The incidence of catheter-associated venous thrombosis in noncritically ill children

Risk factors and incidence of central venous access device-related thrombosis in hospitalized children: a systematic review and meta-analysis

BACKGROUND

The risk factors for central venous access device-related thrombosis (CRT) in children are not fully understood. We used evidence-based medicine to find the risk factors for CRT by pooling current studies reporting risk factors of CRT, aiming to guide clinical diagnosis and treatment.

METHODS

A systematic search of PubMed, Web of Science, Embase, Cochrane Library, Scopus, CNKI, Sinomed, and Wanfang databases was conducted. RevMan 5.4 was employed for data analysis.

RESULTS

The review included 47 studies evaluating 262,587 children with CVAD placement. Qualitative synthesis and quantitative meta-analysis identified D-dimer, location of insertion, type of catheter, number of lumens, catheter indwelling time, and central line-associated bloodstream infection as the most critical risk factors for CRT. Primarily due to observational design, the quality of evidence was regarded as low certainty for these risk factors according to the GRADE approach.

CONCLUSION

Because fewer high-quality studies are available, larger sample sizes and well-designed prospective studies are still needed to clarify the risk factors affecting CRT. In the future, developing pediatric-specific CRT risk assessment tools is important. Appropriate stratified preventive strategies for CRT according to risk assessment level will help improve clinical efficiency, avoid the occurrence of CRT, and alleviate unnecessary suffering of children.

IMPACT

This is the latest systematic review of risk factors and incidence of CRT in children. A total of 47 studies involving 262,587 patients were included in our meta-analysis, according to which the pooled prevalence of CRT was 9.1%. This study identified several of the most critical risk factors affecting CRT in children, including D-dimer, insertion location, type of catheter, number of lumens, catheter indwelling time, and central line-associated bloodstream infection (CLABSI).

Device Related Thrombosis and Bleeding in Pediatric Health Care: A Meta-analysis

CONTEXT

The risk of invasive device-related thrombosis and bleeding contributes to morbidity and mortality, yet their prevalence by device-types is poorly understood.

OBJECTIVES

This study aimed to estimate pooled proportions and rates of thrombotic and bleeding complications associated with invasive devices in pediatric health care.

DATA SOURCES

Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.

STUDY SELECTION

Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) reporting thrombotic and bleeding complications, and (4) published in English, were included.

DATA EXTRACTION

Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used.

MAIN OUTCOMES AND MEASURES

Device-specific pooled thromboses (symptomatic, asymptomatic, unspecified) and bleeding (major, minor).

RESULTS

Of the 107 studies, 71 (66%) focused on central venous access devices. Symptomatic venous thromboembolism in central venous access devices was 4% (95% confidence interval [CI], 3-5; incidence rate 0.03 per 1000 device-days, 95% CI, 0.00-0.07), whereas asymptomatic was 10% (95% CI, 7-13; incidence rate 0.25 per 1000 device-days, 95% CI, 0.14-0.36). Both ventricular assist devices (28%; 95% CI, 19-39) and extracorporeal membrane oxygenation (67%; 95% CI, 52-81) were often associated with major bleeding complications.

CONCLUSIONS

This comprehensive estimate of the incidence and prevalence of device-related thrombosis and bleeding complications in children can inform clinical decision-making, guide risk assessment, and surveillance.

Gut dysbiosis-related thrombosis in inflammatory bowel disease: Potential disease mechanisms and emerging therapeutic strategies

Patients with inflammatory bowel disease (IBD) have an increased risk of developing venous thromboembolic events, which have a considerable impact on morbidity and mortality. Chronic inflammation plays a crucial role in the pathogenesis of thrombotic events in patients with IBD. However, many unresolved questions remain, particularly regarding the mechanisms that determine the persistent inflammatory state independent of disease activity. This review explored the role of gut microbiota dysbiosis and intestinal barrier dysfunction, which are considered distinctive features of IBD, in determining pro-thrombotic tendencies. Gut-derived endotoxemia due to the translocation of bacterial lipopolysaccharides (LPS) from the intestine to the bloodstream and the bacterial metabolite trimethylamine-N-oxide (TMAO) are the most important molecules involved in gut dysbiosis-related thrombosis. The pathogenic prothrombotic pathways linked to LPS and TMAO have been discussed. Finally, we present emerging therapeutic approaches that can help reduce LPS-mediated endotoxemia and TMAO, such as restoring intestinal eubiosis, normalizing intestinal barrier function, and counterbalancing the effects of LPS and TMAO.

Venous thromboembolism characteristics, treatment and outcomes in young adults: findings from the Registro Informatizado de Enfermedad TromboEmbólica registry

BACKGROUND

Venous thromboembolism (VTE) is rare in patients aged <21 years. Young adults aged 18 to 21 years are frequently included in adult VTE studies, whereas pediatric VTE studies include patients aged up to either 18 or 21 years. The clinical characteristics of young adult patients with VTE have not been well defined.

OBJECTIVES

We aimed to highlight any unique characteristics or treatment considerations that may apply to young adult patients with VTE.

METHODS

Data from the prospective, international Registro Informatizado de Enfermedad TromboEmbólica registry were used. Patients were stratified into subcohorts according to age. The clinical characteristics, risk factors, management, and outcomes of young adult patients with VTE were compared with those of adolescents aged 12 to 18 years and adults aged >21 years.

RESULTS

Of 104 253 Registro Informatizado de Enfermedad TromboEmbólica patients enrolled until August 2022, 234 were adolescents and 884 were young adults. Less cases of pulmonary embolism were reported in adolescents (P < .001). Estrogen use was a common risk factor, more prevalent in adolescents and young adults (P < .001), whereas active cancer and immobilization were uncommon in both. Most patients were initially treated with low-molecular-weight heparin. VTE recurrence, major bleeding, and all-cause mortality rates were comparably low among adolescents and young adults. None of the patients aged <21 years died from VTE recurrence.

CONCLUSION

Young adults have some distinctive VTE risk factors. While VTE presentation may be similar among young adults and older patients, the outcomes of patients aged <21 years are more favorable.

Evaluation of venous thromboembolism risk factors reveals subtype heterogenicity in children with central venous catheters: a multicenter study from the Children's Hospital Acquired Thrombosis consortium

BACKGROUND

Acutely ill and medically complex children frequently rely on central venous catheters (CVCs) to provide life-sustaining treatment. Unfortunately, catheter-related thrombosis (CRT) is a serious and common complication. Little is known why some with a CVC develop CRT and others develop venous thromboembolism unrelated to the CVC (non-CRT).

