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Kelley-Quon LI, Acker SN, St Peter S, Goldin A, Yousef Y, Ricca RL, Mansfield SA, Sulkowski JP, Huerta CT, Lucas DJ, Rialon KL, Christison-Lagay E, Ham PB, Rentea RM, Beres AL, Kulaylat AN, Chang HL, Polites SF, Diesen DL, Gonzalez KW, Wakeman D, Baird R. Screening and Prophylaxis for Venous Thromboembolism in Pediatric Surgery: A Systematic Review. J Pediatr Surg 2024; 59:161585. [PMID: 38964986 DOI: 10.1016/j.jpedsurg.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 05/14/2024] [Accepted: 05/28/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVE The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee conducted a systematic review to describe the epidemiology of venous thromboembolism (VTE) in pediatric surgical and trauma patients and develop recommendations for screening and prophylaxis. METHODS The Medline (Ovid), Embase, Cochrane, and Web of Science databases were queried from January 2000 through December 2021. Search terms addressed the following topics: incidence, ultrasound screening, and mechanical and pharmacologic prophylaxis. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available literature. RESULTS One hundred twenty-four studies were included. The incidence of VTE in pediatric surgical populations is 0.29% (Range = 0.1%-0.48%) and directly correlates with surgery type, transfusion, prolonged anesthesia, malignancy, congenital heart disease, inflammatory bowel disease, infection, and female sex. The incidence of VTE in pediatric trauma populations is 0.25% (Range = 0.1%-0.8%) and directly correlates with injury severity, major surgery, central line placement, body mass index, spinal cord injury, and length-of-stay. Routine ultrasound screening for VTE is not recommended. Consider sequential compression devices in at-risk nonmobile, pediatric surgical patients when an appropriate sized device is available. Consider mechanical prophylaxis alone or with pharmacologic prophylaxis in adolescents >15 y and post-pubertal children <15 y with injury severity scores >25. When utilizing pharmacologic prophylaxis, low molecular weight heparin is superior to unfractionated heparin. CONCLUSIONS While VTE remains an infrequent complication in children, consideration of mechanical and pharmacologic prophylaxis is appropriate in certain populations. TYPE OF STUDY Systematic Review of level 2-4 studies. LEVEL OF EVIDENCE Level 3-4.
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Affiliation(s)
- Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine Aurora, CO, USA
| | - Shawn St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Adam Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Yasmine Yousef
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
| | - Robert L Ricca
- Division of Pediatric Surgery, Prisma Health Upstate, University of South Carolina, Greenville, SC, USA
| | - Sara A Mansfield
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jason P Sulkowski
- Division of Pediatric Surgery, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | - Carlos T Huerta
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | - Donald J Lucas
- Department of Surgery, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Division of Pediatric Surgery, Naval Medical Center San Diego, CA, USA
| | - Kristy L Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Emily Christison-Lagay
- Division of Pediatric Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, USA
| | - P Benson Ham
- Division of Pediatric Surgery, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Alana L Beres
- Division of Pediatric Surgery, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia PA, USA
| | - Afif N Kulaylat
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, PA, USA
| | - Henry L Chang
- Department of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | | - Diana L Diesen
- Division of Pediatric Surgery, UT Southwestern, Dallas, TX, USA
| | | | - Derek Wakeman
- Division of Pediatric Surgery, University of Rochester, Rochester, NY, USA
| | - Robert Baird
- Division of Pediatric Surgery, BC Children's Hospital Vancouver Canada, University of British Columbia, Canada
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Cortes-Nieves CJ, Ramirez N, Nieves A, Ramírez N. Lower Limb Deep Venous Thrombosis After Posterior Spinal Fusion as an Initial Manifestation of Factor V Leiden Mutation in a Pediatric Patient: A Case Report. Cureus 2024; 16:e57543. [PMID: 38707128 PMCID: PMC11068075 DOI: 10.7759/cureus.57543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Deep venous thrombosis (DVT) is a serious condition in which a blood clot forms in a deep vein, usually of the lower extremity. In pediatric orthopedic surgery, the incidence of thrombotic events is rare. This is a case presentation of a 12-year-old female patient without previous events or a family history of thrombotic events who underwent a posterior spinal fusion due to severe adolescent idiopathic scoliosis. The patient developed a DVT due to an underlying Factor V Leiden mutation. The purpose of this case report is to create awareness, facilitate the diagnosis and management, and aid in future interventions and clinical outcomes.
