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McGrady ME, Ignjatovic V, Jones S, Bruce A, Goldenberg NA, Rizzi M, Thornburg CD, Todd KE, Luchtman-Jones L. Evaluation, analysis, and reporting of medication adherence for clinical trials of anticoagulants in children: guidance from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis. J Thromb Haemost 2024; 22:2081-2092. [PMID: 38642706 DOI: 10.1016/j.jtha.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/22/2024]
Abstract
In response to growing recognition that nonadherence prevents children, adolescents, and young adults from achieving the therapeutic benefits of anticoagulant medication, the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis convened a working party on medication adherence. The primary aim of this article was to synthesize recommendations from the larger adherence science literature to provide guidance regarding the classification, collection, and interpretation of anticoagulation adherence data. The secondary aim of this article was to evaluate the degree to which trials published from 2013 to 2023 adhered to these guidance recommendations. As less than half of all trials reported on adherence and none included all recommended elements, the proposed International Society on Thrombosis and Haemostasis Scientific and Standardization Committee guidance has the potential to enhance the rigor and reproducibility of pediatric anticoagulant research.
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Affiliation(s)
- Meghan E McGrady
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| | - Vera Ignjatovic
- Haematology, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Sophie Jones
- Haematology, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Nursing, The University of Melbourne, Parkville, Victoria, Australia
| | - Aisha Bruce
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Neil A Goldenberg
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida, USA; Departments of Pediatrics and Medicine, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mattia Rizzi
- Hematology/Oncology Unit, Division of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | - Courtney D Thornburg
- Division of Pediatric Hematology/Oncology, Rady Children's Hospital San Diego, San Diego, California, USA; Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California, USA
| | - Kevin E Todd
- Department of Pediatric Hematology/Oncology, Children's Hospital of the King's Daughters, Norfolk, Virginia, USA
| | - Lori Luchtman-Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Gao H, Chen M, Huang Y, Liu H, Lin Y, Chen M. Efficacy and safety of antithrombotic therapy for preventing and treating pediatric thromboembolic disease: a systematic review. Sci Rep 2024; 14:13378. [PMID: 38862574 PMCID: PMC11166992 DOI: 10.1038/s41598-024-64334-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 06/07/2024] [Indexed: 06/13/2024] Open
Abstract
This review used traditional and network meta-analyses (NMA) to conduct a comprehensive study of antithrombotic therapies in children with thromboembolic disease. We searched the PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov databases from their inception to 26 February, 2023. And we finally included 16 randomized controlled trials. In the prevention of thromboembolic events (TEs), the use of anticoagulants had a low risk of TEs (relative risk (RR) 0.73, 95% CI 0.56 to 0.94) and a high risk of minor bleeding (RR 1.43, 95% CI 1.09 to 1.86) compared with no anticoagulants. In the treatment of TEs, direct oral anticoagulants (DOACs) were not inferior to standard anticoagulation in terms of efficacy and safety outcomes. In NMA, rivaroxaban and apixaban showed the lowest risk for TEs and major or clinically relevant nonmajor bleeding. According to the overall assessment of efficacy and safety, dabigatran may be the best choice for children with thromboembolic disease. The results of our study will provide references and suggestions for clinical drug selection.
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Affiliation(s)
- Hongjin Gao
- Department of Pharmacy, Fujian Provincial Hospital, Fuzhou, 350001, China
| | - Mingyu Chen
- School of Pharmacy, Fujian Medical University, Fuzhou, 350004, China
| | - Youqi Huang
- School of Pharmacy, Fujian Medical University, Fuzhou, 350004, China
| | - Huiting Liu
- School of Pharmacy, Fujian Medical University, Fuzhou, 350004, China
| | - Yuze Lin
- School of Pharmacy, Fujian Medical University, Fuzhou, 350004, China
| | - Min Chen
- Shengli Clinical College of Fujian Medical University, Fujian Provincial Hospital, No.134 Dongjie St., Fuzhou, 350001, China.