OBJECTIVES

The aim of this study was to identify factors associated with CRT in children with hospital-acquired venous thromboembolism (HA-VTE).

METHODS

This case-case study included participants in the Children's Hospital Acquired Thrombosis Registry with HA-VTE and CVC aged 0 to 21 years from 8 US children's hospitals. Participants were excluded if they developed HA-VTE prior to CVC insertion or if the CVC insertion date was unknown. Logistic regression models were used to assess associations between clinical factors and CRT status.

RESULTS

There were 1144 participants with HA-VTE who had a CVC. CRT developed in 833 participants, and 311 developed non-CRT. Multivariable analysis showed increased odds of CRT (compared with non-CRT) in participants with peripherally inserted central catheters (odds ratio [OR], 3.80; 95% CI, 2.04-7.10; p < .001), CVCs inserted in the femoral vein (OR, 4.45; 95% CI, 1.70-11.65; p = .002), multiple CVCs (OR, 1.42; 95% CI, 1.18-1.71; p < .001), and CVC malfunction (OR, 3.30; 95% CI, 1.80-6.03; p < .001).

CONCLUSION

The findings of this study provide new insights on risk factor differences between CRT and non-CRT. Prevention efforts should be directed at modifying the type of CVC, insertion location, and/or number of CVCs placed, if possible, to decrease the incidence of CRT.

Knowledge, attitude, and practice of pediatric nurses in prevention of central venous access device-related thrombosis in hospitalized children: a nationwide cross-sectional survey

Central venous access device-related thrombosis (CRT) is a common complication in hospitalized children. The pediatric nurses' knowledge, attitude, and practice are of great significance for CRT prevention in hospitalized children. The purpose of this study was to elaborate on the level and influencing factors of pediatric nurses' knowledge, attitude, and practice on the prevention related to CRT in hospitalized children. This national cross-sectional study was carried out in China from January 16, 2021, to April 23, 2021. A multi-stage sampling method was adopted, and 1060 pediatric nurses from 21 hospitals participated in this study. The current situation and influencing factors of pediatric nurses' knowledge, attitude, and practice were investigated by descriptive statistics, approximate t test or independent-sample t test, nonparametric Kruskal-Wallis H test, one-way analysis of variance, and multiple linear regression analysis. The relationship among pediatric nurses' knowledge, attitude, and practice was explored by the Pearson correlation analysis. Among all pediatric nurses involved in this study, 25% had insufficient knowledge, 18% had negative attitudes, and 24% had poor behaviors. The main influencing factors on the knowledge, attitude, and practice included the highest education level of pediatric nurses (β = 0.10, P = .001), whether received training related to CRT prevention (β = 0.09-0.14, P < .01), whether CRT-related knowledge was enough for dealing with clinical work (β = 0.18-0.21, P < .001), and the importance of hospitals/departments on children CRT prevention (β = 0.16-0.24, P < .001). There was a positive correlation between knowledge, attitude, and practice (r = 0.24-0.77, P < .01).    Conclusion: Pediatric nurses' CRT-prevention knowledge and practice are unsatisfactory, while their preventive attitude toward CRT prevention is optimistic. This study assists the formulation of comprehensive intervention strategies for pediatric nurses in preventing CRT in hospitalized children by hospital-related organizations and nursing managers, so as to improve the participation of pediatric nurses in CRT prevention and reduce the occurrence of CRT for hospitalized children. What is Known: • As a common complication in hospitalized children, CRT can induce many potentially serious complications. • A professional nursing team is an important prerequisite for reducing CRT incidence. What is New: • The levels of pediatric nurses' knowledge and practice are not satisfactory, while pediatric nurses' preventive attitude toward CRT prevention is optimistic. • Hospital-related organizations and nursing managers should highlight the importance of CRT prevention and encourage pediatric nurses to improve their expertise and strengthen the training related to CRT prevention.

High Rate of Venous Thromboembolism in Severe Pediatric Intestinal Failure

OBJECTIVE

To quantify the rate of venous thromboembolism (VTE) in patients with pediatric intestinal failure and identify associated risk factors.

STUDY DESIGN

We performed a retrospective cohort study in pediatric patients (<21 years old) with severe pediatric intestinal failure (≥90 consecutive days of parenteral nutrition) secondary to short bowel syndrome who were treated from 2014 to 2021 at an interdisciplinary intestinal rehabilitation program. The primary outcome was the incidence of VTE. Multivariable regression was performed to identify independent clinical predictors of VTE.

RESULTS

A total of 263 patients (59.7% male) met the criteria for inclusion. The cumulative incidence of VTE was 28.1%, with a rate of 0.32 VTEs per 1000 catheter-days. On univariate analysis, the number of catheter days, number of catheters, and history of central line-associated blood stream infection were associated with VTE. On multivariable logistic regression, a higher number of catheters was an independent risk factor for VTE (aOR, 1.17; 95% CI, 1.06-1.29). Additionally, earlier gestational age was a risk factor for VTE such that every week decrease in gestational age conferred a 9% increased risk of VTE (aOR, 1.09; 95% CI, 1.02-1.16).

CONCLUSIONS

In this retrospective study, 28.1% of patients with severe pediatric intestinal failure developed VTE; the number of catheters and early gestational age were noted to be independent risk factors for VTE. This high incidence of VTE highlights the need to investigate VTE in pediatric intestinal failure prospectively, including the potential benefit of prophylactic anticoagulation.

Association of low serum albumin with venous thrombosis in pediatric patients

OBJECTIVES

The incidence of venous thromboembolism (VTE) in children is increasing, attributed in part to increased utilization of central venous catheters (CVCs). Children with protein losing disorders (PLDs) and low serum albumin may have an increased incidence of thrombosis. We sought to determine the prevalence of PLDs and hypoalbuminemia at the time of diagnosis of VTE in pediatric patients and its relationship to central venous catheters.

METHODS

We performed a single institution retrospective study of 65 consecutive hospitalized pediatric patients with an acute VTE. Data collected included clinical diagnoses, type of thrombosis, presence or absence of a CVC, and serum albumin level, if available.

RESULTS

Of 65 patients with acute VTE, 51 % (33/65) had catheter-related thrombosis (CRT), including 71 % (19/27) of patients <12 years of age and 37 % (14/38) of patients aged 12 to 23 (P = 0.008). Eleven VTEs occurred in patients with a diagnosis of a PLD; of these, ten (91 %) were CRT and one (9 %) was a non-CRT (P = 0.003). Serum albumin levels obtained within four days of diagnosis of VTE were available for 38 patients. An albumin level below the lower limit of the age-adjusted normal reference range was documented in 27/38 (71 %) patients with VTE compared to 1011/3028 (33 %) of all pediatric patients admitted to the hospital during a two-year period (P < 0.0001). Albumin levels were low in 19/22 (86 %) patients with CRT compared with 8/16 (50 %) patients with non-CRT (P = 0.019).

