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Do Pediatric Trauma (and Non-cardiac Surgery) Patients Need Venous Thrombosis Prophylaxis?
Henry I. Bussey, Pharm.D.
The Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy (published in 2004) contains a chapter on "Antithrombotic Therapy in Children" (1). The chapter provides recommendations for antithrombotic therapy for a variety of conditions (such as cardiac surgery, prosthetic heart valve placement, Kawasaki's disease, and cardiac catheterization); but recommendations for prophylaxis in trauma or surgery are not provided. While the authors point out that the vast majority of venous thrombosis events (VTE) in children are related to malignancy, surgery, trauma, or some other predisposing factor; they also acknowledge that "there are no published data on which to base a formal recommendation."
In 2005, Truitt and colleagues published data on 3,637 pediatric trauma patients who were included in the trauma registry of the Hasbro Children's Hospital in Providence, Rhode Island over a 7-year period.(2) Of the 3,637 patients, 1,752 were between 9 and 16 years of age and venous thrombosis prophylaxis was not used. Only 3 patients with VTE were identified (1 pulmonary embolism or PE, and 2 deep vein thrombosis or DVT). Each event occurred at more than 20 days after the trauma. One patient was 9 years old and the other two were 15 years old. The event rate, therefore, was < 0.08% for the entire group and approximately 0.17% for those 9 to 16 years old. While one is reluctant to place much weight on analysis of only 3 such instances, the authors concluded that length of ICU stay, presence of spinal injury, presence of head injury, and gender were not statistically significant factors for VTE development. However, factors that were associated with VTE included age > 9 yrs, Glasgow Coma Score of 8 or less, central nervous system injuries, and Injury Severity Score of 25 or more. In addition, it must be acknowledged that identification of VTE events was based on recognized clinical symptomatic events and that routine screening was not performed. Consequently, the true number of VTEs in such patients may be higher than reported by Truitt, et al.
Taken collectively – and in the absence of prospective control trial data - the Chest guidelines and the work by Truitt, et al would suggest that VTE prophylaxis may not be necessary in children with trauma - and perhaps non-cardiac surgery - if less than 9 years of age. For those 9 years of age and older, the type and extent of injury (and/or the nature of the surgery) and age may be important in identifying patients who may benefit from prophylaxis.
Monagle P, Chan A, Massicotte P, Chalmers E, Michelson AD. Chest 2004: 126:645s-687s. (or http://www.chestjournal.org/cgi/content/full/126/3_suppl/645S)
Truitt AK, Sorrells DL, Halvorson E, et al. Pulmonary embolism: which pediatric trauma patients are at risk? J Ped Surg 2005; 40:124-127.
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