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Affiliation(s)
| | - Nicole Ramirez
- Orthopaedic Surgery, Ponce Health Sciences University, Ponce, PRI
| | | | - Norman Ramírez
- Pediatric Orthopedic Surgery, Mayagüez Medical Center, Mayagüez, PRI
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Boulet M, Langlais T, Pelet S, Belzile É, Forsythe C. Incidence of venous thromboembolism in pediatric orthopedics: A systematic review. Orthop Traumatol Surg Res 2024:103830. [PMID: 38336248 DOI: 10.1016/j.otsr.2024.103830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/23/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUNDS Children undergoing orthopedic procedures often present numerous risk factors for thromboembolism. A recent survey, conducted by the Pediatric Orthopaedic Society of North America (POSNA), indicates that pediatric orthopedic surgeons are unaware of venous thromboembolism (VTE) prevention protocols and feel that certain procedures should require thromboprophylaxis. The aim of this systematic review was to properly assess the incidence of VTE in pediatric orthopedics. By using a thorough and broad search of the literature, the incidence according to different subspecialties of pediatric orthopedics was evaluated. METHODS A systematic review on VTE in pediatric orthopedics was conducted. Four databases were searched for articles reporting these events. Three major search concepts: "pediatrics", "orthopedic surgery/trauma" and "VTE complications" were used and broken down in MeSH, EmTree and their free vocabulary synonyms for proper literature review. Two independent authors screened 8467 titles and abstracts. Seventy articles reporting VTE in children treated by orthopedic surgeons were selected for data extraction. We reported median incidences by orthopedic subtypes and by study characteristics with a semi-quantitative review model. RESULTS The 70 articles yielded a total of 845,010 participants. Spine articles (33/70) provided 25,2% of the children included in the review. Trauma studies (16/70) accounted for 47.5% of the participants. The overall VTE median incidence was 0.16% [95% CI: 0.0-1.01%]. Musculoskeletal infections had a noticeably higher median incidence of 3.5% [CI: 0.0-13.8%]. Small variations were seen for the other subtypes: trauma, spine and elective surgeries. Subgroups by article characteristics did not differ significantly either. CONCLUSION Thrombotic complications are rare events in pediatric orthopedics, but knowledge epidemiologic is important because its potential severity. In this review, VTE median incidence for all orthopedic subtypes was around 0.16% [CI: 0.0-1.01%]. According to subspecialty assessment, musculoskeletal infections were associated with greater risk of VTE occurrence. LEVEL OF EVIDENCE III - Systematic review.
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Affiliation(s)
- Mathieu Boulet
- Department of Surgery, Division of Orthopaedic Surgery, CHU de Québec, Université Laval, Québec, QC, Canada
| | - Tristan Langlais
- Orthopaedic Paediatric Department, Children Hospital, CHU Purpan, Toulouse Universitary, Toulouse, France
| | - Stéphane Pelet
- Department of Surgery, Division of Orthopaedic Surgery, CHU de Québec, Université Laval, Québec, QC, Canada
| | - Étienne Belzile
- Department of Surgery, Division of Orthopaedic Surgery, CHU de Québec, Université Laval, Québec, QC, Canada
| | - Caroline Forsythe
- Department of Surgery, Division of Orthopaedic Surgery, CHU de Québec, Université Laval, Québec, QC, Canada.
