Children's Wisconsin, Medical College of Wisconsin, Milwaukee.
Nationwide Children's Hospital, Columbus, Ohio.
JAMA Surg. 2024 Oct 1;159(10):1149-1156. doi: 10.1001/jamasurg.2024.2487.
The indications, safety, and efficacy of chemical venous thromboembolism prophylaxis (cVTE) in pediatric trauma patients remain unclear. A set of high-risk criteria to guide cVTE use was recently recommended; however, these criteria have not been evaluated prospectively.
To examine high-risk criteria and cVTE use in a prospective multi-institutional study of pediatric trauma patients.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study was completed between October 2019 and October 2022 in 8 free-standing pediatric hospitals designated as American College of Surgeons level I pediatric trauma centers. Participants were pediatric trauma patients younger than 18 years who met defined high-risk criteria on admission. It was hypothesized that cVTE would be safe and reduce the incidence of VTE.
Receipt and timing of chemical VTE prophylaxis.
The primary outcome was overall VTE rate stratified by receipt and timing of cVTE. The secondary outcome was safety of cVTE as measured by bleeding or other complications from anticoagulation.
Among 460 high-risk pediatric trauma patients, the median (IQR) age was 14.5 years (10.4-16.2 years); 313 patients (68%) were male and 147 female (32%). The median (IQR) Injury Severity Score (ISS) was 23 (16-30), and median (IQR) number of high-risk factors was 3 (2-4). A total of 251 (54.5%) patients received cVTE; 62 (13.5%) received cVTE within 24 hours of admission. Patients who received cVTE after 24 hours had more high-risk factors and higher ISS. The most common reason for delayed cVTE was central nervous system bleed (120 patients; 30.2%). There were 28 VTE events among 25 patients (5.4%). VTE occurred in 1 of 62 patients (1.6%) receiving cVTE within 24 hours, 13 of 189 patients (6.9%) receiving cVTE after 24 hours, and 11 of 209 (5.3%) who had no cVTE (P = .31). Increasing time between admission and cVTE initiation was significantly associated with VTE (odds ratio, 1.01; 95% CI, 1.00-1.01; P = .01). No bleeding complications were observed while patients received cVTE.
In this prospective study, use of cVTE based on a set of high-risk criteria was safe and did not lead to bleeding complications. Delay to initiation of cVTE was significantly associated with development of VTE. Quality improvement in pediatric VTE prevention may center on timing of prophylaxis and barriers to implementation.
小儿创伤患者化学性静脉血栓栓塞症预防（cVTE）的适应证、安全性和疗效仍不清楚。最近推荐了一套指导 cVTE 使用的高危标准；然而，这些标准尚未经过前瞻性评估。
在一项针对小儿创伤患者的前瞻性多机构研究中，检查高危标准和 cVTE 的使用情况。
设计、地点和参与者：这项队列研究于 2019 年 10 月至 2022 年 10 月在 8 家独立的儿科医院进行，这些医院被指定为美国外科医师学会一级儿科创伤中心。参与者是年龄小于 18 岁的小儿创伤患者，入院时符合定义的高危标准。假设 cVTE 是安全的，可以降低 VTE 的发生率。
接受和时机化学性 VTE 预防。
主要结局是根据 cVTE 的接受和时机分层的总体 VTE 率。次要结局是 cVTE 的安全性，通过抗凝治疗的出血或其他并发症来衡量。
在 460 名高危小儿创伤患者中，中位（IQR）年龄为 14.5 岁（10.4-16.2 岁）；313 名患者（68%）为男性，147 名女性（32%）。损伤严重程度评分（ISS）的中位数（IQR）为 23（16-30），中位数（IQR）高危因素的数量为 3（2-4）。共有 251 名（54.5%）患者接受了 cVTE；62 名（13.5%）在入院后 24 小时内接受了 cVTE。在 24 小时后接受 cVTE 的患者具有更多的高危因素和更高的 ISS。延迟 cVTE 的最常见原因是中枢神经系统出血（120 例；30.2%）。在接受 cVTE 的 25 名患者中有 28 例 VTE 事件（5.4%）。在 24 小时内接受 cVTE 的 62 名患者中有 1 例（1.6%）发生 VTE，24 小时后接受 cVTE 的 189 名患者中有 13 例（6.9%）发生 VTE，而未接受 cVTE 的 209 名患者中有 11 例（5.3%）发生 VTE（P = .31）。入院和 cVTE 开始之间的时间间隔延长与 VTE 显著相关（优势比，1.01；95%CI，1.00-1.01；P = .01）。在接受 cVTE 的患者中没有观察到出血并发症。
在这项前瞻性研究中，根据一套高危标准使用 cVTE 是安全的，不会导致出血并发症。cVTE 起始时间的延迟与 VTE 的发生显著相关。儿科 VTE 预防的质量改进可能集中在预防的时机和实施的障碍上。