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Sochet AA, Jaffray J, Branchford BR, Havlicek EE, Mosha M, Amankwah EK, Ignjatovic V, Faustino EVS, Goldenberg NA. Hospital-Acquired Venous Thromboembolism and Invasive Mechanical Ventilation: A Report From the Children's Hospital Acquired Thrombosis Consortium. Pediatr Crit Care Med 2024; 25:e82-e90. [PMID: 37882641 PMCID: PMC10843146 DOI: 10.1097/pcc.0000000000003383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
OBJECTIVES To determine if the duration of invasive mechanical ventilation (IMV) was associated with hospital-acquired venous thromboembolism (HA-VTE) among critically ill children. DESIGN A multicenter, matched case-control study as a secondary analysis of Children's Hospital Acquired Thrombosis (CHAT) Consortium registry. SETTING PICUs within U.S. CHAT Consortium participating centers. PATIENTS Children younger than 21 years old admitted to a PICU receiving IMV for greater than or equal to 1 day duration from January 2012 to March 2022 were included for study. Cases with HA-VTE were matched 1:2 to controls without HA-VTE by patient age groups: younger than 1, 1-12, and older than 12 years. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was IMV duration in days. Descriptive data included demographics, anthropometrics, HA-VTE characteristics (i.e., type, location, and timing), central venous catheterization data, thromboprophylaxis practices, and Braden Q mobility scores. Descriptive, comparative, and associative (multivariate conditional logistic regression for HA-VTE) statistics were employed. A total of 152 cases were matched to 304 controls. Cases with HA-VTE were diagnosed at a median of 7 days (interquartile range [IQR], 3-16 d) after IMV. The HA-VTE were limb deep venous thromboses in 130 of 152 (85.5%) and frequently central venous catheterization-related (111/152, 73%). Cases with HA-VTE experienced a longer length of stay (median, 34 d [IQR, 18-62 d] vs. 11.5 d [IQR, 6-21 d]; p < 0.001) and IMV duration (median, 7 d [IQR, 4-15 d] vs. 4 d [IQR, 1-7 d]; p < 0.001) as compared with controls. In a multivariate logistic model, greater IMV duration (adjusted odds ratio, 1.09; 95% CI, 1.01-1.17; p = 0.023) was independently associated with HA-VTE. CONCLUSIONS Among critically ill children undergoing IMV, HA-VTE was associated with greater IMV duration. If prospectively validated, IMV duration should be included as part of prothrombotic risk stratification and future pediatric thromboprophylaxis trials.
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Affiliation(s)
- Anthony A. Sochet
- Department of Medicine, Divisions of Critical Care Medicine , Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Julie Jaffray
- Department of Pediatrics, Division of Hematology/Oncology, Rady Children’s Hospital, San Diego, CA
| | - Brian R. Branchford
- Division of Hematology, Oncology, and Bone Marrow Transplant, Medical College of Wisconsin, Milwaukee, WI and Versiti Medical Sciences Institute, Milwaukee, WI
| | - Elizabeth E. Havlicek
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Maua Mosha
- Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Ernest K. Amankwah
- Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Vera Ignjatovic
- Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Neil A. Goldenberg
- Cancer and Blood Disorders Institute, Division of Hematology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Quinn T, Cholette JM, Pinto MG, Schreiber H, Madden MA, Bennett E, Kolmar A, Poole A, Silva CT, Ehrlich L, Navarro OM, Faustino EVS. Antithrombin activity and central venous catheter-associated thrombosis in critically ill children at high risk of bleeding. J Thromb Haemost 2024; 22:213-224. [PMID: 37797693 DOI: 10.1016/j.jtha.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/21/2023] [Accepted: 09/21/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Normalization of antithrombin activity may prevent catheter-associated thrombosis in critically ill children at high risk of bleeding. OBJECTIVES To characterize the temporal pattern of antithrombin activity, assess its association with catheter-associated thrombosis and clinically relevant bleeding, and evaluate its relationship with thrombin generation in these children. METHODS In this prospective cohort study, critically ill children <18 years old at high risk of bleeding with central venous catheter were eligible. Antithrombin activity and thrombin generation were measured from platelet-poor plasma and after in vitro antithrombin supplementation. Systematic surveillance ultrasound was performed to diagnose thrombosis. Children were followed for bleeding. RESULTS We enrolled 8 infants (median age: 0.2 years, IQR: 0.2, 0.3 years) and 72 older children (median age: 14.3 years, IQR: 9.1, 16.1 years). Mean antithrombin on the day of catheter insertion was 64 IU/dL (SD: 32 IU/dL) in infants and 83 IU/dL (SD: 35 IU/dL) in older children. Antithrombin normalized by the day of catheter removal. Thrombosis developed in 27 children, while 31 children bled. Thrombosis (regression coefficient: 0.008, 95% CI: -0.01, 0.03) and bleeding (regression coefficient: -0.0007, 95% CI: -0.02, 0.02) were not associated with antithrombin. Antithrombin was not correlated with in vivo change in endogenous thrombin potential (correlation coefficient: -0.07, 95% CI: -0.21, 0.08). In vitro supplementation reduced endogenous thrombin potential (correlation coefficient: -0.78; 95% CI: -0.95, -0.23). CONCLUSION These findings may not support normalization of antithrombin activity to prevent catheter-associated thrombosis in critically ill children at high risk of bleeding.
