Venous Thromboembolism among Critically Ill Children: A Narrative Review

Abstract

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality among hospitalized patients, including children. In recent years, it has become clear that hospitalization and critical illness bestow an increased VTE risk in pediatrics and relate to mortality and life-limiting comorbidities. For critically ill children, reported rates of VTE vary by study sampling techniques, presence of inherited or acquired thrombophilia, acute and chronic immobility, underlying illness prompting hospitalization, and clinical factors related to illness severity such as central venous catheterization, length of stay, mechanical ventilation, and patient age. Accordingly, critically ill children with new signs of venous congestion, acute inflammation, or unexplained acute organ dysfunction should be routinely evaluated for VTE. This narrative review summarizes recent and historical literature regarding risk factors, prevention, presentation, treatment, and outcomes of VTE in critically ill children. In addition, we identify knowledge gaps and priorities for future collaborative research on this vital condition. Special attention is given to the clinical trial opportunities, challenges, and ongoing efforts in thromboprophylaxis in critically ill children, including those hospitalized for disease related to novel coronavirus (COVID-19) and multisystem inflammatory disease in children.

Venous Thromboembolism among Noncritically Ill Hospitalized Children: Key Considerations for the Pediatric Hospital Medicine Specialist

“…Initial descriptors often include the anatomical distribution of the vasculature affected (e.g., distal vs. central, superficial vs. deep) or organ systems affected (e.g., renal vein thrombosis, cerebral sinovenous thrombosis, or PE) due to their association with clinical sequelae related to the specific location (summarized in Sochet et al). 6 Thrombi are further categorized based on symptoms at the time of presentation (symptomatic vs. asymptomatic), extent (occlusive vs. nonocclusive), duration (acute vs. chronic), recurrence (first episode vs. recurrent), and underlying cause (provoked vs. unprovoked). 7 Additional descriptors include whether or not the VTE occurred during hospitalization (HA-VTE) and whether it was associated with a venous catheter (catheter-related thromboembolism [CRT]).…”

The Incidence of Thromboembolic Events During Hospitalizations Following Surgical Resection of Lower Extremity Sarcomas in Children: Utilizing the Pediatric Health Information System Database

“…Venous thromboembolism (VTE) is a frequent occurrence during treatment for adults with sarcoma, and the British Orthopaedic Oncology Society VTE Committee recommends consideration of mechanical and chemical VTE prophylaxis for adults undergoing orthopaedic oncologic surgery, with special consideration for high-risk patients (pelvic or hip resections, prosthetic reconstruction, malignant diagnosis, presence of metastases, or surgical procedures longer than 3 hours) 1. These risk factors for the development of deep venous thrombosis (DVT) and pulmonary embolism (PE) among adults have been well-established for many years 2–5. Heit et al5 reported a 22-fold increased risk of VTE in patients who underwent recent surgery, a 4-fold increase in patients with malignant neoplasms with an additional 2-fold increase in those undergoing concurrent chemotherapy, and an 8-fold increase in patients confined to hospitals and nursing homes due to relative immobilization.…”

“…Previous studies have reported a VTE incidence of 0.07 to 0.14 per 10,000 children7 with greater frequency in critically ill children 2,8,9. Existing protocols in various institutions for thromboprophylaxis in hospitalized pediatric populations have been reported to vary significantly along with provider perceptions 4,10,11. A survey by Badawy et al12 (2016) showed that <42% of centers had any institutional policies and 55% of respondents reported an unwillingness to administer universal pharmacological thromboprophylaxis for children.…”

“…1 These risk factors for the development of deep venous thrombosis (DVT) and pulmonary embolism (PE) among adults have been well-established for many years. [2][3][4][5] Heit et al 5 reported a 22-fold increased risk of VTE in patients who underwent recent surgery, a 4-fold increase in patients with malignant neoplasms with an additional 2-fold increase in those undergoing concurrent chemotherapy, and an 8-fold increase in patients confined to hospitals and nursing homes due to relative immobilization. The Caprini et al risk assessment model provides a weighted score for the development of DVT based on a large array of risk factors that are often utilized for guidelines of perioperative chemoprophylaxis.…”

“…2,8,9 Existing protocols in various institutions for thromboprophylaxis in hospitalized pediatric populations have been reported to vary significantly along with provider perceptions. 4,10,11 A survey by Badawy et al 12 (2016) showed that <42% of centers had any institutional policies and 55% of respondents reported an unwillingness to administer universal pharmacological thromboprophylaxis for children. Accordingly, the approach to thromboprophylaxis in the pediatric population may require a more highly risk-stratified approach, which targets a subpopulation at substantively higher than baseline/average VTE risk.…”