imperfect registry data. This tool aids in VTE screening and prophylaxis guidance for injured children.
Area of Science:
- Pediatric Traumatology
- Vascular Medicine
- Health Informatics
Background:
- Venous thromboembolism (VTE) is rare but serious in pediatric trauma.
- Existing VTE risk algorithms lack consensus and rely on potentially inaccurate registry data.
- Multicenter review needed to assess trauma registry accuracy and algorithm effectiveness.
Purpose of the Study:
- Evaluate trauma registry fidelity in pediatric VTE cases.
- Confirm the effectiveness of a 10-variable VTE prediction algorithm across diverse centers.
- Improve VTE risk stratification and management in pediatric trauma.
Main Methods:
- Multicenter retrospective review of pediatric trauma registries (2009-2018).
- Chart review to correct VTE misclassifications.
- Application of a 10-variable prediction algorithm to corrected data.
- Performance analysis using sensitivity, specificity, and AUC.
Main Results:
- Corrected VTE rate was 0.16% (86/52,524), with 13 registry misclassifications.
- The algorithm demonstrated strong performance (AUC 0.96, sensitivity 69%).
- High specificity (>91%) and NPV (>99.7%) maintained across centers despite variable VTE rates.
- Central lines, particularly femoral, were associated with 54% of VTEs; prophylaxis underreporting was significant.
Conclusions:
- The VTE prediction algorithm is effective across diverse pediatric trauma centers using corrected data.
- Findings support VTE screening and prophylaxis guidance initiatives.
- Prospective studies are warranted to further validate the algorithm and its clinical utility.
Background:
Venous thromboembolism (VTE) in injured children is rare, but its consequences are significant. Several risk stratification algorithms for VTE in pediatric trauma exist with little consensus, and all are hindered in development by relying on registry data with known inaccuracies. We performed a multicenter review to evaluate trauma registry fidelity and confirm the effectiveness of one established algorithm across diverse centers.
Methods:
Local trauma registries at 10 institutions were queried for all patients younger than 18 years admitted between 2009 and 2018. Additional chart review was performed on all "VTE" cases and random non-VTE controls to assess registry errors. Corrected data were then applied to our prediction algorithm using 10 real-time variables (Glasgow Coma Scale, age, sex, intensive care unit admission, transfusion, central line placement, lower extremity/pelvic fracture, major surgery) to calculate VTE risk scores. Contingency table classifiers and the area under a receiver operator characteristic curve were calculated.
Results:
Registries identified 52,524 pediatric trauma patients with 99 episodes of VTE; however, chart review found that 13 cases were misclassified for a corrected total of 86 cases (0.16%). After correction, the algorithm still displayed strong performance in discriminating VTE-fated encounters (sensitivity, 69%; area under the receiver operating characteristic curve, 0.96). Furthermore, despite wide institutional variability in VTE rates (0.04-1.7%), the algorithm maintained a specificity of >91% and a negative predictive value of >99.7% across centers. Chart review also revealed that 54% (n = 45) of VTEs were directly associated with a central line, usually femoral (n = 34, p < 0.001 compared with upper extremity), and that prophylaxis rates were underreported in the registries by about 50%; still, only 19% of the VTE cases had been on prophylaxis before diagnosis.
Conclusion:
The VTE prediction algorithm performed well when applied retrospectively across 10 diverse pediatric centers using corrected registry data. These findings can advance initiatives for VTE screening/prophylaxis guidance following pediatric trauma and warrant prospective study.
Level Of Evidence:
Clinical decision rule evaluated in a single population, level III.
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