Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland.
Division of Biostatistics, Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland.
JAMA Surg. 2016 Jan;151(1):50-7. doi: 10.1001/jamasurg.2015.2670.
Although rare, the incidence of venous thromboembolism (VTE) in pediatric trauma patients is increasing, and the consequences of VTE in children are significant. Studies have demonstrated increasing VTE risk in older pediatric trauma patients and improved VTE rates with institutional interventions. While national evidence-based guidelines for VTE screening and prevention are in place for adults, none exist for pediatric patients, to our knowledge.
To develop a risk prediction calculator for VTE in children admitted to the hospital after traumatic injury to assist efforts in developing screening and prophylaxis guidelines for this population.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of 536,423 pediatric patients 0 to 17 years old using the National Trauma Data Bank from January 1, 2007, to December 31, 2012. Five mixed-effects logistic regression models of varying complexity were fit on a training data set. Model validity was determined by comparison of the area under the receiver operating characteristic curve (AUROC) for the training and validation data sets from the original model fit. A clinical tool to predict the risk of VTE based on individual patient clinical characteristics was developed from the optimal model.
Diagnosis of VTE during hospital admission.
Venous thromboembolism was diagnosed in 1141 of 536,423 children (overall rate, 0.2%). The AUROCs in the training data set were high (range, 0.873-0.946) for each model, with minimal AUROC attenuation in the validation data set. A prediction tool was developed from a model that achieved a balance of high performance (AUROCs, 0.945 and 0.932 in the training and validation data sets, respectively; P = .048) and parsimony. Points are assigned to each variable considered (Glasgow Coma Scale score, age, sex, intensive care unit admission, intubation, transfusion of blood products, central venous catheter placement, presence of pelvic or lower extremity fractures, and major surgery), and the points total is converted to a VTE risk score. The predicted risk of VTE ranged from 0.0% to 14.4%.
We developed a simple clinical tool to predict the risk of developing VTE in pediatric trauma patients. It is based on a model created using a large national database and was internally validated. The clinical tool requires external validation but provides an initial step toward the development of the specific VTE protocols for pediatric trauma patients.
尽管罕见，但儿科创伤患者的静脉血栓栓塞症（VTE）发病率正在增加，且 VTE 对儿童的影响显著。研究表明，老年儿科创伤患者的 VTE 风险增加，且机构干预可提高 VTE 发生率。虽然有针对成人的基于循证的 VTE 筛查和预防指南，但据我们所知，目前尚无针对儿科患者的指南。
为创伤后住院的儿科患者开发 VTE 风险预测计算器，以协助制定针对该人群的筛查和预防指南。
设计、地点和参与者：对 2007 年 1 月 1 日至 2012 年 12 月 31 日期间国家创伤数据库中 536423 名 0 至 17 岁的儿科患者进行回顾性分析。在训练数据集上拟合了五个具有不同复杂程度的混合效应逻辑回归模型。通过比较原始模型拟合的训练数据集和验证数据集的接受者操作特征曲线下面积（AUROC），确定模型的有效性。从最优模型中开发了一种基于个体患者临床特征预测 VTE 风险的临床工具。
住院期间 VTE 的诊断。
536423 名儿童中共有 1141 名（总体发生率为 0.2%）诊断为 VTE。每个模型在训练数据集中的 AUROC 均较高（范围为 0.873-0.946），在验证数据集中 AUROC 衰减最小。从实现高性能（训练和验证数据集中的 AUROC 分别为 0.945 和 0.932；P = .048）和简约性之间平衡的模型中开发了预测工具。为每个考虑的变量（格拉斯哥昏迷量表评分、年龄、性别、重症监护病房入院、插管、输血制品、中心静脉导管放置、骨盆或下肢骨折存在和大手术）分配分数，然后将分数总和转换为 VTE 风险评分。VTE 的预测风险范围为 0.0%至 14.4%。
我们开发了一种简单的临床工具，用于预测儿科创伤患者发生 VTE 的风险。它是基于一个使用大型国家数据库创建的模型，并进行了内部验证。该临床工具需要外部验证，但为制定儿科创伤患者的特定 VTE 方案提供了初步步骤。
