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

Results

Of the 1,300 candidate and active members in POSNA, a total of 239 surveys were completed, an 18% response rate. Most respondents were from an academic/university practice (65%). Most (60%) of the respondents were in a small practice, reporting one or two partners. Half of the respondents were in practice ≥15 years, and >90% reported an almost exclusive pediatric practice (>75% pediatric patients). Fifty-one (21%) respondents could recall that they completed the survey in 2011, 127 (53%) did not complete, and 61 (26%) could not recall whether they completed the previous survey.

Seventy-five (33%) respondents reported familiarity with their institution-defined VTE prophylaxis protocol, and 49 (21%) were aware of an age limit at which their institutional implemented some form of VTE prophylaxis for all patients. The most frequently reported triggers for initiating institutional VTE prophylaxis protocols were the patient's diagnosis and age. Eighty-nine (40%) respondents were aware of the BESt guidelines on VTE prophylaxis in children. The most frequently listed risk factors to guide clinician implementation for VTE prophylaxis initiation were oral contraceptive use (194 responses), positive family history (174 responses), and obesity (169 responses). In patients without known risk factors for VTE, the most frequently listed age to start prophylaxis was 18 years, whereas in patients with known risk factors, the most frequently listed age dropped to 12 years.

When queried on utilization of particular agents of VTE prophylaxis, the most commonly listed mechanical agents used were compression devices or thromboembolic deterrent stockings, with 194 (87%) respondents reporting the usage of any mechanical prophylaxis. The most frequently listed chemical VTE prophylaxis agents of prophylaxis used were aspirin and enoxaparain, with 166 (73%) respondents reporting the usage of any chemical prophylaxis. If used, most respondents (164, 86%) initiated chemical prophylaxis within 24 hours of surgery, and respondents reported discontinuing chemical prophylaxis either when the patients mobilizes independently (46%) or at a predetermined time after surgery (41%). The four most commonly listed reasons for duration of mechanical or chemical VTE prophylaxis were age of the patient, the presence of comorbid risk factors, type of surgery, and period of immobility.

Respondents indicated with a similar frequency utilization of any type of VTE prophylaxis for spinal fusion (64%), hip reconstruction (60%), and trauma (65%). There was a lower frequency of the use of VTE prophylaxis in neuromuscular surgery (34%) (P < 0.001). The use of chemical prophylaxis was the lowest in spine surgery, with only eight respondents reporting the use of any chemical agent. The use of combined mechanical and chemical prophylaxis was highest in pelvis/lower extremity trauma surgery (56 respondents). Figure 1 demonstrates the frequency of responses for the use of any VTE prophylaxis agent in the four clinical scenarios.

Figure 1.

Chart illustrating the respondent frequency of usage of mechanical or chemical venous thromboembolism prophylaxis by surgery type.

Fifty-one current respondents had completed the previous survey on POSNA member VTE experience and practices.[13] Regarding the frequency of caring for a child with a VTE from 2011 to 2018, there has been a modest increase in DVT (55% versus 62%) and PE (29% versus 30%). A greater proportion of respondents in 2018, compared with 2011, reported using some agent for VTE prophylaxis, both mechanical (87% versus 77%; P = 0.006) and chemical (73% versus 55%; P < 0.001). Compared with responses from 2011, only 20 more respondents reported familiarity with their institutions' VTE prophylaxis protocol (75 versus 55). In 2018, aspirin was used more frequently than in 2011 (52% versus 19%; P < 0.001) and enoxaparin was used less frequently (20% versus 41%; P < 0.001).

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