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Venous Thromboembolism Prophylaxis in High-Risk Pediatric Trauma Patients
Amanda B Witte1, Kyle Van Arendonk2, Carisa Bergner1
1Children's Wisconsin, Medical College of Wisconsin, Milwaukee.
Insights
Chemical venous thromboembolism prophylaxis (cVTE) is safe in high-risk pediatric trauma patients. Delayed cVTE initiation increases VTE risk, highlighting the importance of timely prophylaxis in pediatric trauma care.
Area of Science:
- Pediatric Trauma Care
- Venous Thromboembolism Prevention
- Pharmacology
Background:
- The safety and efficacy of chemical venous thromboembolism prophylaxis (cVTE) in pediatric trauma patients are not well-established.
- Recent recommendations proposed high-risk criteria for cVTE use, but prospective evaluation is lacking.
Purpose of the Study:
- To prospectively evaluate high-risk criteria and the use of cVTE in pediatric trauma patients.
- To assess the safety and efficacy of cVTE in preventing venous thromboembolism (VTE) in this population.
Main Methods:
- A prospective, multi-institutional cohort study involving 8 Level I pediatric trauma centers.
- Included pediatric trauma patients (<18 years) meeting defined high-risk criteria.
- Assessed receipt, timing of cVTE, VTE rates, and safety outcomes (bleeding complications).
Main Results:
- 460 high-risk pediatric trauma patients were studied; 54.5% received cVTE.
- VTE occurred in 1.6% of patients receiving cVTE within 24 hours, 6.9% receiving it after 24 hours, and 5.3% receiving no cVTE.
- Delayed cVTE initiation (after 24 hours) was significantly associated with increased VTE risk (OR 1.01).
- No bleeding complications were observed with cVTE use.
Conclusions:
- cVTE is safe in high-risk pediatric trauma patients, with no observed bleeding complications.
- Timely initiation of cVTE (within 24 hours) is crucial for effective VTE prevention.
- Quality improvement efforts should focus on optimizing prophylaxis timing and addressing implementation barriers.
Importance:
The indications, safety, and efficacy of chemical venous thromboembolism prophylaxis (cVTE) in pediatric trauma patients remain unclear. A set of high-risk criteria to guide cVTE use was recently recommended; however, these criteria have not been evaluated prospectively.
Objective:
To examine high-risk criteria and cVTE use in a prospective multi-institutional study of pediatric trauma patients.
Design, Setting, And Participants:
This cohort study was completed between October 2019 and October 2022 in 8 free-standing pediatric hospitals designated as American College of Surgeons level I pediatric trauma centers. Participants were pediatric trauma patients younger than 18 years who met defined high-risk criteria on admission. It was hypothesized that cVTE would be safe and reduce the incidence of VTE.
Exposures:
Receipt and timing of chemical VTE prophylaxis.
Main Outcomes And Measures:
The primary outcome was overall VTE rate stratified by receipt and timing of cVTE. The secondary outcome was safety of cVTE as measured by bleeding or other complications from anticoagulation.
Results:
Among 460 high-risk pediatric trauma patients, the median (IQR) age was 14.5 years (10.4-16.2 years); 313 patients (68%) were male and 147 female (32%). The median (IQR) Injury Severity Score (ISS) was 23 (16-30), and median (IQR) number of high-risk factors was 3 (2-4). A total of 251 (54.5%) patients received cVTE; 62 (13.5%) received cVTE within 24 hours of admission. Patients who received cVTE after 24 hours had more high-risk factors and higher ISS. The most common reason for delayed cVTE was central nervous system bleed (120 patients; 30.2%). There were 28 VTE events among 25 patients (5.4%). VTE occurred in 1 of 62 patients (1.6%) receiving cVTE within 24 hours, 13 of 189 patients (6.9%) receiving cVTE after 24 hours, and 11 of 209 (5.3%) who had no cVTE (P = .31). Increasing time between admission and cVTE initiation was significantly associated with VTE (odds ratio, 1.01; 95% CI, 1.00-1.01; P = .01). No bleeding complications were observed while patients received cVTE.
Conclusions And Relevance:
In this prospective study, use of cVTE based on a set of high-risk criteria was safe and did not lead to bleeding complications. Delay to initiation of cVTE was significantly associated with development of VTE. Quality improvement in pediatric VTE prevention may center on timing of prophylaxis and barriers to implementation.
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