CONCLUSION

Low serum albumin levels are highly prevalent among pediatric patients with VTE, especially in those patients with CRT.

Charakteristika und klinische Manifestation katheterassoziierter Thrombosen bei Frühgeborenen

Hintergrund

In der Neonatologie sind peripher eingeführte zentrale Katheter ein häufiger Zugangsweg zur parenteralen Ernährung und Verabreichung von Medikamenten und Flüssigkeit. Die Vorteile stehen den Risiken wie Infektion, Thrombose und Fehllage gegenüber.

Fragestellung

Welche Charakteristika und klinischen Zeichen weisen auf das Vorliegen einer katheterassoziierten Thrombose hin?

Material und Methoden

In einer retrospektiven Betrachung aus dem Zeitraum 2010–2016 wurden alle Fälle von katheterassoziierten Thrombosen untersucht. Identifiziert wurden 10 Frühgeborene, deren Indikation zur Katheteranlage, Zugangsweg, Lage der Katheterspitze, Liegedauer, klinische Symptome und Krankheitsverlauf analysiert wurden.

Ergebnisse

Bei 10 Frühgeborenen mit einem Gestationsalter von 23 + 4 bis 34 + 5 SSW wurden 11 Thromboseereignisse beobachtet. Zehn der 11 Thromboseereignisse betrafen die V. cava inferior nach Katheteranlage an der unteren Extremität. Die Indikation zur Katheteranlage waren parenterale Ernährung und chirurgische Eingriffe. Bei 9 Patienten traten perinatale Komplikationen auf. Bei allen Patienten bestand während der Liegedauer der Katheter der Verdacht auf eine Infektion. Das Auftreten der Thrombose wurde nach 3 bis 27 Tagen sonographisch dokumentiert. In 8 Thromboseereignissen war eine Thrombozytopenie, in 4 Fällen eine Beinschwellung auffällig.

Diskussion

Das Patientenkollektiv zeigt Gemeinsamkeiten im klinischen Verlauf und bei den Symptomen, welche auf das Vorliegen einer Thrombose deuten. Auffällig ist außerdem, dass die meisten Thromboseereignisse das Stromgebiet der V. cava inferior betrafen.

Symptomatic pulmonary embolus after catheter removal in children with catheter related thrombosis: A report from the CHAT Consortium

BACKGROUND

Appropriate timing of central venous catheter (CVC) removal, in relation to start of anticoagulation, in children after the diagnosis of a CVC-related thrombosis (CRT) is not well established.

OBJECTIVES

This retrospective cohort study evaluated the incidence of symptomatic pulmonary embolism (PE) after CVC removal using data from the multi-institutional Children's Hospital-Acquired Thrombosis (CHAT) Consortium Registry.

PATIENTS/METHODS

The CHAT Registry consists of data from children aged 0-21 years with a hospital-acquired venous thromboembolism. Eligible subjects were those with CRT diagnosed <3 days after CVC removal. Subjects were excluded if the CRT was due to a failed CVC insertion. Subjects were divided into three groups: those with CVC removal without anticoagulation, those with CVC removal <48 h after starting anticoagulation, and those with CVC removal ≥48 h after starting anticoagulation.

RESULTS

A total of 687 CRT events from 663 subjects were included. A majority of CRT events were in subjects with peripherally inserted central catheters (62.3%, n = 428). For the 611 CRT events in which the CVC was removed, there was only one case of symptomatic PE (0.16%), which occurred <48 h after initiation of anticoagulation.

CONCLUSIONS

While current guidelines suggest anticoagulation before CVC removal in the setting of a CRT to prevent embolization, CVC removal is not associated with symptomatic PE regardless of duration of anticoagulation before CVC removal.

Venous Thromboembolism among Noncritically Ill Hospitalized Children: Key Considerations for the Pediatric Hospital Medicine Specialist

Venous thromboembolism (VTE) is a leading cause of morbidity and preventable harm among noncritically ill hospitalized children. Several clinical factors relevant to the noncritically ill hospitalized child significantly increase the risk of VTE including the presence of central venous catheters, systemic inflammation, and prolonged immobilization. Although risk mitigation strategies have been described, the diagnosis, treatment, and prevention of VTE require standardization of institutional practices combined with multidisciplinary collaboration among pediatric hospitalists, hematologists, and other care providers. In this narrative review, we summarize the epidemiology of VTE, risk models identifying high-risk conditions associated with VTE, and prevention and treatment strategies. We further describe successful quality improvement efforts implementing institutional VTE risk stratification and thromboprophylaxis procedures. Finally, we highlight unique challenges facing pediatric hospital medicine specialists in the era of the COVID-19 pandemic, including caring for adults admitted to pediatric hospital units, and describe future research opportunities for VTE in the noncritically ill hospitalized child.

Catheter related thrombosis in hospitalized infants: A neural network approach to predict risk factors

INTRODUCTION

We sought to investigate the predictors of catheter-related thrombosis (CRT) in a cohort of critically ill hospitalized infants and using a novel approach (the artificial neural network - ANN) in combination with conventional statistics to identify/confirm those predictors.

METHODS

We performed a retrospective analysis of all infants with a central or peripherally inserted central venous catheter (CVC/PICC) between 2015 and 2018. ANN was generated to investigate the predictors of CRT. The predictive variables examined in the ANN were age, gender, weight, co-morbid conditions, line type, use of ultrasound (USG), emergent line placement, location of line tip, any major surgical procedures, use of mechanical ventilation, exposure to cardio-pulmonary bypass (CPB), past-history of CVC/PICC, or thrombosis. Binary logistic regression was performed to calculate odds ratios (ORs) and determine which factors were significant in predicting CRT.

RESULTS

Of total of 613 infants, 59.9% of patients had a history of previous CVC or PICC and 12.2% had a history of thrombus as documented by USG in the past three months. CPB exposure was present in 48.1%. The incidence of CRT was 10.7%. Independent predictors of CRT were the line tip in IVC (OR: 2.37, 1.08-5.21, P = 0.032), history of thrombosis (OR: 2.40, 1.16-4.96, P = 0.019), previous CVC/PICC (OR: 2.80, 1.24-6.33, P = 0.014) and exposure to CPB (OR: 2.749, 1.08-6.98, P = 0.034). A sensitivity analysis was performed to determine the normalized importance of each variable used to create the ANN. The most important variables were age (with normalized importance of 100%), history of thrombosis, weight, and exposure to CPB (normalized importance of 68.2%).

