149 – Is early ambulation and/or mechanical intermittent devices sufficient for VTE prophylaxis in otherwise healthy pediatric patients undergoing orthopaedic procedures?

149 – Is early ambulation and/or mechanical intermittent devices sufficient for VTE prophylaxis in otherwise healthy pediatric patients undergoing orthopaedic procedures?

Robert F. Murphy, Chadi Tannoury.

Response/Recommendation: Considering the rarity of venous thromboembolism (VTE) events in healthy pediatric patients (under the age of 11 years) who undergo elective orthopaedic procedures, early ambulation and/or mechanical intermittent devices should be sufficient for VTE prophylaxis.  However, if a pediatric orthopaedic patient undergoes a trauma procedure or a major reconstruction resulting in immobility, requires critical care and/or central venous catheter placement, or carries other risk factors for VTE, prophylaxis with a supplementary pharmacologic agent should be considered.

Strength of Recommendation: For elective procedures: Moderate; For procedures following trauma and major reconstructive surgeries warranting critical care and/or immobility: Limited.

Rationale: The rate of VTE following pediatric orthopaedic procedures is extremely low and has been mostly reported in national database studies.  The lowest incidence rates of VTE have been reported in pediatric patients undergoing elective orthopaedic procedures, reaching as low as 0.0515%1, and 4 per 10,000 in another series2.  Reported rates rise to 0.10% when including patients who undergo any orthopaedic operation, including those for trauma and infection3.  The highest rates have been reported in reviews of patients following trauma (up to 0.68%), requiring postoperative critical care admissions (6%), requiring placement of a central venous catheter, and prolonged immobility4–6.

Literature is even more limited when reporting the rates of VTE in specific pediatric orthopaedic conditions or procedures.  A rate of 0.25% of symptomatic VTE was reported in a single-center cohort of adolescents undergoing knee arthroscopy7.  Jain et al., reported a rate of VTE of 21/10,000 spinal fusions in children and adolescents using data from the National Inpatient Sample (NIS)8.  The remainder of reports were based on surveys of members of the Pediatric Orthopaedic Society of North America (POSNA)9–11.

In the United States, guidelines published by the American Academy of Pediatrics (AAP) have provided recommendations for mechanical versus chemical prophylaxis based on risk assessment12.  Unfortunately, the only specific elective orthopaedic risk factor was for hip and knee reconstruction, and the only orthopaedic reference came from the American College of Chest Physicians (ACCP) guidelines, which focus on adult reconstruction13.  Nevertheless, when examining the AAP recommendations, early ambulation and mechanical prophylaxis appear to be sufficient for VTE prophylaxis following most pediatric orthopaedic operations.  High-risk scenarios where chemical prophylaxis should be considered include the presence of multiple other compounding risk factors, such as a history of VTE, obesity, sickle cell disease, oncologic diagnosis, and trauma, among others.  Similar risk-stratified recommendations have been provided by the Association of Paediatric Anaesthetists of Great Britain and Ireland14.

References:

1.         Georgopoulos G, Hotchkiss MS, McNair B, Siparsky G, Carry PM, Miller NH. Incidence of Deep Vein Thrombosis and Pulmonary Embolism in the Elective Pediatric Orthopaedic Patient. J Pediatr Orthop. 2016;36(1):101-109. doi:10.1097/BPO.0000000000000391

2.         Shore BJ, Hall M, Matheney TH, Snyder B, Trenor CC, Berry JG. Incidence of Pediatric Venous Thromboembolism After Elective Spine and Lower-Extremity Surgery in Children With Neuromuscular Complex Chronic Conditions: Do we Need Prophylaxis? J Pediatr Orthop. 2020;40(5):e375-e379. doi:10.1097/BPO.0000000000001483

3.         Baker D, Sherrod B, McGwin G, Ponce B, Gilbert S. Complications and 30-day Outcomes Associated With Venous Thromboembolism in the Pediatric Orthopaedic Surgical Population. J Am Acad Orthop Surg. 2016;24(3):196-206. doi:10.5435/JAAOS-D-15-00481

4.         Guzman D, Sabharwal S, Zhao C, Sabharwal S. Venous thromboembolism among pediatric orthopedic trauma patients: a database analysis. J Pediatr Orthop Part B. 2018;27(2):93-98. doi:10.1097/BPB.0000000000000424

5.         Murphy RF, Naqvi M, Miller PE, Feldman L, Shore BJ. Pediatric orthopaedic lower extremity trauma and venous thromboembolism. J Child Orthop. 2015;9(5):381-384. doi:10.1007/s11832-015-0697-1

6.         Hanson SJ, Punzalan RC, Arca MJ, et al. Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma Acute Care Surg. 2012;72(5):1292-1297. doi:10.1097/TA.0b013e31824964d1

7.         Murphy RF, Heyworth B, Kramer D, et al. Symptomatic Venous Thromboembolism After Adolescent Knee Arthroscopy. J Pediatr Orthop. 2019;39(3):125-129. doi:10.1097/BPO.0000000000000894

8.         Jain A, Karas DJ, Skolasky RL, Sponseller PD. Thromboembolic complications in children after spinal fusion surgery. Spine. 2014;39(16):1325-1329. doi:10.1097/BRS.0000000000000402

9.         Sabharwal S, Passannante MR. Venous thromboembolism in children: preliminary results of a survey of POSNA members. J Pediatr Orthop. 2013;33(8):852-856. doi:10.1097/BPO.0b013e3182a35c7e

10.       Sabharwal S, Zhao C, Passanante M. Venous thromboembolism in children: details of 46 cases based on a follow-up survey of POSNA members. J Pediatr Orthop. 2013;33(7):768-774. doi:10.1097/BPO.0b013e31829d55e3

11.       Murphy RF, Williams D, Hogue GD, et al. Prophylaxis for Pediatric Venous Thromboembolism: Current Status and Changes Across Pediatric Orthopaedic Society of North America From 2011. J Am Acad Orthop Surg. 2020;28(9):388-394. doi:10.5435/JAAOS-D-19-00578

12.       Meier KA, Clark E, Tarango C, Chima RS, Shaughnessy E. Venous thromboembolism in hospitalized adolescents: an approach to risk assessment and prophylaxis. Hosp Pediatr. 2015;5(1):44-51. doi:10.1542/hpeds.2014-0044

13.       Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S. doi:10.1378/chest.11-2404

14.       Morgan J, Checketts M, Arana A, et al. Prevention of perioperative venous thromboembolism in pediatric patients: Guidelines from the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI). Paediatr Anaesth. 2018;28(5):382-391. doi:10.1111/pan.13355

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