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Affiliation(s)
- Tyler Quinn
- Pediatric Intensive Care Unit, Yale-New Haven Children's Hospital, New Haven, Connecticut, USA
| | - Jill M Cholette
- Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, New York, USA
| | - Matthew G Pinto
- Department of Pediatrics, New York Medical College, Maria Fareri Children's Hospital, Valhalla, New York, USA
| | - Hilary Schreiber
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Maureen A Madden
- Department of Pediatrics, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Erin Bennett
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Amanda Kolmar
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri, USA
| | - Alan Poole
- Division of Critical Care, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Cicero T Silva
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lauren Ehrlich
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Oscar M Navarro
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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Labuz DF, Tobias J, Selesner L, Han X, Cunningham A, Marenco CW, Escobar MA, Hazeltine MD, Cleary MA, Kotagal M, Falcone RA, Vogel AM, MacArthur T, Klinkner DB, Shah A, Chernoguz A, Orioles A, Zagel A, Gosain A, Knaus M, Hamilton NA, Jafri MA. Impact of institutional prophylaxis guidelines on rates of pediatric venous thromboembolism following trauma-A multicenter study from the pediatric trauma society research committee. J Trauma Acute Care Surg 2023; 95:341-346. [PMID: 36872513 DOI: 10.1097/ta.0000000000003918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND A paucity of data exists with regard to the incidence, management, and outcomes of venous thromboembolism (VTE) in injured children. We sought to determine the impact of institutional chemoprophylaxis guidelines on VTE rates in a pediatric trauma population. METHODS A retrospective review of injured children (≤15 years) admitted between 2009 and 2018 at 10 pediatric trauma centers was performed. Data were gathered from institutional trauma registries and dedicated chart review. The institutions were surveyed as to whether they had chemoprophylaxis guidelines in place for high-risk pediatric trauma patients, and outcomes were compared based on the presence of guidelines using χ 2 analysis ( p < 0.05). RESULTS There were 45,202 patients evaluated during the study period. Three institutions (28,359 patients, 63%) had established chemoprophylaxis policies during the study period ("Guidelines"); the other seven centers (16,843 patients, 37%) had no such guidelines ("Standard"). There were significantly lower rates of VTE in the Guidelines group, but these patients also had significantly fewer risk factors. Among critically injured children with similar clinical presentations, there was no difference in VTE rate. Specifically within the Guidelines group, 30 children developed VTE. The majority (17/30) were actually not indicated for chemoprophylaxis based on institutional guidelines. Still, despite protocols only one VTE patient in the guidelines group who was indicated for intervention ended up receiving chemoprophylaxis prior to diagnosis. No consistent ultrasound screening protocol was in place at any institution during the study. CONCLUSION The presence of an institutional policy to guide chemoprophylaxis for injured children is associated with a decreased overall frequency of VTE, but this disappears when controlling for patient factors. However, the overall efficacy is impacted by a combination of deficits in guideline compliance and structure. Further prospective data are needed to help determine the ideal role for chemoprophylaxis and protocols in pediatric trauma. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Daniel F Labuz
- From the Division of Pediatric Surgery, Department of Surgery (D.F.L., J.T., L.S., X.Y.H., A.C., N.A.H., M.A.J.), Oregon Health & Science University, Portland, Oregon; Department of Surgery (C.W.M.), Madigan Army Medical Center, Tacoma, Washington; Department of Pediatric Surgery (M.A.E.Jr.), 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.Jr.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Pediatric Surgery (A.M.V.), Texas Children's Hospital, Houston, Texas; Division of Pediatric Surgery, Department of Surgery (T.M.A., 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
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Gilholm P, Ergetu E, Gelbart B, Raman S, Festa M, Schlapbach LJ, Long D, Gibbons KS. Adaptive Clinical Trials in Pediatric Critical Care: A Systematic Review. Pediatr Crit Care Med 2023; 24:738-749. [PMID: 37195182 DOI: 10.1097/pcc.0000000000003273] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
OBJECTIVES This systematic review investigates the use of adaptive designs in randomized controlled trials (RCTs) in pediatric critical care. DATA SOURCES PICU RCTs, published between 1986 and 2020, stored in the www.PICUtrials.net database and MEDLINE, EMBASE, CENTRAL, and LILACS databases were searched (March 9, 2022) to identify RCTs published in 2021. PICU RCTs using adaptive designs were identified through an automated full-text screening algorithm. STUDY SELECTION All RCTs involving children (< 18 yr old) cared for in a PICU were included. There were no restrictions to disease cohort, intervention, or outcome. Interim monitoring by a Data and Safety Monitoring Board that was not prespecified to change the trial design or implementation of the study was not considered adaptive. DATA EXTRACTION We extracted the type of adaptive design, the justification for the design, and the stopping rule used. Characteristics of the trial were also extracted, and the results summarized through narrative synthesis. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2. DATA SYNTHESIS Sixteen of 528 PICU RCTs (3%) used adaptive designs with two types of adaptations used; group sequential design and sample size reestimation. Of the 11 trials that used a group sequential adaptive design, seven stopped early due to futility and one stopped early due to efficacy. Of the seven trials that performed a sample size reestimation, the estimated sample size decreased in three trials and increased in one trial. CONCLUSIONS Little evidence of the use of adaptive designs was found, with only 3% of PICU RCTs incorporating an adaptive design and only two types of adaptations used. Identifying the barriers to adoption of more complex adaptive trial designs is needed.
