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Venous Thromboembolism Prophylaxis In Trauma Patients: Practice Gap...
hosted by Dr. Todd Ponsky
Chapter 1 of 4 · Fundamentals
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Pediatric surgeons historically did not routinely address VTE prophylaxis, with general teaching some time ago being that kids just didn't get this problem.
Recognition of pediatric VTE has increased significantly over the last 10-20 years, possibly to the point of overuse (e.g., SCDs for 30-minute inguinal hernia repairs).
The Midwest Pediatric Surgery Consortium is conducting a multi-center study (at 11 centers) of a standardized VTE prophylaxis protocol involving chemoprophylaxis with antithrombin 1A, compression devices, and daily ultrasound evaluation.
The number of DVT complications in pediatric patients is very small but catastrophic when they occur.
The vast majority of pediatric DVTs occur around central lines, and all central lines have a fibrin sheath if examined closely.
SCDs should be activated prior to induction of anesthesia in the operating room.
The Landish article (David Gourlay's article) is probably the best protocol available for pediatric VTE prophylaxis and forms the basis for the MWPSC multi-center study.
The theoretically correct answer for the case is screening ultrasound on ICU day 7, because pharmacologic prophylaxis is contraindicated due to significant head bleed.
A 2017 seminars summary by Dr. Perry (current chair of the Abstinence trauma Committee) provides a comprehensive review of pediatric VTE prophylaxis in trauma.
VTE incidence in pediatric trauma patients is estimated between 0.16% and 1%, probably on the order of 1% or less in general.
In adult trauma patients, VTE incidence is about 3-5%.
In adult neuro trauma patients, VTE incidence is significantly higher at 10-15%.
Pediatric VTE risk factors include central catheters, inflammatory bowel disease (chronic inflammatory states), blood transfusion, and obesity.
According to the Landish schema, high-risk patients are defined as those greater than 12 years with one or more risk factors, or less than 12 years with more than 4 risk factors.
For high-risk patients without bleeding concerns, treatment is low molecular weight heparin plus SCDs until ambulatory.
For high-risk patients who are not candidates for pharmacologic prophylaxis, treatment is SCDs until ambulatory plus screening ultrasound on day 7.