A New Risk Assessment Model for Hospital-Acquired Venous Thromboembolism in Critically Ill Children: A Report From the Children’s Hospital-Acquired Thrombosis Consortium

Abstract

To create a risk model for hospital-acquired venous thromboembolism in critically ill children upon admission to an ICU. DESIGN:Case-control study. SETTING:ICUs from eight children's hospitals throughout the United States. SUBJECTS:Critically ill children with hospital-acquired venous thromboembolism (cases) 0-21 years old and similar children without hospital-acquired venous thromboembolism (controls) from January 2012 to December 2016. Children with a recent cardiac surgery, asymptomatic venous thromboembolism, or a venous thromboembolism diagnosed before ICU admission were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:The multi-institutional Children's Hospital-Acquired Thrombosis registry was used to identify cases and controls. Multivariable logistic regression was used to determine the association between hospital-acquired venous thromboembolism and putative risk factors present at or within 24 hours of ICU admission to develop the final model. A total of 548 hospital-acquired venous thromboembolism cases (median age, 0.8 yr; interquartile range, 0.1-10.2) and 187 controls (median age, 2.4 yr; interquartile range, 0.2-8.3) were analyzed. In the multivariable model, recent central venous catheter placement (odds ratio, 4.4; 95% CI, 2.7-7.1), immobility (odds ratio 3.6, 95% CI, 2.1-6.2), congenital heart disease (odds ratio 2.9, 95% CI, 1.7-4.7), length of hospital stay prior to ICU admission greater than or equal to 3 days (odds ratio, 2.5; 95% CI, 1.1-5.6), and history of autoimmune/inflammatory condition or current infection (odds ratio, 2.1; 95% CI, 1.2-3.4) were each independently associated with hospital-acquired venous thromboembolism. The risk model had an area under the receiver operating characteristic curve of 0.79 (95% CI, 0.73-0.84). CONCLUSIONS:Using the multicenter Children's Hospital-Acquired Thrombosis registry, we identified five independent risk factors for hospitalacquired venous thromboembolism in critically ill children, deriving a new hospital-acquired venous thromboembolism risk assessment model. A prospective validation study is underway to define a high-risk group for risk-stratified interventional trials investigating the efficacy and safety of prophylactic anticoagulation in critically ill children.

Current practices in pediatric hospital‐acquired thromboembolism: Survey of the Children's Hospital Acquired Thrombosis (CHAT) Consortium

“…Beyond these previously identified risks, our survey results show concern for the impact of systemic inflammation, which is in line with previous CHAT studies. 6,13 Our survey elucidated specific concerns with prescribing prophylaxis in the pediatric population.…”

“…In 2012, to overcome this paucity of guidelines, the Children's Hospitals' Solutions for Patient Safety (SPS), a quality improvement network of over 130 children's hospitals aiming to reduce hospital‐acquired conditions, created recommendations based on expert opinion for HA‐VTE prevention including risk factors and prevention strategies, such as the use of sequential compression devices and pharmacologic prophylaxis based on the level of VTE risk 10 . These recommendations are still not standardly implemented by children's hospitals 6,11–13 . The multicenter Children's Hospital‐Acquired Thrombosis (CHAT) Consortium created a registry to identify HA‐VTE risk factors and developed two HA‐VTE risk assessment models (RAMs) to be applied to children upon hospital admission 6,13,14 .…”

“…10 These recommendations are still not standardly implemented by children's hospitals. 6,[11][12][13] The multicenter Children's Hospital-Acquired Thrombosis (CHAT) Consortium created a registry to identify HA-VTE risk factors and developed two HA-VTE risk assessment models (RAMs) to be applied to children upon hospital admission. 6,13,14 The first of these RAMs was created to identify HA-VTE risk for all hospitalized children at hospital admission, while the second RAM focused on those who were critically ill at admission or transfer into an intensive care unit.…”

“…6,13,14 The first of these RAMs was created to identify HA-VTE risk for all hospitalized children at hospital admission, while the second RAM focused on those who were critically ill at admission or transfer into an intensive care unit. 6,13 The highest-risk variables for HA-VTE identified by the CHAT RAM for hospitalized children included both presence of a central venous catheter (CVC) and complete immobility defined by Braden mobility score 1 15 upon admission. 6 To identify the current HA-VTE practices and implementation of guidelines for pediatric HA-VTE risk assessment and prevention strategies, we surveyed members of the US-based, multicenter CHAT Consortium.…”

A Narrative Review of Postoperative Anticoagulation Therapy for Congenital Cardiac Disease

“…Surgical advancements have significantly increased the lifespan of children with CHD; however, postoperative complications of bleeding and thrombosis remain a significant cause of morbidity and mortality ( 3 ). CHD is also independently associated with non-cardiac hospital-acquired venous thromboembolism in the multi-institutional Children’s Hospital-Acquired Thrombosis registry ( 4 ). Despite these recognized risks, methods of immediate and/or long-term anticoagulation after congenital heart surgery remain variable and controversial.…”