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Affiliation(s)
- Patricia Gilholm
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Endrias Ergetu
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital Melbourne, Parkville, VIC, Australia
| | - Sainath Raman
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Marino Festa
- Kids Critical Care Research, Paediatric Intensive Care Unit, Children's Hospital at Westmead, Westmead, NSW, Australia
- Sydney Children's Hospital Network, Sydney, NSW, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Debbie Long
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kristen S Gibbons
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Whitworth H, Amankwah EK, Betensky M, Castellucci LA, Cuker A, Goldenberg NA, Male C, Rinzler E, Zia A, Raffini L. Updated guidance for efficacy and safety outcomes for clinical trials in venous thromboembolism in children: communication from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis. J Thromb Haemost 2023; 21:1666-1673. [PMID: 36921919 PMCID: PMC10472337 DOI: 10.1016/j.jtha.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/15/2023] [Accepted: 03/02/2023] [Indexed: 03/15/2023]
Abstract
Despite the growing number of pediatric antithrombotic clinical trials, standardized safety and efficacy outcome definitions for pediatric venous thromboembolism (VTE) clinical trials have not been updated since 2011. Many recent trials have adapted the recommended definitions, leading to heterogeneity in outcomes and limiting our ability to compare studies. The International Society on Thrombosis and Haemostasis Scientific and Standardization Subcommittee (SSC) on Pediatric and Neonatal Thrombosis and Hemostasis organized a Task Force to update the efficacy and safety outcome definitions for pediatric VTE clinical trials. The outcome definitions used in the recent pediatric antithrombotic trials, definitions recommended for adult studies, and regulatory guidelines were summarized and reviewed by the Task Force as the basis for this updated guidance. Major updates to the efficacy outcomes include the removal of VTE-related mortality as a part of a composite primary outcome and explicit inclusion of all deep venous anatomic sites. Safety outcomes were updated to include a new bleeding severity category: patient important bleeding, no intervention, which encompasses bleeding for which a patient seeks care but there is no change in management. Menstrual bleeding can now be included in any bleeding category when the criteria are met. We hope that these updated outcome definitions will allow the investigators to focus on clinically relevant and patient-important outcomes and provide standardization to facilitate continued high-quality evidence for the use of antithrombotic therapies in children.