CONCLUSIONS

Nearly 1 in 10 infants developed CRT. We found that catheter tip in IVC, exposure to CPB, history of vein thrombosis and history of CVC/PICC placement in the past 3 months are independently associated with a higher risk of CRT in infants by using conventional and neural network methods.

Secondary Anticoagulation Prophylaxis for Catheter-Related Thrombosis in Pediatric Intestinal Failure: Comparison of Short- Vs Long-Term Treatment Protocols

INTRODUCTION

Catheter-related thrombosis (CRT) is a devastating complication of central venous catheters in children with intestinal failure (IF), but the optimal preventive therapy of CRT is unknown. This study assessed the efficacy and safety of 2 protocols of secondary anticoagulation prophylaxis with low-molecular-weight heparin (LMWH).

METHODS

This is a comparative cohort study of children from 2 IF programs who received secondary anticoagulation prophylaxis with LMWH for CRT. The short-term protocol group (N = 13) received therapeutic dosing until thrombus resolution or ≤3 months. In the long-term protocol group (N = 26), prophylactic dosing continued until line removal. Patients underwent routine annual vascular ultrasound and were followed for ≥1 year. The primary outcome was development of secondary thrombosis; post hoc analysis assessed rates of secondary thrombosis at 12 months.

RESULTS

Patient demographics were similar between groups. Secondary thrombosis occurred in 8 of 13 (62%) patients in the short-term group and in 9 of 26 (35%) in the long-term protocol group (P = .019) in a median time of 144.5 and 689 days, respectively (P = .01). Secondary thrombosis within 12 months occurred in 7 of 13 (54%, short term) and 2 of 26 (8%, long term) patients (P = .001). Secondary thrombosis was associated with catheter replacements (23.5 vs 5.5 catheters per 1000 catheter days; P = .016) and longer daily parenteral nutrition (PN) infusion (24 vs 15.25 hours; P = .044). Compliance was good (>80% of doses) in 92% of patients.

CONCLUSIONS

Long-term secondary anticoagulation prophylaxis with LMWH reduces the incidence of secondary thrombosis and should be considered in children with CRT that require PN for prolonged periods of time.

Occurrence and Risk Factors for Unplanned Catheter Removal in a PICU: Central Venous Catheters Versus Peripherally Inserted Central Venous Catheters

OBJECTIVES

We aimed to identify the occurrence and risk factors for unplanned catheter removal due to catheter-associated complications and the effects on catheter survival probability in a PICU.

DESIGN

Retrospective, single-center, observational study of cases involving conventional central venous catheters or peripherally inserted central venous catheters.

SETTING

The PICU of a tertiary children's hospital.

PATIENTS

Consecutive PICU patients with central venous catheters between April 2016 and February 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified unplanned catheter removals that were related to central line-associated bloodstream infection, thrombosis, and mechanical complications. During the study period, 582 central venous catheters and 474 peripherally inserted central venous catheters were identified. The median durations of catheter placement were 4.0 days for central venous catheters and 13.0 days for peripherally inserted central venous catheters (p < 0.001), and unplanned catheter removals due to catheter-associated complications were in 52 (8.9%) central venous catheter cases and 132 (27.8%) peripherally inserted central venous catheter cases (p < 0.001) (15.0 and 16.0 per 1,000 catheter-days, respectively [p = 0.75]). Unplanned catheter removal was associated with a peripheral catheter tip position among both central venous catheters and peripherally inserted central venous catheters (p < 0.001 and p = 0.001), and it was associated with surgical patient status among peripherally inserted central venous catheters (p = 0.009). In contrast, the use of ultrasound-guided insertion was associated with a lower occurrence of unplanned catheter removal among peripherally inserted central venous catheters (p = 0.01). With regard to catheter survival probability, there was no significant difference between central venous catheters and peripherally inserted central venous catheters (p = 0.23). However, peripherally inserted central venous catheters had a lower occurrence of central line-associated bloodstream infection than central venous catheters (p = 0.03), whereas there was no significant difference in the rates of thrombosis (p = 0.29) and mechanical complications (p = 0.84) between central venous catheters and peripherally inserted central venous catheters.

CONCLUSIONS

In a PICU, peripherally inserted central venous catheters had lower occurrence of central line-associated bloodstream infection than central venous catheters; however, similar catheter survival probabilities were observed between both catheters. A central catheter tip position for both catheters and ultrasound-guided insertion for peripherally inserted central venous catheters may help limit unplanned catheter removal due to catheter-associated complications.

Selection and Insertion of Vascular Access Devices in Pediatrics: A Systematic Review

OBJECTIVE

To critically review the evidence for the selection and insertion of pediatric vascular access devices (VADs).

DATA SOURCES

Data were sourced from the US National Library of Medicine, Cumulative Index to Nursing and Allied Health, the Cochrane Library databases, Embase, and international clinical trial databases.

STUDY SELECTION

Clinical practice guidelines, systematic reviews, cohort designs, randomized control trials (RCTs), quasi RCTs, before-after trials, or case-control studies that reported on complications and/or risk as well as reliability of VADs in patients aged 0 to 18 years were included.

DATA EXTRACTION

Articles were independently reviewed to extract and summarize details on the number of patients and catheters, population, age of participants, VAD type, study method, indication, comparators, and the frequency of VAD failure or complications.

RESULTS

VAD selection and insertion decision-making in general hospitalized and some specialized patient populations were well evidenced. The use of single-lumen devices and ultrasound-guided techniques was also broadly supported. There was a lack of RCTs, and for neonates, cardiac patients, patients with difficult venous access, midline catheters, catheter-to-vein ratio, and near-infrared devices, the lack of evidence necessitated broadening the review scope.

LIMITATIONS

Limitations include the lack of formal assessment of the quality of evidence and the lack of RCTs and systematic reviews. Consequently, clinical decision-making in certain pediatric populations is not guided by strong, evidence-based recommendations.

CONCLUSIONS

This is the first synthesis of available evidence for the selection and insertion of VADs in pediatric patients and is important for determining the appropriateness of VADs in pediatric patients.