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Rodriguez-Merchan EC. Pharmacological Thromboprophylaxis in People with Hemophilia Experiencing Orthopedic Surgery: What Does the Literature Say in 2023? J Clin Med 2023; 12:5574. [PMID: 37685641 PMCID: PMC10488906 DOI: 10.3390/jcm12175574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
This narrative review of the literature, consisting of papers found in PubMed and The Cochrane Library published up to 31 July 2023, analyzed those that were deemed to be closely related to the title of this paper. It was encountered that the peril of deep vein thrombosis (DVT) in people with hemophilia (PWH) after orthopedic surgery is very small, such that pharmacological thromboprophylaxis is not necessary in most cases. The hemophilia literature states that the use of pharmacological thromboprophylaxis should only be performed in PWH undergoing major orthopedic surgery (total-knee arthroplasty, total-hip arthroplasty, ankle arthrodesis) who have additional venous thromboembolism (VTE) risk factors, such as old age, prior VTE, varicose veins, general anesthesia, cancer, factor V (Leiden) mutation, overweight, and treatment with the oral contraceptive pill (in females with von Willebrand's illness). If we notice various risk factors for VTE in PWH who experience orthopedic surgery, theoretically, we should perform the identical type of pharmacological thromboprophylaxis advised for non-hemophilia patients: low-molecular weight heparins (LMWHs), such as enoxaparin (40 mg subcutaneous/24 h); or direct oral anticoagulants (DOACs), either thrombin inhibitors (dabigatran, 150 mg oral/12 h) or activated factor X (FXa) inhibitors (rivaroxaban, 20 mg oral/24 h; apixaban, 5 mg oral/24 h), or subcutaneous fondaparinux (2.5 mg/24 h subcutaneously). However, the review of the literature on hemophiliac patients has shown that only a few authors have used pharmacological prophylaxis with LMWH (subcutaneous enoxaparin) for a short period of time (10-14 days) in some patients who had risk factors for VTE. Only one group of authors used a low dose of DOAC in the dusk after the surgical procedure and the next day, specifically in individuals at elevated risk of VTE and elevated risk of bleeding after the surgical procedure.
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Tsantes AG, Loukopoulou I, Papadopoulos DV, Trikoupis IG, Roustemis AG, Goumenos S, Sokou R, Tsante KA, Kriebardis AG, Koulouvaris P, Houhoula D, Piovani D, Papagelopoulos PJ, Bonovas S, Tsantes AE. The Hypercoagulable Profile of Patients with Bone Tumors: A Pilot Observational Study Using Rotational Thromboelastometry. Cancers (Basel) 2022; 14:3930. [PMID: 36010924 PMCID: PMC9406421 DOI: 10.3390/cancers14163930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/12/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: A detailed evaluation of the malignancy-associated coagulopathy (MAC) in surgical patients with bone tumors may allow for more effective thromboprophylactic measures. The purpose of this study was to assess the perioperative hemostatic changes in patients with bone tumors, using rotational thromboelastometry (ROTEM). Methods: An observational study was performed, including 50 patients with bone tumors who underwent oncologic resection and 30 healthy controls, matched for age and gender. The preoperative and postoperative laboratory evaluation of coagulation in both groups included conventional coagulation tests and a ROTEM analysis. The results of the conventional coagulation tests and the ROTEM analysis were compared between the two groups. Results: The results of the conventional coagulation tests were comparable between the tumor patients and the healthy controls. However, compared to the healthy adults, the tumor patients had lower CT (p < 0.001) and CFT (p < 0.001) values suggesting a rapid induction of the coagulation cascade, elevated A10 (p < 0.001) and MCF (p < 0.001) values indicating a higher clot strength and platelet activation, and elevated LI60 (p < 0.001) values indicating hypofibrinolysis in patients with bone tumors. The multiple linear regression analysis (controlling for potential confounding factors) confirmed the independent association of bone tumors with these hemostatic changes. Conclusions: Our results support the advantageous use of a ROTEM in patients with bone tumors over conventional coagulation tests because the qualitative changes in the hemostatic profile of these patients that can be detected by a ROTEM analysis cannot be identified by conventional tests. The ROTEM results indicate that the hypercoagulable state in patients with bone tumors is caused by the malignancy-associated activation of the coagulation cascade, platelet activation, and hypofibrinolysis.