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Affiliation(s)
- Hilary Whitworth
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Ernest K Amankwah
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA; Division of Quantitative Science, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marisol Betensky
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA; Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA; Departments of Pediatrics and Medicine, Divisions of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Elliot Rinzler
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ayesha Zia
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Leslie Raffini
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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8
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Randolph AG, Bembea MM, Cheifetz IM, Curley MAQ, Flori HR, Khemani RG, Kudchadkar SR, Nishisaki A, Watson RS, Tucci M, Lacroix J, Thompson AE, Thomas NJ. Pediatric Acute Lung Injury and Sepsis Investigators (PALISI): Evolution of an Investigator-Initiated Research Network. Pediatr Crit Care Med 2022; 23:1056-1066. [PMID: 36454002 PMCID: PMC9747245 DOI: 10.1097/pcc.0000000000003100] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network originated over 20 years ago to foster research to optimize the care of critically ill infants and children. Over this period, PALISI has seen two major evolutions: formalization of our network infrastructure and a broadening of our clinical research focus. First, the network is unique in that its activities and meetings are funded by subscriptions from members who now comprise a multidisciplinary group of investigators from over 90 PICUs all over the United States (US) and Canada, with collaborations across the globe. In 2020, the network converted into a standalone, nonprofit organizational structure (501c3), making the PALISI Network formally independent of academic and clinical institutions or professional societies. Such an approach allows us to invest in infrastructure and future initiatives with broader opportunities for fund raising. Second, our research investigations have expanded beyond the original focus on sepsis and acute lung injury, to incorporate the whole field of pediatric critical care, for example, efficient liberation from mechanical ventilator support, prudent use of blood products, improved safety of intubation practices, optimal sedation practices and glucose control, and pandemic research on influenza and COVID-19. Our network approach in each field follows, where necessary, the full spectrum of clinical and translational research, including: immunobiology studies for understanding basic pathologic mechanisms; surveys to explore contemporary clinical practice; consensus conferences to establish agreement about literature evidence; observational prevalence and incidence studies to measure scale of a clinical issue or question; case control studies as preliminary best evidence for design of definitive prospective studies; and, randomized controlled trials for informing clinical care. As a research network, PALISI and its related subgroups have published over 350 peer-reviewed publications from 2002 through September 2022.
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Affiliation(s)
- Adrienne G Randolph
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, MA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ira M Cheifetz
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Heidi R Flori
- Division of Critical Care Medicine, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Robinder G Khemani
- Division of Critical Care Medicine, Department of Anesthesia, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Akira Nishisaki
- Division of Critical Care Medicine, Department of Anesthesia, Children's Hospital of Philadelphia, Philadelphia, PA
| | - R Scott Watson
- Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Marisa Tucci
- Division of Critical Care Medicine, CHU Sainte-Justine, Montreal, QC, Canada
| | - Jacques Lacroix
- Division of Critical Care Medicine, CHU Sainte-Justine, Montreal, QC, Canada
| | - Ann E Thompson
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Neal J Thomas
- Division of Critical Care Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA
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Prophylactic Enoxaparin Against Catheter-Associated Thrombosis in Postoperative Cardiac Children: An Interrupted Time Series Analysis. Pediatr Crit Care Med 2022; 23:774-783. [PMID: 35699766 DOI: 10.1097/pcc.0000000000003010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The effectiveness of pharmacologic prophylaxis against catheter-associated thrombosis in children is unclear. We evaluated the compliance and outcomes associated with a prophylactic enoxaparin protocol in postoperative cardiac children. DESIGN The protocol was implemented as a quality improvement initiative and then analyzed using interrupted time series method. Data collected from November 2014 to December 2018 were divided into preprotocol (period 1), protocol implementation (period 2), and protocol revision (period 3). SETTING A 12-bed academic pediatric cardiac ICU. PATIENTS Children less than or equal to 18 years old with congenital heart disease admitted postoperatively with central venous catheter in situ for greater than or equal to 1 day. INTERVENTIONS Before 2016, prophylactic enoxaparin was administered according to physician preference. In January 2016, an enoxaparin protocol was implemented with a goal anti-Xa range of 0.25-0.49 international units/mL. Protocol was revised in February 2017 to increase the starting dose by 25% for infants less than 1 year old. MEASUREMENTS AND MAIN RESULTS We analyzed 780 hospitalizations from 636 children. Median percentage of catheter-days on prophylactic enoxaparin was 33% (interquartile range [IQR], 23-47%), 42% (IQR, 30-51%), and 38% (IQR, 35-52%) in periods 1-3, respectively. Percentage of catheter-days on enoxaparin showed immediate increase of 90% (95% CI, 17-210%) between periods 1 and 2 and sustained increase of 2% (95% CI, 0.3-4%) between periods 2 and 3. Median rates of thrombosis per 1,000 catheter-days were 5.8 (IQR, 0-9.3), 3.8 (IQR, 0-12), and 0 (IQR, 0-5.3) in periods 1-3, respectively. Rate of thrombosis showed immediate decrease of 67% (95% CI, 12-87%) between periods 1 and 2 and sustained decrease of 11% (95% CI, 2-18%) between periods 1 and 3. CONCLUSIONS The temporal association between increase in percentage of catheter-days on enoxaparin and decrease in rate of thrombosis suggests the effectiveness of prophylactic enoxaparin.