Peripherally inserted central catheters lead to a high risk of venous thromboembolism in children

Venous thromboembolism (VTE) incidence in children has sharply increased with the majority of cases secondary to central venous catheters (CVCs). Among CVCs, the number of peripherally inserted central catheters (PICCs) placed has risen significantly. In this multicenter, prospective, observational cohort study, we enrolled patients aged 6 months to 18 years with newly placed PICCs or tunneled lines (TLs). We evaluated the incidence of VTE, central line-associated bloodstream infections (CLABSIs), and catheter malfunctions in PICCs and TLs, and risk factors of CVC-related VTE. A total of 1967 CVCs were included in the analysis. The incidence of CVC-related VTE was 5.9% ± 0.63%. The majority of the cases, 80%, were in subjects with PICCs, which had a significantly higher risk of catheter-related VTE than subjects with TLs (hazard ratio [HR] = 8.5; 95% confidence interval [CI], 3.1-23; P < .001). PICCs were significantly more likely to have a CLABSI (HR = 1.6; 95% CI, 1.2-2.2; P = .002) and CVC malfunction (HR = 2.0; 95% CI, 1.6-2.4; P < .001). Increased risk of CVC-related VTE was found in patients with a prior history of VTE (HR = 23; 95% CI, 4-127; P < .001), multilumen CVC (HR = 3.9; 95% CI, 1.8-8.9; P = .003), and leukemia (HR = 3.5; 95% CI, 1.3-9.0; P = .031). Children with PICCs had a significantly higher incidence of catheter-related VTE, CLABSI, and CVC malfunction over TLs. The results suggest that pause be taken prior to placing CVCs, especially PICCs, due to the serious complications they have been shown to cause.

Hemodialysis Catheters in Infants: A Retrospective Single-Center Cohort Study

PURPOSE

Evaluate technical aspects and outcomes of insertion/maintenance of hemodialysis (HD) central venous catheter (CVC) during infancy.

MATERIALS AND METHODS

Single-center retrospective study of 29 infants who underwent 49 HD-CVC insertions between 2002 and 2016. Demographics, procedural, and post-procedural details, interventional radiology (IR) maintenance procedures, technical modifications, complications, and outcomes were evaluated. Technical adjustments during HD-CVC placement to adapt catheter length to patient size were labeled "modifications." CVCs requiring return visit to IR were called IR-maintenance procedures. Mean age and weight at HD-CVC insertion were 117 days and 4.9 kg.

RESULTS

Of the 29 patients, 13 (45%) required renal-replacement-therapy (RRT) as neonates, 10 (34%) commenced RRT with peritoneal dialysis (PD), and 19 (66%) with HD. Fifteen nontunneled and 34 tunneled HD-CVCs were inserted while patients were ≤1 year. Technical modifications were required placing 25/49 (51%) HD-CVCs: 5/15 (33%) nontunneled and 20/34 (59%) tunneled catheters (P = .08). Patients underwent ≤6 dialysis-cycles/patient during infancy (mean 2.3), and a mean of 4.1 and 49 HD-sessions/catheter for nontunneled and tunneled HD-CVCs, respectively. Mean primary and secondary device service, and total access site intervals for tunneled HD-CVCs were 75, 115, and 201 days, respectively. A total of 26 of 49 (53%) patients required IR-maintenance procedures. Nontunneled lines had greater catheter-related bloodstream infections per 1,000 catheter-days than tunneled HD-CVCs (9.25 vs. 0.85/1,000 catheter days; P = .02). Nineteen patients (65%) survived over 1 year. At final evaluation (December 2017): 8/19 survived transplantation, 5/19 remained on RRT, 2/19 completely recovered, 1/19 lost to follow-up, and 3 died at 1.3, 2, and 10 years.

CONCLUSIONS

Placement/maintenance of HD-CVCs in infants pose specific challenges, requiring insertion modifications, and IR-maintenance procedures to maintain function.

Treatment of venous thromboembolism in pediatric patients

Venous thromboembolism (VTE) is rare in healthy children, but is an increasing problem in children with underlying medical conditions. Pediatric VTE encompasses a highly heterogenous population, with variation in age, thrombosis location, and underlying medical comorbidities. Evidence from pediatric clinical trials to guide treatment of VTE is lacking so treatment is often extrapolated from adult trials and expert consensus opinion. Aspects unique to children include developmental hemostasis and the major role of central venous access devices. There is an absence of information regarding the optimal target levels of anticoagulation for neonates and infants and lack of suitable drug formulations. Anticoagulants, primarily low-molecular-weight heparin and warfarin, are used to treat children with symptomatic VTE. These drugs have significant limitations, including the need for subcutaneous injections and frequent monitoring. Randomized clinical trials of direct oral anticoagulants in pediatric VTE are ongoing, with results anticipated soon. These trials will provide new evidence and options for therapy that have the potential to improve care. International collaborative registries offer the ability to study outcomes of rare subgroups of pediatric VTE (eg, renal vein thrombosis), and will be important to ultimately guide therapy in a more disease-specific manner.

[Central venous access in interventional radiology]

Some patients require iteratives intravenous administrations on a central catheter, for example in oncology or infectiology, which represents a challenge for ambulatory treatment. Interventional radiology could provide solutions with the implant and monitoring of PICC-lines and ports. These are implanted in sterile environment and under imaging guidance in an interventional radiology room by an operator and with a paramedical team that need to be experienced. This development focus on the interest of one method with respect to the other, as well as the differents ways to do, the complications that could arise and the monitoring of these devices.

Promising biomarkers for the prediction of catheter-related venous thromboembolism in hospitalized children: An exploratory study

BACKGROUND

Pediatric venous thromboembolism (VTE) has increased over the past 10 years, with central venous catheters (CVC) being the strongest risk factor. Current tools are not sufficient to predict VTE risk. The utility of biomarkers in predicting CVC-related VTE has been minimally explored. Our objective is to determine the utility of microparticles (MPs), factor VIII (FVIII) activity, and thrombin generation (TG) in prospectively predicting VTE occurrence in hospitalized children with CVCs.

PROCEDURE

In this nested case-control pilot study, consecutive hospitalized children needing CVC placement (1 month to 21 years) were enrolled. Venous samples were collected prior to or within 24 h of CVC placement. MPs were measured using factor Xa initiated clot-based assay. FVIII was measured using a one-stage clot-based assay. TG was measured using calibrated automated thrombogram.