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Affiliation(s)
- Andreas G. Tsantes
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Ilectra Loukopoulou
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | | | - Ioannis G. Trikoupis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Anastasios G. Roustemis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Stavros Goumenos
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Rozeta Sokou
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Konstantina A. Tsante
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Anastasios G. Kriebardis
- Laboratory of Reliability and Quality Control in Laboratory Hematology, Department of Biomedical Science, School of Health and Caring Science, University of West Attica, 12243 Athens, Greece
| | - Panagiotis Koulouvaris
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Dimitra Houhoula
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Panayiotis J. Papagelopoulos
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Argirios E. Tsantes
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece
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Moisa SM, Trandafir LM, Brinza C, Miron IC, Tarca E, Butnariu LI, Burlacu A. Current Antithrombotic Therapy Strategies in Children with a Focus on Off-Label Direct Oral Anticoagulants-A Narrative Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1093. [PMID: 35884077 PMCID: PMC9319670 DOI: 10.3390/children9071093] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022]
Abstract
(1) Background: The incidence of thromboembolic events is relatively low in the general population, but it increases in hospitalized children and those who underwent thrombogenic procedures. Although the evidence regarding direct oral anticoagulants (DOACs) in children with venous thromboembolism (VTE) is growing, DOACs were excluded from existing guidelines due to the lack of reliable data at that moment. Therefore, current evidence on VTE management in children needs to be critically reviewed. (2) Methods: We have conducted a literature search in the Scopus, EMBASE, and MEDLINE databases using prespecified keywords to retrieve studies published between 2010 and 2022. (3) Results: Clinical trials highlighted that rivaroxaban and dabigatran had predictable pharmacokinetic and pharmacodynamic profiles in children, similar to those observed in adults. Dabigatran and rivaroxaban had a similar safety profile to standard therapy but improved thrombotic burden and resolution during follow-up. Most studies involving apixaban and edoxaban are ongoing, and results are awaited. (4) Conclusions: Dabigatran and rivaroxaban could be valid therapeutic options for VTE management in children. In the case of apixaban and edoxaban, results from ongoing clinical studies are required before using them in pediatric VTE.
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Affiliation(s)
- Stefana Maria Moisa
- Pediatrics Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (S.M.M.); (L.M.T.); (I.C.M.); (L.I.B.)
- “Sfanta Maria” Clinical Emergency Hospital, 700309 Iasi, Romania
| | - Laura Mihaela Trandafir
- Pediatrics Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (S.M.M.); (L.M.T.); (I.C.M.); (L.I.B.)
- “Sfanta Maria” Clinical Emergency Hospital, 700309 Iasi, Romania
| | - Crischentian Brinza
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania;
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania
| | - Ingrith Crenguta Miron
- Pediatrics Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (S.M.M.); (L.M.T.); (I.C.M.); (L.I.B.)
- “Sfanta Maria” Clinical Emergency Hospital, 700309 Iasi, Romania
| | - Elena Tarca
- Pediatrics Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (S.M.M.); (L.M.T.); (I.C.M.); (L.I.B.)
- “Sfanta Maria” Clinical Emergency Hospital, 700309 Iasi, Romania
| | - Lacramioara Ionela Butnariu
- Pediatrics Department, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (S.M.M.); (L.M.T.); (I.C.M.); (L.I.B.)
- “Sfanta Maria” Clinical Emergency Hospital, 700309 Iasi, Romania
| | - Alexandru Burlacu
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania;
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania
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Pedersen LH, Villadsen GB, Hellfritzsch M, Hvas AM. Prophylaxis of Venous Thromboembolism in Children: A Systematic Review. Semin Thromb Hemost 2022; 48:413-421. [PMID: 35772401 DOI: 10.1055/s-0042-1748151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Venous thromboembolism (VTE) in children is a rare but serious event. Current guidance on pharmacological thromboprophylaxis in children is mostly based on adult studies and expert opinions. The aim of this systematic review was to examine under which conditions children (age ≤ 18 years) would benefit from pharmacological thromboprophylaxis with low molecular weight heparin or unfractionated heparin. Eligible studies included children, who did not receive pharmacological thromboprophylaxis as comparator, and VTE events were radiologically verified. MEDLINE and Embase were searched up to October 3, 2021. Ten studies were included presenting data for 976 children receiving pharmacological thromboprophylaxis. We divided the studies into three categories based on the population studied: children in the intensive care unit (n = 2), children with fractures and/or undergoing surgery (n = 5), and children with systemic disease (n = 3). A lower incidence of VTE was found when pharmacological thromboprophylaxis was used compared with no prophylaxis in children in intensive care unit with central venous catheter and mechanical ventilation (7/27 vs. 13/24), children in the intensive care unit admitted after trauma with a very high risk of VTE based on several risk factors (0/21 vs. 13/96), and children with acute lymphoblastic leukemia treated with L-asparaginase concomitant with steroid and presence of central venous catheter (0/82 vs. 8/121). Pharmacological thromboprophylaxis was not associated with an increased bleeding risk. In conclusion, pharmacological thromboprophylaxis in children is sparsely investigated. Only children with several risk factors for VTE are likely to benefit from pharmacological thromboprophylaxis.