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Huibonhoa RMT, Pinto MG, Faustino EVS. Accuracy of physical examination in detecting central venous catheter-associated thrombosis in critically ill children. Thromb Res 2022; 218:192-198. [DOI: 10.1016/j.thromres.2022.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/11/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
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11
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Enoxaparin to Prevent Catheter-Associated Thrombosis: Effective, But Is This a Tool We Need? Pediatr Crit Care Med 2022; 23:845-847. [PMID: 36190361 DOI: 10.1097/pcc.0000000000003033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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12
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Central venous catheter-associated deep vein thrombosis in critically ill pediatric patients: risk factors, prevention, and treatment. Curr Opin Pediatr 2022; 34:273-278. [PMID: 35634701 DOI: 10.1097/mop.0000000000001128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Central venous catheter (CVC) placement and ICU admission are the two most important risk factors for pediatric deep vein thrombosis. The optimal prevention and treatment strategies for CVC-associated deep vein thrombosis (CADVT) are unclear, but recently, seminal studies have been published. This review aims to summarize the recent literature on CADVT in critically ill children. RECENT FINDINGS Recent publications focused on three themes: risk factors, prevention, and treatment of CADVT. Newly identified risk factors for CADVT relate to Virchow's triad of hemostasis, blood vessel injury, and hypercoagulability. New risk prediction models have moderately good accuracy in predicting CADVT. Though previous data on pharmacologic CADVT prophylaxis was equivocal, recent studies indicate that low-molecular-weight heparin may be effective in preventing CADVT, particularly in critically ill children. Finally, new studies suggest that direct oral anticoagulants and shorter treatment times are noninferior to traditional agents and treatment durations in the treatment of CADVT. SUMMARY Recent research suggests new ways to accurately identify children at high risk of CADVT, effectively prevent CADVT, and optimize CADVT treatment. Future research should focus on understanding the pathobiology of CADVT formation, prevention, and treatment in critically ill children.
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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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Bennett E, Delgado-Corcoran C, Pannucci CJ, Wilcox R, Heyrend C, Faustino EV. Outcomes of Prophylactic Enoxaparin Against Venous Thromboembolism in Hospitalized Children. Hosp Pediatr 2022; 12:617-625. [PMID: 35531629 DOI: 10.1542/hpeds.2021-006386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess the biochemical and clinical outcomes of hospitalized children who received prophylactic enoxaparin. METHODS We conducted a retrospective observational study of hospitalized children aged <18 years who received prophylactic enoxaparin against hospital-acquired venous thromboembolism (HA-VTE). Weight-based enoxaparin dosing was administered using a pharmacy-driven protocol, which later included a low molecular weight, anti-Xa level directed-dose adjustment strategy. Primary biochemical and clinical outcomes were achievement of goal anti-Xa range of 0.2 to 0.5 IU/mL and development of HA-VTE, respectively. Secondary clinical outcome was development of clinically relevant bleed. RESULTS We analyzed 194 children with 13 (6.7%) infants aged <1 year and 181 (93.3%) older children aged ≥1 year. After the initial dose, only 1 (11.1%) infant, but 62 (57.9%) older children, achieved goal. Median number of anti-Xa levels until goal was 2 (interquartile range: 2-3) in infants and 1 (interquartile range: 1-2) in older children (P = .01). HA-VTE developed in 2 (15.4%) infants and 9 (5.0%) older children. Among children with anti-Xa level, HA-VTE developed less frequently in children who achieved (2.1%) than in those who did not achieve (13.6%) goal (P = .046). A total of 4 (2.1%) older children and no infants developed clinically relevant bleed. Among children with anti-Xa level, frequency of bleeding was comparable between children who did (3.2%) and did not achieve (0%) goal (P >.99). CONCLUSIONS Our findings suggest the effectiveness and safety of an anti-Xa level directed strategy of prophylactic enoxaparin. However, this strategy should be investigated in prospective controlled studies.