RESULTS

There were three CVC-related VTE events (7%) in our cohort of 42 subjects. Xa clotting time (XaCT) ratio was lower (0.68 ± 0.07 vs 0.95 ± 0.21, P = .4), while FVIII (461 ± 120 vs 267 ± 130, P = .02), peak thrombin (418 ± 89 vs 211 ± 101, P = .001), endogenous thrombin potential (ETP) (1828 ± 485 vs 1282 ± 394, P = .03), and velocity index (VI) (182 ± 28 vs 75 ± 53, P = .001) were higher in subjects with CVC-related VTE compared to those without CVC-related VTE. Sensitivity/specificity analysis revealed optimal cutoff values for XaCT ratio (0.75), FVIII (370), ETP (1680), peak (315), and VI (130), with receiver operating characteristic area under the curve values >0.9.

CONCLUSION

MPs, FVIII, and TG can potentially predict pediatric CVC-related VTE in a prospective fashion. Stratification according to VTE risk may aid in guiding preventative efforts in future studies.

Central venous catheter-associated thrombosis in children with congenital hyperinsulinism

Congenital hyperinsulinism (CHI) is an important cause of severe hypoglycaemia in infancy. To correct hypoglycaemia, high concentrations of dextrose are often required through a central venous catheter (CVC) with consequent risk of thrombosis. We describe a series of six cases of CHI due to varying aetiologies from our centre requiring CVC for the management of hypoglycaemia, who developed thrombosis in association with CVC. We subsequently analysed the incidence and risk factors for CVC-associated thrombosis, as well as the outcomes of enoxaparin prophylaxis. The six cases occurred over a 3-year period; we identified an additional 27 patients with CHI who required CVC insertion during this period (n = 33 total), and a separate cohort of patients with CHI and CVC who received enoxaparin prophylaxis (n = 7). The incidence of CVC-associated thrombosis was 18% (6/33) over the 3 years, a rate of 4.2 thromboses/1000 CVC days. There was no difference in the frequency of genetic mutations or focal CHI in those that developed thromboses. However, compound heterozygous/homozygous potassium ATP channel mutations correlated with thrombosis (R² = 0.40, P = 0.001). No difference was observed in CVC duration, high concentration dextrose or glucagon infused through the CVC. In patients receiving enoxaparin prophylaxis, none developed thrombosis or bleeding complications. The characteristics of these patients did not differ significantly from those with thrombosis not on prophylaxis. We therefore conclude that CVC-associated thrombosis can occur in a significant proportion (18%) of patients with CHI, particularly in severe CHI, for which anticoagulant prophylaxis may be indicated.

Should you pick the PICC? Prolonged use of peripherally inserted central venous catheters in children with intestinal failure

PURPOSE

Prolonged central vascular access is a source of significant morbidity in children with intestinal failure (IF). In an effort to decrease morbidity, our multidisciplinary IF team has primarily used peripherally inserted central catheters (PICCs) for these patients. We compared outcomes of PICCs to Broviacs®.

METHODS

A review of children with IF (2006-2018) at an academic children's hospital was conducted.

INCLUSION CRITERIA

total parenteral nutrition duration >42 days or small bowel length < 25% of total for gestational age. Complications/1000 catheter days were extracted, and a Poisson model was used to compare complications between PICCs and Broviacs®.

RESULTS

Thirty-seven patients with IF were included, accounting for 19,452 catheter days. There were 209 PICCs (1.2-4F) and 39 Broviacs® (2.7-7F). The median duration of overall PICC access/patient was 166 days (range: 35 days-8 years). Incidences of central line associated blood stream infection and venous thrombosis were 3.95 and 0.55 per 1000 catheter days, respectively. There were no significant differences in complication rates per line per catheter day between PICCs and Broviacs® on multivariate analysis. Broviacs® showed a trend towards increased of catheter-related hospital admissions when compared to PICCs.

CONCLUSIONS

PICCs in children with intestinal failure have similar complication rates to Broviacs® but may reduce catheter-related hospital admissions. Use of tunneled PICCs and increasing experience with this vascular access method may allow it to realize its potential advantages.

LEVEL OF EVIDENCE

Retrospective study, level III.

Increased risk of symptomatic upper-extremity venous thrombosis with multiple peripherally inserted central catheter insertions in pediatric patients

BACKGROUND

Peripherally inserted central catheters (PICCs) are associated with superficial and deep venous thrombosis of the arm.

OBJECTIVE

The purpose of this study was to analyze the sequelae of repeated upper limb PICC insertions in children, in terms of the frequency of upper limb thrombosis in this patient group.

MATERIALS AND METHODS

The study population included all children who underwent their first successful arm PICC insertion between January 2010 and December 2015. We included subsequent ipsilateral arm PICCs in the analysis. Patients were followed until March 2016 or until any alternative central venous line insertion. For each PICC insertion, we collected demographic variables and line characteristics. We correlated all symptomatic deep and superficial thromboses of the arm with the PICC database.

RESULTS

Applying inclusion and exclusion criteria, 2,180 PICCs remained for analysis. We identified first, second, third and fourth PICC insertions in the same arm in 1,955, 181, 38 and 6 patients, respectively. In total there were 57 upper body deep symptomatic thrombotic events. An increasing odds ratio was seen with higher numbers of PICC insertions, which was significant when comparing the first with the third and fourth PICC insertions in the same arm (odds ratio [OR] 6.00, 95% confidence interval [CI] 2.25-16.04, P=0.0004). Double-lumen PICCs were associated with a significantly higher risk of thrombosis than single lumen (OR 2.77, 95% CI 1.72-4.47, P=0.0003).

CONCLUSION

Repetitive PICC insertions in the same arm are associated with an increased risk of symptomatic thrombosis. Double-lumen PICCs are associated with a higher risk of thrombosis compared to single-lumen lines.

Catheter-Related Venous Thrombosis in Hospitalized Pediatric Patients with Inflammatory Bowel Disease: Incidence, Characteristics, and Role of Anticoagulant Thromboprophylaxis with Enoxaparin

OBJECTIVE

To describe the incidence and characteristics of central venous catheter (CVC)-related thrombosis in hospitalized pediatric patients with active inflammatory bowel disease (IBD) and report the potential usefulness of anticoagulant thromboprophylaxis (AT).

STUDY DESIGN

We conducted a retrospective study of patients who were admitted to our children's hospital in the last 2 years with active IBD and required a CVC and identified all patients with an objectively confirmed symptomatic CVC-related thrombosis. To assess the usefulness of a recently implemented institutional AT protocol, we compared the frequency of CVC-related thrombosis, nadir hemoglobin, and red blood cell transfusion requirements in patients who received AT with those who did not during the study period.

