Prophylaxis for Pediatric Venous Thromboembolism

Current Status and Changes Across Pediatric Orthopaedic Society of North America From 2011

Robert F. Murphy, MD; David Williams, PhD; Grant D. Hogue, MD; David D. Spence, MD; Howard Epps, MD; Henry G. Chambers, MD; Benjamin J. Shore, MD

Disclosures

J Am Acad Orthop Surg. 2020;28(9):388-394. 

In This Article

Abstract and Introduction

Abstract

Introduction: Pediatric venous thromboembolism (VTE) is a concern for orthopaedic surgeons. We sought to query the Pediatric Orthopaedic Society of North America (POSNA) members on current VTE prophylaxis practice and compare those results with those of a previous survey (2011).

Methods: A 35-question survey was emailed to all active and candidate POSNA members. The survey consisted of questions on personal and practice demographics; knowledge and implementation of various VTE prophylaxis protocols, mechanical and chemical VTE prophylaxis agents, and risk factors; and utilization of scenarios VTE prophylaxis agents for various clinical scenarios. One- and two-way frequency tables were constructed comparing results from the current survey and those of the 2011 survey.

Results: Two hundred thirty-nine surveys were completed (18% respondent rate), with most respondents from an academic/university practice reporting one or two partners (>60%). Half were in practice ≥15 years, and >90% reported an almost exclusive pediatric practice. One-third of the respondents reported familiarity with their institution-defined VTE prophylaxis protocol, and 20% were aware of an institutionally driven age at which all patients receive VTE prophylaxis. The most frequently recognized risk factors to guide VTE prophylaxis were oral contraceptive use, positive family history, and obesity. Respondents indicated a similar frequency of use of a VTE prophylaxis agent (either mechanical or chemical) for spinal fusion, hip reconstruction, and trauma (60% to 65%), with lower frequency for neuromuscular surgery (34%) (P < 0.001). One hundred thirty-seven respondents had a patient sustain a deep vein thrombosis, and 66 had a patient sustain a pulmonary embolism. Compared with responses from 2011, only 20 more respondents reported familiarity with their institution VTE prophylaxis protocol (75 versus 55). In 2018, aspirin was used more frequently than in 2011 (52% versus 19%; P < 0.0001) and enoxaparin was used less frequently (20% versus 41%; P < 0.0001).

Discussion: Over the past 7 years since the first POSNA survey on VTE prophylaxis, most POSNA members are still unaware of their institution specific VTE prophylaxis protocol. Most respondents agree that either mechanical or chemical VTE prophylaxis should be used for spinal fusion, hip reconstruction, and trauma. The use of aspirin as an agent of chemical VTE prophylaxis has increased since 2011.

Level of Evidence: Level IV. Type of evidence: therapeutic

Introduction

Venous thromboembolism (VTE) is a coagulopathic condition that manifests as a deep vein thrombosis (DVT), pulmonary embolism (PE), or both. However, in children, VTE is a relatively rare event for which there is a paucity of literature available. Recently, the reported rate of pediatric VTE appears to be increasing[1] and has been associated with critical care and trauma patients,[2] pediatric oncology patients,[3] cystic fibrosis patients,[4] and those with central venous catheters.[5] Pediatric VTE events are a growing concern for pediatric orthopaedic surgeons because recent publications have reported on the rates of VTE associated with lower extremity trauma[6,7] and operative pediatric orthopaedic patients.[8,9] However, limited data exist on the optimal strategies for prophylaxis against VTE in children and, in particular, pediatric orthopaedic patients.

Recently, the Best evidence statement (BESt) for VTE prophylaxis in children was published and has been implemented in many children's hospitals across the United States.[10] Increasing pressure across North American children's hospitals to adopt a prophylaxis practice exists; however, the orthopaedic guidelines included in the BESt statement come from the adult literature regarding hip and knee reconstruction, which is not a relevant risk factor in most pediatric orthopaedic patients. Other authors have also proposed guidelines[10–12] to assist clinicians in assessing the risk factors for VTE and guiding mechanical or chemical VTE prophylaxis. However, these guidelines may not be applicable to all pediatric orthopaedic patients.

In 2011, Sabharwal and Passainnante[13] surveyed the membership of the Pediatric Orthopaedic Society of North America (POSNA) regarding clinical experience and practice patterns regarding VTE and VTE prophylaxis. At that time, 55% of the responding POSNA members could recall a pediatric patient with a DVT and 29% could recall a patient with a PE. However, despite the prevalence of this condition, only 77% of the respondents had used mechanical prophylaxis and 55% had used chemical prophylaxis agents against VTE. Furthermore, only 16% of the respondents were familiar with an institutional protocol for VTE prophylaxis. Sabharwal's survey highlighted the significant practice variation associated with pediatric VTE, and this survey was followed up with a detailed report on the clinical characteristics associated with 46 cases of VTE.[14]

Therefore, the purpose of this study was twofold. First, we sought to query the POSNA members on current practices on the assessment of and prophylaxis against pediatric VTE. Second, we sought compare those results with those of the original survey by Sabharwal and Passannante[13] in 2011 and determine the significance of any differences. We hypothesized that the overall VTE awareness and prophylaxis practice across POSNA has increased significantly over the past 7 years.

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