儿童创伤患者静脉血栓栓塞的预防：来自东部创伤外科学会和儿童创伤学会的实践管理指南。
Prophylaxis against venous thromboembolism in pediatric trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society.
作者信息
Mahajerin Arash, Petty John K, Hanson Sheila J, Thompson A Jill, O'Brien Sarah H, Streck Christian J, Petrillo Toni M, Faustino E Vincent S
机构信息
Division of Hematology, Department of Pediatrics, University of California Irvine School of Medicine, Orange, California (A.M.); Division of Pediatric Surgery, Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (J.K.P.); Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (S.J.H.); Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina (A.J.T.); Division of Hematology and Oncology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio (S.H.O.); Division of Pediatric Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina (C.J.S.); Division of Critical Care, Department of Pediatrics Emory School of Medicine, Atlanta, Georgia (T.M.P.); and Section of Pediatric Critical Care, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut (E.V.S.F.).
出版信息
J Trauma Acute Care Surg. 2017 Mar;82(3):627-636. doi: 10.1097/TA.0000000000001359.
BACKGROUND
Despite the increasing incidence of venous thromboembolism (VTE) in hospitalized children, the risks and benefits of VTE prophylaxis, particularly for those hospitalized after trauma, are unclear. The Pediatric Trauma Society and the Eastern Association for the Surgery of Trauma convened a writing group to develop a practice management guideline on VTE prophylaxis for this cohort of children using the Grading of Recommendations Assessment, Development, and Evaluation framework.
METHODS
A systematic review of MEDLINE using PubMed from January 1946 to July 2015 was performed. The search retrieved English-language articles on VTE prophylaxis in children 0 to 21 years old with trauma. Topics of investigation included pharmacologic and mechanical VTE prophylaxis, active radiologic surveillance for VTE, and risk factors for VTE.
RESULTS
Forty-eight articles were identified and 14 were included in the development of the guideline. The quality of evidence was low to very low because of the observational study design and risks of bias.
CONCLUSIONS
In children hospitalized after trauma who are at low risk of bleeding, we conditionally recommend pharmacologic prophylaxis be considered for children older than 15 years old and in younger postpubertal children with Injury Severity Score (ISS) greater than 25. For prepubertal children, even with ISS greater than 25, we conditionally recommend against routine pharmacologic prophylaxis. Second, in children hospitalized after trauma, we conditionally recommend mechanical prophylaxis be considered for children older than 15 years and in younger postpubertal children with ISS greater than 25 versus no prophylaxis or in addition to pharmacologic prophylaxis. Lastly, in children hospitalized after trauma, we conditionally recommend against active surveillance for VTE with ultrasound compared with routine daily physical examination alone for earlier detection of VTE. The limited pediatric data and paucity of high-quality evidence preclude providing more definitive recommendations and highlight the need for clinical trials of prophylaxis.
LEVEL OF EVIDENCE
Systematic review/meta-analysis, level III.
背景
尽管住院儿童静脉血栓栓塞症（VTE）的发病率不断上升，但VTE预防的风险和益处，尤其是对创伤后住院儿童而言，仍不明确。儿科创伤学会和东部创伤外科学会召集了一个写作小组，使用推荐分级评估、制定和评价框架，为这一儿童群体制定VTE预防的实践管理指南。
方法
对1946年1月至2015年7月期间使用PubMed的MEDLINE进行系统评价。检索出关于0至21岁创伤儿童VTE预防的英文文章。研究主题包括药物和机械性VTE预防、VTE的主动放射学监测以及VTE的危险因素。
结果
共识别出48篇文章，其中14篇纳入指南制定。由于观察性研究设计和偏倚风险，证据质量低至极低。
结论
对于创伤后住院且出血风险低的儿童，我们有条件地建议，对于15岁以上儿童以及青春期后受伤严重程度评分（ISS）大于25的较年幼儿童，考虑进行药物预防。对于青春期前儿童，即使ISS大于25，我们有条件地建议不进行常规药物预防。其次，对于创伤后住院儿童，我们有条件地建议，对于15岁以上儿童以及青春期后ISS大于25的较年幼儿童，考虑进行机械预防，而非不预防或在药物预防之外进行。最后，对于创伤后住院儿童，我们有条件地建议，与仅进行常规每日体格检查相比，不建议采用超声对VTE进行主动监测以更早发现VTE。儿科数据有限且高质量证据匮乏，无法提供更明确的建议，并凸显了预防临床试验的必要性。
证据级别
系统评价/荟萃分析，III级。
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