RESULTS

A total of 40 patients with IBD who required 47 consecutive hospitalizations were included. AT was administered during 24 of 47 hospitalizations (51%). Patients who received AT were similar to those who did not receive AT with regard to demographics, IBD phenotypes, extent of colonic involvement, and thrombotic risk factors. CVC-related thrombosis occurred in 5 of 23 hospitalizations (22%) in which AT was withheld compared with 0 of 24 hospitalizations (0%) in which patients received AT (P = .02). The red blood cell transfusion requirements and nadir hemoglobin were not significantly different between the 2 groups.

CONCLUSIONS

We observed a high incidence of CVC-related thrombosis in hospitalized children with IBD. Administration of AT in our population was associated with significant reduction in CVC-related thrombosis without evidence of increased bleeding.

Obtaining central access in challenging pediatric patients

PURPOSE

Central catheter placement is one of the most commonly performed procedures by pediatric surgeons. Here, we present a case series of patients where central access was obtained at our institution with the utilization of a novel ultrasound-guided technique. This series represents the first of its kind where the native, parent vessels were inaccessible, resulting in a challenging situation for providers.

METHODS

A retrospective chart review was performed in pediatric patients (0-17 years) at a tertiary care institution between July 2012 and November 2017 on all central line procedures where ultrasound was utilized to cannulate the brachiocephalic or superior vena cava in face of proximal occlusion. Our group has previous experience utilizing an image-guided in-plane approach to central line placement in the pediatric population. Demographics, operative characteristics, and postoperative complications were reviewed.

RESULTS

A total of 11 procedures were included in this case series where the BC (N = 9) or SVC (N = 2) were cannulated for access. Internal jugular vein cannulation was attempted on each patient unless preoperative imaging demonstrated occlusion. The median operative time was 43 ± 23 min. Most procedures were performed on the right sided (63%), with catheters ranging from 4.2F single lumen to 14F double lumen. Since being placed, three (27%) catheters have been removed, with one due to non-use, one due to sepsis, and the final one due to malposition.

CONCLUSION

With the continued need for long-term central access in the pediatric population, distal vein occlusion or inaccessibility can prove challenging when attempting to obtain central access. Here, demonstrated a safe alternative technique that provides an additional option in the pediatric surgeon's armamentarium for patients with difficult central access.

Deep vein thrombosis in pediatric patients

Due to advances in caring for critically ill children and those with chronic diseases, rates of deep vein thrombosis (DVT) are increasing in children. Risk factors consist of central venous catheters, chronic medical conditions, thrombophilia, and various medications. Compression Doppler ultrasonography is the method most commonly used to diagnose DVT, and patients will usually present with pain and swelling of the affected limb. Anticoagulation via subcutaneous injection is the most common treatment regime for children with DVT, and the new, direct oral anticoagulants are currently under investigation. Prevention techniques are not established, but clinical studies are addressing this need.

Long-term outcomes of pediatric intestinal failure

Management of pediatric intestinal failure has evolved in recent decades, with improved survival since the advent of specialized multidisciplinary intestinal failure centers. Though sepsis and intestinal failure associated liver disease still contribute to mortality, we now have growing data on the long-term outcomes for this population. While intestinal adaptation and parenteral nutrition weaning is most rapid during the first year on parenteral support, achievement of enteral autonomy is possible even after many years as energy and protein requirements decline dramatically with age. Intestinal transplant is an option for patients experiencing complications of long-term parenteral nutrition who are expected to have permanent intestinal failure, but outcomes are hindered by immunosuppression-related complications. Much of the available data comes from single center retrospective reports, with variable inclusion criteria, intestinal failure definitions, and follow-up durations; this limits the ability to analyze outcomes and identify best practices. As most children now survive long-term, the focus of management has shifted to the avoidance and management of comorbidities, support of normal growth and development, and optimization of quality of life for these medically and surgically complex patients.

Increased rate of venous thrombosis may be associated with inpatient dihydroergotamine treatment

OBJECTIVE

To review whether the incidence of catheter-associated venous thromboses was higher in patients receiving IV dihydroergotamine compared to lidocaine.

METHODS

We retrospectively reviewed all admissions at the University of California, San Francisco Headache Center from February 25, 2008, through October 31, 2014, for age, sex, diagnosis, aura, treatment dose, type of IV line used, days with line, superficial (SVT) or deep venous thrombosis (DVT), and pulmonary embolism (PE).

RESULTS

A peripherally inserted central catheter (PICC) or midline catheter was placed in 315 of 589 (53%) admissions. Mean age was 38 years with a range of 6 to 79 years; 121 patients (21%) were ≤18 years old. Seventy-four percent (433 of 589) of patients were female. Of 263 dihydroergotamine admissions using a PICC or midline catheter, 19 (7.2%) had either an SVT or DVT or a PE; 2 patients were diagnosed with both DVT and PE. Of 52 lidocaine admissions using a PICC or midline catheter, none had a thrombotic event (p = 0.05, Fisher exact test). Age, sex, aura, total dihydroergotamine dose, and number of days with line were not significant predictors of venous thrombosis.

CONCLUSIONS

IV dihydroergotamine treatment may be associated with an increased risk of catheter-associated venous thrombosis. A low threshold for diagnostic ultrasound investigation is appropriate because anticoagulation therapy was frequently required.

Pediatric Hospital Acquired Venous Thromboembolism

Pediatric hospital acquired venous thromboembolism (HA-VTE) is an increasing problem with an estimated increase from 5.3 events per 10,000 pediatric hospital admissions in the early 1990s to a current estimate of 30-58 events per 10,000 pediatric hospital admissions. Pediatric HA-VTE is associated with significant morbidity and mortality. The etiology is multifactorial but central venous catheters remain the predominant risk factor. Additional HA-VTE risk factors include both acquired (recent surgery, immobility, inflammation, and critical illness) and inherited risk factors. Questions remain regarding the most effective method to assess for HA-VTE risk in hospitalized pediatric patients and what preventative strategies should be implemented. While several risk-assessment models have been published in pediatric patients, these studies have limited power due to small sample size and require prospective validation. Potential thromboprophylactic measures include mechanical and pharmacologic methods both of which have associated harms, the most significant of which is bleeding from anticoagulation. Standard anticoagulation options in pediatric patients currently include unfractionated heparin, low molecular weight heparin, or warfarin all of which pose a monitoring burden. Ongoing pediatric studies with direct oral anticoagulants could potentially revolutionize the prevention and treatment of pediatric thrombosis with the possibility of a convenient route of administration and no requirement for monitoring. Further studies assessing clinical outcomes of venous thromboembolism (VTE) prevention strategies are critical to evaluate the effectiveness and harm of prophylactic interventions in children. Despite HA-VTE prevention efforts, thrombotic events can still occur, and it is important that clinicians have a high clinical suspicion to ensure prompt diagnosis and treatment to prevent further associated harms.