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Affiliation(s)
- Erin Bennett
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Claudia Delgado-Corcoran
- Section of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah.,Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | | | - Roger Wilcox
- Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Caroline Heyrend
- Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Edward Vincent Faustino
- Section of Critical Care, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
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15
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O'Brien SH, Stanek JR, Witmer CM, Raffini L. The Continued Rise of Venous Thromboembolism Across US Children's Hospitals. Pediatrics 2022; 149:184770. [PMID: 35156127 DOI: 10.1542/peds.2021-054649] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES In 2009, a large multicenter study demonstrated that the rate of pediatric venous thromboembolism (VTE) across US children's hospitals had significantly increased from 2001 to 2007. The objective of this study was to evaluate the rate of pediatric VTE from 2008 to 2019 using similar methodology. METHODS A retrospective cohort study using the Pediatric Health Information System (PHIS) database. Subjects from birth to <18 years admitted from 2008 through 2019 who had an ICD-9-CM or ICD-10-CM code for VTE were included. Demographics, underling medical comorbidities and mortality were collected. VTE location and anticoagulation data during admission were extracted. RESULTS During the 12-year study period, there were 52 401 hospital admissions among 39 713 pediatric patients with a diagnosis of VTE. The VTE admission rate increased from 46 VTE cases per 10 000 admissions in 2008 to 106 VTE cases per 10 000 admissions in 2019, a 130% increase (P < .0001) in VTE events. The median age at admission was 6.1 years, and almost one-third (31.3%) of patients with VTE were in the adolescent age group (13-17 years). Most patients (78%) had an underlying chronic medical condition. CONCLUSIONS The rate of VTE in hospitalized pediatric patients continues to increase from a 70% increase reported from 2001 to 2007 to the 130% increase from 2008 to 2019. These findings support the need for more effective VTE prevention strategies. Clinical trials focused on risk stratification and VTE prevention are needed.
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Affiliation(s)
- Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio.,Center for Health Equity and Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph R Stanek
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio.,Biostatistics Resource at Nationwide Children's Hospital, Columbus, Ohio
| | - Char M Witmer
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Leslie Raffini
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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16
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Baby steps in managing CVAD-related thrombosis. Blood 2022; 139:321-322. [PMID: 35050336 DOI: 10.1182/blood.2021014615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/09/2021] [Indexed: 11/20/2022] Open
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17
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Clark HH, Ballester L, Whitworth H, Raffini L, Witmer C. Prevention of recurrent thrombotic events in children with central venous catheter-associated venous thrombosis. Blood 2022; 139:452-460. [PMID: 34727184 PMCID: PMC8777201 DOI: 10.1182/blood.2021013453] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/22/2021] [Indexed: 01/22/2023] Open
Abstract
Central venous catheters (CVC) are the most significant risk factor for pediatric venous thromboembolism (VTE). After an index CVC-associated VTE (CVC-VTE), the role of secondary prophylaxis for subsequent CVC placement is uncertain. Aims of this single-center retrospective study were to evaluate the efficacy of secondary prophylaxis for patients with a prior CVC-VTE and identify risk factors associated with recurrent VTE in patients less than 19 years with an index CVC-VTE between 2003 and 2013. Data collection included clinical and demographic factors, subsequent CVC placement, secondary prophylaxis strategy, recurrent VTE, and bleeding. Risk factors for recurrence and effectiveness of secondary prophylaxis were evaluated using survival and binomial models. Among 373 patients with an index CVC-VTE, 239 (64.1%) had subsequent CVC placement; 17.4% (65/373) of patients had recurrent VTE, of which 90.8% (59/65) were CVC-associated. On multivariable survival analysis, each additional CVC (hazards ratio [HR] 12.00; 95% confidence interval [CI] 2.78-51.91), congenital heart disease (HR 3.70; 95% CI 1.97-6.95), and total parenteral nutrition dependence (HR 4.02; 95% CI 2.23-7.28) were associated with an increased hazard of recurrence. Full dose anticoagulation for secondary prophylaxis was associated with decreased odds of recurrent CVC-VTE (odds ratio [OR] 0.35; 95% CI 0.19-0.65) but not prophylactic dosing (OR 0.61; 95% CI 0.28-1.30). Only 1.3% of CVCs experienced major bleeding with prophylactic or full-dose anticoagulation. In summary, children with CVC-VTE are at increased risk for recurrent VTE. Secondary prophylaxis with full-dose anticoagulation was associated with a 65% reduction in odds of thrombotic events.
