Venous Thromboembolism Prophylaxis in High-Risk Pediatric Trauma Patients.

IF 15.7 1区 医学 Q1 SURGERY JAMA surgery Pub Date : 2024-10-01 DOI:10.1001/jamasurg.2024.2487
Amanda B Witte, Kyle Van Arendonk, Carisa Bergner, Martin Bantchev, Richard A Falcone, Suzanne Moody, Heather A Hartman, Emily Evans, Rajan Thakkar, Kelli N Patterson, Peter C Minneci, Grace Z Mak, Mark B Slidell, MacKenton Johnson, Matthew P Landman, Troy A Markel, Charles M Leys, Linda Cherney Stafford, Jessica Draper, David S Foley, Cynthia Downard, Tracy M Skaggs, Dave R Lal, David Gourlay, Peter F Ehrlich
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Abstract

Importance: The indications, safety, and efficacy of chemical venous thromboembolism prophylaxis (cVTE) in pediatric trauma patients remain unclear. A set of high-risk criteria to guide cVTE use was recently recommended; however, these criteria have not been evaluated prospectively.

Objective: To examine high-risk criteria and cVTE use in a prospective multi-institutional study of pediatric trauma patients.

Design, setting, and participants: This cohort study was completed between October 2019 and October 2022 in 8 free-standing pediatric hospitals designated as American College of Surgeons level I pediatric trauma centers. Participants were pediatric trauma patients younger than 18 years who met defined high-risk criteria on admission. It was hypothesized that cVTE would be safe and reduce the incidence of VTE.

Exposures: Receipt and timing of chemical VTE prophylaxis.

Main outcomes and measures: The primary outcome was overall VTE rate stratified by receipt and timing of cVTE. The secondary outcome was safety of cVTE as measured by bleeding or other complications from anticoagulation.

Results: Among 460 high-risk pediatric trauma patients, the median (IQR) age was 14.5 years (10.4-16.2 years); 313 patients (68%) were male and 147 female (32%). The median (IQR) Injury Severity Score (ISS) was 23 (16-30), and median (IQR) number of high-risk factors was 3 (2-4). A total of 251 (54.5%) patients received cVTE; 62 (13.5%) received cVTE within 24 hours of admission. Patients who received cVTE after 24 hours had more high-risk factors and higher ISS. The most common reason for delayed cVTE was central nervous system bleed (120 patients; 30.2%). There were 28 VTE events among 25 patients (5.4%). VTE occurred in 1 of 62 patients (1.6%) receiving cVTE within 24 hours, 13 of 189 patients (6.9%) receiving cVTE after 24 hours, and 11 of 209 (5.3%) who had no cVTE (P = .31). Increasing time between admission and cVTE initiation was significantly associated with VTE (odds ratio, 1.01; 95% CI, 1.00-1.01; P = .01). No bleeding complications were observed while patients received cVTE.

Conclusions and relevance: In this prospective study, use of cVTE based on a set of high-risk criteria was safe and did not lead to bleeding complications. Delay to initiation of cVTE was significantly associated with development of VTE. Quality improvement in pediatric VTE prevention may center on timing of prophylaxis and barriers to implementation.

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高风险儿科创伤患者的静脉血栓栓塞预防。
重要性:儿科创伤患者预防化学性静脉血栓栓塞症(cVTE)的适应症、安全性和有效性仍不明确。最近推荐使用一套高风险标准来指导 cVTE 的使用,但尚未对这些标准进行前瞻性评估:在一项针对儿科创伤患者的多机构前瞻性研究中,研究高风险标准和 cVTE 的使用:这项队列研究于 2019 年 10 月至 2022 年 10 月期间在 8 家被指定为美国外科学院一级儿科创伤中心的独立儿科医院完成。参与者均为入院时符合规定高风险标准的 18 岁以下儿科创伤患者。假设 cVTE 是安全的,并能降低 VTE 的发生率:主要结果和测量指标:主要结果和测量指标:主要结果是按接受 cVTE 和时间分层的 VTE 总发生率。次要结果是根据抗凝治疗引起的出血或其他并发症来衡量 cVTE 的安全性:在 460 名高风险儿科创伤患者中,中位(IQR)年龄为 14.5 岁(10.4-16.2 岁);313 名患者(68%)为男性,147 名患者(32%)为女性。受伤严重程度评分(ISS)的中位数(IQR)为 23(16-30),高危因素的中位数(IQR)为 3(2-4)。共有 251 名(54.5%)患者接受了 cVTE;62 名(13.5%)患者在入院 24 小时内接受了 cVTE。24 小时后接受 cVTE 的患者具有更多的高危因素和更高的 ISS。延迟发生 cVTE 的最常见原因是中枢神经系统出血(120 例患者;30.2%)。25 名患者中发生了 28 起 VTE 事件(5.4%)。62 名患者中有 1 人(1.6%)在 24 小时内接受了 cVTE,189 名患者中有 13 人(6.9%)在 24 小时后接受了 cVTE,209 名患者中有 11 人(5.3%)没有发生 cVTE(P = .31)。从入院到开始接受 cVTE 的时间越长,VTE 的发生率越高(几率比 1.01;95% CI,1.00-1.01;P = .01)。在患者接受 cVTE 治疗期间,未观察到出血并发症:在这项前瞻性研究中,根据一套高风险标准使用 cVTE 是安全的,不会导致出血并发症。延迟开始使用 cVTE 与 VTE 的发生密切相关。提高儿科 VTE 预防质量的关键在于预防时机和实施障碍。
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来源期刊
JAMA surgery
JAMA surgery SURGERY-
CiteScore
20.80
自引率
3.60%
发文量
400
期刊介绍: JAMA Surgery, an international peer-reviewed journal established in 1920, is the official publication of the Association of VA Surgeons, the Pacific Coast Surgical Association, and the Surgical Outcomes Club.It is a proud member of the JAMA Network, a consortium of peer-reviewed general medical and specialty publications.
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