A technique for re-utilizing catheter insertion sites in children with difficult central venous access

Maintenance of central venous access in patients with chronic medical conditions such as short bowel syndrome demands forethought and ingenuity. We describe an innovative technique for re-utilizing central venous access sites in patients who have chronic central venous access needs. Records of patients undergoing this technique were reviewed between August 2012 and December 2015. The technique involves "cutting-down" to the sterile fibrous tunnel that naturally forms around tunneled catheters. The fibrous sheath is then isolated and controlled much as would be done for a venous "cut-down." A separate exit site is then created for the new catheter and it is tunneled to the "cut-down" site per routine. The non-functioning catheter is then removed from the surgical field. The proximal fibrous sheath is finally cannulated either directly with the new catheter or with a wire/dilator system. This technique effectively re-uses the same venous access point while allowing for a complete change of the physical line and external site. Twenty attempts at this technique were made in twelve patients; six patients underwent the site re-utilization procedure multiple times. Re-using the fibrous tunnel to re-cycle the internal catheter site was successful in seventeen of twenty attempts. All patients had chronic conditions leading to difficult long-term central venous access [short bowel syndrome (6), hemophilia (2), cystic fibrosis (1), chronic need for central IV access (3)]. Indications for catheter replacement included catheter occlusion/mechanical failure/breakage (9), dislodgement (6), infection (1), and inadequate catheter length due to patient growth (4). Broviac/Hickman catheter sites were most commonly re-used (13; one failure); re-using a portcath site was successful in 5 of 7 attempts. There were no short term infections or mechanical complications. We describe a novel technique for salvaging tunneled central venous catheter access sites. This technique is well suited for patients with difficult and long-term central venous access needs, particularly those with chronic conditions such as intestinal failure. It is specifically useful when tunneled lines are broken, precipitated or clotted and unamenable to wiring.

Central venous thrombosis in children with intestinal failure on long-term parenteral nutrition

PURPOSE

Central venous thrombosis (CVT) is a serious complication of long-term central venous access for parenteral nutrition (PN) in children with intestinal failure (IF). We reviewed thse incidence of CVT and possible risk factors.

METHODS

Children with IF on home PN (2010-2014) with central venous imaging were reviewed. Patient demographics, catheter characteristics and related complications, and markers of liver function were compared between children with and without CVT. Serum thrombophilia markers were reviewed for patients with CVT.

RESULTS

Thirty children with central venous imaging were included. Seventeen patients had thrombosis of ≥1 central vein, and twelve had ≥2 thrombosed central veins. Patients with and without CVT had similar demographics and catheter characteristics. Patients with CVT had a significantly lower albumin level (2.76±0.38g/dL vs. 3.12±0.41g/dL, p=0.0223). The most common markers of thrombophilia in children with CVT were antithrombin, protein C and S deficiencies, and elevated factor VIII. There was a statistically significant correlation between a combined protein C and S deficiency and having >1 CVT.

CONCLUSIONS

Children with IF on long-term PN are at high risk for CVT potentially owing to low levels of natural anticoagulant proteins and elevated factor FVIII activity, likely a reflection of liver insufficiency and chronic inflammation.

RUNX1 Amplification Increases the Risk for Thrombosis in Children With B-cell Acute Lymphoblastic Leukemia

BACKGROUND

RUNX1 (AML1) amplification in patients with B-cell acute lymphoblastic leukemia (B-ALL) has been associated with poor survival for unclear reasons. Our anecdotal experience suggests that children with B-ALL and RUNX1 amplification might be predisposed to thrombosis.

PROCEDURE

We performed a retrospective cohort study of children with B-ALL treated from 2008 to 2014 at the North Carolina Children's Hospital. Patient demographics, cytogenetics, and diagnosis of thrombosis were extracted by blinded chart review. Analysis was performed examining the relationship between RUNX1 amplification and thrombosis.

RESULTS

We identified 119 patients with B-ALL and a median age of 4.9 years (interquartile range, 2.9 to 8.6 y) at diagnosis. Four patients (3%) had RUNX1 amplification. The average number of RUNX1 copies among those with amplification was 5 (SD 0.81 [range, 4 to 6]). Eighteen thromboses were diagnosed within 6 months of starting treatment. These events were more likely among patients with RUNX1 amplification than in patients without amplification (75% vs. 13%; RR 5.75, 95% confidence interval, 2.75-12.01).

CONCLUSIONS

RUNX1 amplification may predispose to early thrombotic events in children with B-ALL which could, in part, contribute to their poorer outcomes. Treatment implications, including possible prophylactic anticoagulation of patients with of RUNX1 amplification, justify larger studies to confirm these findings.

Complications and 30-day Outcomes Associated With Venous Thromboembolism in the Pediatric Orthopaedic Surgical Population

INTRODUCTION

The risk of morbidity associated with venous thromboembolism (VTE) after pediatric orthopaedic surgery remains unclear despite increased use of thromboprophylaxis measures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program, Pediatric database was queried for patients undergoing an orthopaedic surgical procedure between 2012 and 2013. Upper extremity and skin/subcutaneous surgeries were excluded. Associations between VTE and procedure, demographics, comorbidities, preoperative laboratory values, and 30-day postoperative outcomes were evaluated.

RESULTS

Of 14,776 cases, 15 patients (0.10%) experienced postoperative VTE. Deep vein thrombosis (DVT) occurred in 13 patients (0.09%), and pulmonary embolism developed in 2 patients (0.01%). The procedure with the highest VTE rate was surgery for infection (1.2%). Patient factors associated with the development of VTE included hyponatremia (P = 0.003), abnormal partial thromboplastin time (P = 0.046), elevated aspartate transaminase level (P = 0.004), and gastrointestinal (P = 0.011), renal (P = 0.016), and hematologic (P = 0.019) disorders. Nearly half (46.2%) of DVTs occurred postdischarge. Complications associated with VTE included prolonged hospitalization (P < 0.001), pneumonia (P < 0.001), unplanned intubation (P = 0.003), urinary tract infection (P = 0.003), and central line-associated bloodstream infection (P < 0.001). Most of the postoperative complications (66.7%) occurred before VTE diagnosis, and no patients with VTE died.

CONCLUSION

In the absence of specified risk factors, thromboprophylaxis may be unnecessary for this population.