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Affiliation(s)
| | | | | | | | - Char Witmer
- Children's Hospital of Philadelphia, Philadelphia, PA
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19
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Östlund ÅKM, Fläring U, Larsson P, Kaiser S, Vermin L, Frisk T, Dahlberg A, Berner J, Norberg Å, Andersson A. Incidence of venous thromboembolic events not related to vascular catheters in a prospective cohort of critically ill children. Eur J Pediatr 2022; 181:3031-3038. [PMID: 35652985 PMCID: PMC9352609 DOI: 10.1007/s00431-022-04487-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/20/2022] [Accepted: 04/23/2022] [Indexed: 12/29/2022]
Abstract
UNLABELLED The risk for venous thromboembolism (VTE) is considered to be low in the general paediatric intensive care unit (PICU) population, and pharmacological thromboprophylaxis is not routinely used. PICU patients considered at high-risk of VTE could possibly benefit from pharmacological thromboprophylaxis, but the incidence of VTE in this group of patients is unclear. This was an observational, prospective study at a tertiary multi-disciplinary paediatric hospital. We used comprehensive ultrasonography screening for VTE in critically ill children with multiple risk factors for VTE. Patients admitted to PICU ≥ 72 h and with ≥ two risk factors for VTE were included. Patients receiving pharmacological thromboprophylaxis during their entire PICU stay were excluded. The primary outcome of the study was VTEs not related to the use of a CVC. Ultrasonography screening of the great veins was performed at PICU discharge. Seventy patients with median (interquartile range) 3 (2-4) risk factors for VTE were evaluated. Median age was 0.3 years (0.03-4.3) and median PICU length of stay 9 days (5-17). Regarding the primary outcome, no symptomatic VTEs occurred and no asymptomatic VTEs were found on ultrasonography screening, resulting in an incidence of VTEs not related to a vascular catheter of 0% (95% CI: 0-5.1%). CONCLUSION Our results indicate that VTEs not related to a vascular catheter are a rare event even in a selected group of severely ill small children considered to be at high risk of VTE. WHAT IS KNOWN • Children in the PICU often have several risk factors for venous thromboembolism (VTE). • The incidence of VTE in PICU patients is highly uncertain, and there are no evidence-based guidelines regarding VTE prophylaxis. WHAT IS NEW • This study found an incidence of VTEs not related to a vascular catheter of 0% (95% CI: 0-5.1%). • This indicates that such VTE events are rare even in PICU patients with multiple risk factors for VTE.
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Affiliation(s)
- Åsa K M Östlund
- Department of Paediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
| | - Urban Fläring
- Department of Paediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Larsson
- Department of Paediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Sylvie Kaiser
- Department of Paediatric Radiology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Lena Vermin
- Department of Paediatric Radiology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Tony Frisk
- Department of Children's Health, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Ann Dahlberg
- Department of Paediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Berner
- Department of Paediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Åke Norberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Andersson
- Department of Paediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Gupta A, Chegondi M, Billa RD, Bloxham J, Badheka A, Faustino IV, Faustino EVS. Validation of risk assessment models for venous thromboembolism and bleeding in critically ill adolescents. Thromb Res 2021; 208:106-111. [PMID: 34743033 DOI: 10.1016/j.thromres.2021.10.024] [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: 07/27/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine the performance of risk assessment models that were developed for adults, in predicting venous thromboembolism (VTE) and bleeding in critically ill adolescents. STUDY DESIGN We conducted a retrospective cohort study of adolescents 12 to 17 years old admitted to the pediatric intensive care unit who received cardiopulmonary support but did not have VTE on admission nor received anticoagulation. Discrimination, using areas under the receiver operating characteristic (AUROC) and precision-recall (AUPRC) curves, and calibration, using Hosmer-Lemeshow test, of the Geneva, Padua, IMPROVE VTE and IMPROVE Bleed models were calculated. RESULTS Of 536 adolescents analyzed, 7 (1.3%) developed VTE and 13 (2.4%) bled. AUROCs of the Geneva, Padua and IMPROVE VTE models ranged from 0.46 to 0.59, with 95% confidence intervals (CI) including 0.5. AUPRCs ranged from 0.011 to 0.017, with 95% CIs including 0.013. Only IMPROVE VTE model had non-statistically significant Hosmer-Lemeshow test. IMPROVE Bleed model had AUROC and AUPRC of 0.75 and 0.062, with 95% CIs excluding 0.5 and 0.024, respectively. Hosmer-Lemeshow test was not statistically significant. CONCLUSION Despite similarities in coagulation between adolescents and adults, risk assessment models for VTE in adults should not be used for critically ill adolescents. The model for bleeding may be useful.
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Affiliation(s)
- Anjali Gupta
- Pediatric Intensive Care Unit, Yale-New Haven Children's Hospital, New Haven, CT, USA
| | - Madhuradhar Chegondi
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Ramya Deepthi Billa
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Jodi Bloxham
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Aditya Badheka
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Isaac V Faustino
- Department of Statistics, University of Connecticut, Storrs, CT, USA
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Catheter-Associated Deep Venous Thrombosis Prevention: Which Path to Choose? Crit Care Med 2021; 49:537-540. [PMID: 33616355 DOI: 10.1097/ccm.0000000000004833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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