Pediatric trauma venous thromboembolism prediction algorithm outperforms current anticoagulation prophylaxis guidelines: a pilot study

Abstract

Purpose Venous thromboembolism (VTE) in injured children is rare, but sequelae can be morbid and life-threatening. Recent trauma society guidelines suggesting that all children over 15 years old should receive thromboprophylaxis may result in overtreatment. We sought to evaluate the efficacy of a previously published VTE prediction algorithm and compare it to current recommendations. Methods Two institutional trauma registries were queried for all pediatric (age < 18 years) patients admitted from 2007 to 2018. Clinical data were applied to the algorithm and the area under the receiver operating characteristic (AUROC) curve was calculated to test algorithm efficacy. Results A retrospective review identified 8271 patients with 30 episodes of VTE (0.36%). The VTE prediction algorithm classified 51 (0.6%) as high risk (> 5% risk), 322 (3.9%) as moderate risk (1-5% risk) and 7898 (95.5%) as low risk (< 1% risk). AUROC was 0.93 (95% CI 0.89-0.97). In our population, prophylaxis of the 'moderate-' and 'high-risk' cohorts would outperform the sensitivity (60% vs. 53%) and specificity (96% vs. 77%) of current guidelines while anticoagulating substantially fewer patients (373 vs. 1935, p < 0.001). Conclusion A VTE prediction algorithm using clinical variables can identify injured children at risk for venous thromboembolic disease with more discrimination than current guidelines. Prospective studies are needed to investigate the validity of this model. Level of evidence III-Clinical decision rule evaluated in a single population.

Use of Pharmacologic Prophylaxis Against Venous Thromboembolism in Hospitalized Injured Children

“…The frequency of patients who received pharmacologic prophylaxis in our study is consistent with others who reported frequencies ranging from 1% to 18%. 8,10,[23][24][25] These frequencies are low compared with hospitalized injured adults of whom > 60% receive pharmacologic prophylaxis. 26 However, it is unclear if these frequencies in children are inappropriately low given the paucity of pediatric-specific evidence on the effectiveness of pharmacologic prophylaxis.…”

“…An extension of the Wilcoxon rank sum test was used to test for linear trends across years in proportions of patients 18. Using κ statistic, we estimated the concordance between receipt of pharmacologic prophylaxis and practice management guideline and between receipt of pharmacologic prophylaxis and predicted risk of VTE ≥1.0% 8. Multivariable analyses were conducted using logistic regression models with receipt of pharmacologic prophylaxis, receipt of LMWH vs UFH or hospitalization to a level 1 pediatric trauma center as dependent variable.…”

“…18 Using κ statistic, we estimated the concordance between receipt of pharmacologic prophylaxis and practice management guideline and between receipt of pharmacologic prophylaxis and predicted risk of VTE ≥ 1.0%. 8 Multivariable analyses were conducted using logistic regression models with receipt of pharmacologic prophylaxis, receipt of LMWH vs UFH or hospitalization to a level 1 pediatric trauma center as dependent variable. Time of start of pharmacologic prophylaxis was categorized as < 24 hours, 24 to < 48 hours, 48 to < 72 hours, and ≥ 72 hours after admission, and was analyzed using ordinal logistic regression.…”

Venous thromboembolic risk stratification in pediatric trauma: A Pediatric Trauma Society Research Committee multicenter analysis

“…International Classification of Diseases, Ninth or Tenth Revision (ICD-9/10), codes from each institution's respective trauma registry identified endotracheal intubation, blood product transfusion, central venous line (CVL) placement, pelvic or lower extremity fracture, and major surgical procedures. 12 Endotracheal intubation was defined as >2 hours of ventilator time exclusive of operative procedure. Lower extremity fractures were defined as fractures from the femur to the level of the metatarsal, and CVLs include both centrally and peripherally inserted central catheters (PICCs).…”

Use of a real-time risk-prediction model to identify pediatric patients at risk for thromboembolic events: study protocol for the Children’s Likelihood Of Thrombosis (CLOT) trial

“…Risk-prediction models have been shown to identify patients at elevated risk for venous thromboembolism (VTE) better than physician judgment alone [ 6 , 7 ]. However, these models are often limited to specific subpopulations—including patients undergoing surgery [ 8 , 9 ], patients admitted to the intensive care unit [ 10 ] or to the general wards [ 11 ], and patients with malignancy [ 12 ]—and are mostly derived from case–control studies [ 13 – 16 ].…”