Venous Thromboembolism in Critical Illness and Trauma: Pediatric Perspectives

Abstract

Critically ill children and those sustaining severe traumatic injuries are at higher risk for developing venous thromboembolism (VTE) than other hospitalized children. Multiple factors including the need for central venous catheters, immobility, surgical procedures, malignancy, and dysregulated inflammatory state confer this increased risk. As well as being at higher risk of VTE, this population is frequently at an increased risk of bleeding, making the decision of prophylactic anticoagulation even more nuanced. The use of pharmacologic and mechanical prophylaxis remains variable in this high-risk cohort. VTE pharmacologic prophylaxis is an accepted practice in adult trauma and intensive care to prevent VTE development and associated morbidity, but it is not standardized in critically ill or injured children. Given the lack of pediatric specific guidelines, prevention strategies are variably extrapolated from the successful use of mechanical and pharmacologic prophylaxis in adults, despite the differences in developmental hemostasis and thrombosis risk between children and adults. Whether the burden of VTE can be reduced in the pediatric critically ill or injured population is not known given the lack of robust data. There are no trials in children showing efficacy of mechanical compression devices or prophylactic anticoagulation in reducing the rate of VTE. Risk stratification using clinical factors has been shown to identify those at highest risk for VTE and allows targeted prophylaxis. It remains unproven if such a strategy will mitigate the risk of VTE and its potential sequelae.

ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state

“…An arterial catheter may, rarely, be necessary in some critically ill patients managed in an intensive care unit. Unless absolutely necessary, avoid placing a central venous catheter because of the high risk of thrombosis, especially in the very young child. If a central catheter has been inserted, the catheter should be removed as soon as the patient's clinical status permits . Mechanical and pharmacologic prophylaxis (low molecular weight heparin) should be considered especially in children >12 years. Insulin should preferably not be given through a central line unless it is the only available option because its infusion may be interrupted when other fluids are given through the same line. Give antibiotics to febrile patients after obtaining appropriate cultures of body fluids. Bladder catheterization usually is not necessary, but if the child is unconscious or unable to void on demand (eg, infants and very ill young children) the bladder should be catheterized. Obtain a blood sample for laboratory measurement of: serum or plasma glucose electrolytes (including serum bicarbonate) blood urea nitrogen, creatinine serum osmolality venous pH, pCO2 hemoglobin, hematocrit and complete blood count.…”

“…An arterial catheter may, rarely, be necessary in some critically ill patients managed in an intensive care unit. Unless absolutely necessary, avoid placing a central venous catheter because of the high risk of thrombosis, especially in the very young child. If a central catheter has been inserted, the catheter should be removed as soon as the patient's clinical status permits . Mechanical and pharmacologic prophylaxis (low molecular weight heparin) should be considered especially in children >12 years. Insulin should preferably not be given through a central line unless it is the only available option because its infusion may be interrupted when other fluids are given through the same line. …”

Trauma-Induced Coagulopathy in Children

“…87,90 The following risk factors for VTE in pediatric trauma patients have been identified: increasing age, injury severity, indwelling central venous catheters, total parenteral nutrition, immobility, pressor support, TBI, and AHT. 86,88,[91][92][93] The effectiveness of pharmacological prophylaxis against VTE in children is largely unknown and is assumed to be similar to that in adults or postpubertal adolescents. The Eastern Association for the Surgery of Trauma published guidelines in 2016 that suggest the use of pharmacological prophylaxis in children aged 15 years and older with low bleeding risk and younger than 15 years but postpubertal with an injury severity score of > 25.…”

Association of perioperative red blood cell transfusion with postoperative venous thromboembolism in pediatric patients: A propensity score matched analysis

“…The incidence of venous thromboembolism (VTE) appears is rising in the pediatric population . Although enhanced vigilance through screening and diagnostic imaging likely has contributed to this rise, the expanded utilization of central venous catheters, which may create local or systemic prothrombotic states, is also likely a major contributor . We are also seeing increasingly complex operations being performed on increasingly complex patients.…”