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Affiliation(s)
| | | | | | - Anne-Mette Hvas
- Faculty of Health, Aarhus University, Aarhus, Denmark.,Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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Ponatinib in pediatric patients with Philadelphia chromosome-positive leukemia: a retrospective survey of the Japan Children’s Cancer Group. Int J Hematol 2022; 116:131-138. [DOI: 10.1007/s12185-022-03329-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/10/2022] [Accepted: 03/10/2022] [Indexed: 11/25/2022]
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10
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Georgeades C, Van Arendonk K, Gourlay D. Venous thromboembolism prophylaxis after pediatric trauma. Pediatr Surg Int 2021; 37:679-694. [PMID: 33462655 DOI: 10.1007/s00383-020-04855-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 11/24/2022]
Abstract
In recent years, there has been an increased focus on developing and validating venous thromboprophylaxis guidelines in the pediatric trauma population. We review the current literature regarding the incidence of and risk factors for venous thromboembolism (VTE) and the use of prophylaxis in the pediatric trauma population. Risk factors such as age, injury severity, central venous catheters, mental status, injury type, surgery, and comorbidities can lead to a higher incidence of VTE. Risk stratification tools have been developed to determine whether mechanical and/or pharmacologic prophylaxis should be implemented depending on the degree of VTE risk. When VTE risk is high, pharmacologic prophylaxis, such as with low molecular weight heparin, is often initiated. However, the timing and duration of VTE prophylaxis is dependent on patient factors including ambulatory status and contraindications such as bleeding. In addition, the utility of screening ultrasound for VTE surveillance has been evaluated and though they are not widely recommended, no formal guidelines exist. While more research has been done in recent years to assess the most appropriate type, timing, and duration of VTE prophylaxis, further studies are warranted to create optimal guidelines for decreasing the risk of VTE after pediatric trauma.
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Affiliation(s)
- Christina Georgeades
- Division of Pediatric Surgery, Children's Wisconsin, 999 N 92nd Street, Suite 320, Milwaukee, WI, 53226, USA. .,Department of Surgery, Medical College of Wisconsin, 8701 W. Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Kyle Van Arendonk
- Division of Pediatric Surgery, Children's Wisconsin, 999 N 92nd Street, Suite 320, Milwaukee, WI, 53226, USA
| | - David Gourlay
- Division of Pediatric Surgery, Children's Wisconsin, 999 N 92nd Street, Suite 320, Milwaukee, WI, 53226, USA
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Allahabadi S, Faust M, Swarup I. Venous Thromboembolism After Pelvic Osteotomy in Adolescent Patients: A Database Study Characterizing Rates and Current Practices. J Pediatr Orthop 2021; 41:306-311. [PMID: 33710126 DOI: 10.1097/bpo.0000000000001798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current risks and practices in medical prophylaxis of venous thromboembolism (VTE) after major elective lower extremity surgeries such as pelvic osteotomies have not been well-defined in the pediatric population. The purpose of this study was to (1) evaluate population rates of VTE in adolescents undergoing pelvic osteotomies, and (2) characterize current practices on types of VTE prophylaxis being utilized after pelvic osteotomies. METHODS The study evaluated the Pediatric Health Information System database between October 1, 2015 and January 1, 2020 for patients between 10 and 18 years of age meeting selected ICD-10 procedure and diagnosis codes relating to pelvic osteotomies. The rate of VTE was calculated within 90 days of index procedure. Types of pharmacologic prophylaxis were characterized. Continuous variables were compared with 2-sample t tests; proportions and categorical variables were compared with Fisher exact or χ2 tests, all with 2-tailed significance <0.05. RESULTS Of 1480 included patients, 9 were diagnosed with VTE within 90 days of surgery (VTE rate: 0.61%). Four of 9 (44.4%) had received pharmacologic prophylaxis postoperatively. There were no differences in baseline demographics or length of stay between patients that did or did not develop VTE (P>0.05). Overall, 52.0% received at least one form of pharmacologic prophylaxis postoperatively. The most common pharmacologic prophylaxis used was aspirin (47.6%), of which 64.4% received 81 mg dosing. There was no difference in VTE rates in those with or without prophylaxis (0.52% vs. 0.70%, P=0.75). However, those prescribed prophylaxis were significantly older (15.2±2.3 vs. 13.6±2.4 y, P<0.0001) and had a higher proportion of females (71.8% vs. 54.6%, P<0.01). CONCLUSIONS The overall rate of VTE in pediatric patients after pelvic osteotomies is non-negligible. There is heterogeneity in the type of anticoagulant utilized; however, VTE prophylaxis is most commonly prescribed in older adolescents and female patients. Guidelines for medical prevention of deep venous thrombosis and pulmonary embolism in the pediatric population are warranted after hip preservation surgery. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
| | - Millis Faust
- School of Medicine, University of California, San Francisco, San Francisco, CA
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Congiusta DV, Amer KM, Thomson J, Ippolito J, Beebe KS, Benevenia J. Risk factors of venous thromboembolism in patients with benign and malignant musculoskeletal tumors: a dual database analysis. INTERNATIONAL ORTHOPAEDICS 2020; 44:2147-2153. [PMID: 32654057 DOI: 10.1007/s00264-020-04707-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/03/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Venous thromboembolism (VTE) is a potentially life-threatening condition associated with both orthopaedic surgery and tumour growth. In this study, we identify risk factors associated with VTE in patients with musculoskeletal tumours using two national datasets. METHODS The ACS-NSQIP and NIS databases were queried for patients undergoing surgery with a diagnosis of benign or malignant musculoskeletal tumours. Chi-square and binary logistic regression analyses were used to determine risk factors for VTE. RESULTS The incidence of VTE was 2% in both databases. Patients with malignant tumours, those with tumours of the pelvis, sacrum, or coccyx, obesity, arrhythmias, paralysis, metastatic disease, coagulopathy, and recent weight loss were at increased risk for VTE. In patients with benign tumours, those who were African American, those with tumours of the pelvis, sacrum, or coccyx, diabetes, anaemia, and coagulopathy were at increased risk of VTE. CONCLUSIONS Patients with malignant or benign lesion are at greater risk of VTE if they are age 30 and over, of the African American population, or with tumors of the pelvis/sacrum/coccyx, or any of the following comorbidities: pulmonary disease, paralysis, other neurological disorders, or coagulopathy.
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Affiliation(s)
- Dominick V Congiusta
- Department of Orthopaedics, Rutgers New Jersey Medical School, 140 Bergen Street, ACC D1610, Newark, NJ, 07103, USA.
| | - Kamil M Amer
- Department of Orthopaedics, Rutgers New Jersey Medical School, 140 Bergen Street, ACC D1610, Newark, NJ, 07103, USA
| | - Jennifer Thomson
- Department of Orthopaedics, Rutgers New Jersey Medical School, 140 Bergen Street, ACC D1610, Newark, NJ, 07103, USA
| | - Joseph Ippolito
- Department of Orthopaedics, Rutgers New Jersey Medical School, 140 Bergen Street, ACC D1610, Newark, NJ, 07103, USA
| | - Kathleen S Beebe
- Department of Orthopaedics, Rutgers New Jersey Medical School, 140 Bergen Street, ACC D1610, Newark, NJ, 07103, USA
| | - Joseph Benevenia
- Department of Orthopaedics, Rutgers New Jersey Medical School, 140 Bergen Street, ACC D1610, Newark, NJ, 07103, USA
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