Robert F. Murphy, Chadi Tannoury.
Response/Recommendation: Considering the rarity of venous thromboembolism (VTE) events in healthy pediatric and adolescent patients undergoing elective orthopaedic procedures, early ambulation and/or mechanical intermittent devices are sufficient for the prevention of VTE. However, pediatric orthopaedic patients undergoing surgery following major trauma, as well as patients undergoing major reconstruction resulting in prolonged immobilization, require critical care. Additionally, they exhibit other risk factors for VTE, and prophylaxis with a supplementary pharmacologic agent should be considered.
Strength of Recommendation: Moderate.
Rationale: Studies of national databases have found that the incidence of VTE following pediatric orthopaedic procedures is generally quite low. The lowest incidence rates of VTE have been reported in pediatric patients undergoing elective orthopaedic procedures, with estimates as low as 0.0515%1, and 0.04%2. Additionally, the incidence of VTE rose to 0.10% when including patients undergoing any orthopedics procedure, including patients where the indication was trauma or infection3. The highest rates have been reported in studies of pediatric orthopaedic patients undergoing surgery following trauma (up to 0.68%)4,5.
Current literature is also considerably limited when examining the rates of VTE occurrence in specific pediatric orthopaedic conditions or procedures. In one study of adolescents undergoing knee arthroscopy, 0.25% of patients experienced a symptomatic VTE event6. Additionally, Jain et al., found that in a review of the National Inpatient Sample (NIS), 0.21% of pediatric patients undergoing spinal fusion surgery experienced a VTE event7. The remainder of studies were surveys of current members of the Pediatric Orthopaedic Society of North America (POSNA)8–10.
Clinical practice guidelines (CPG) by the American Academy of Pediatrics (AAP) recommend that the decision of whether to use mechanical or chemical prophylaxis be determined based on the level of an individual patient’s VTE risk11. Unfortunately, the only specific elective orthopaedic risk factor was for hip and knee reconstruction. Additionally, the only orthopaedic reference came from the American College of Chest Physicians (ACCP) guidelines, which focus on adult reconstruction12. Nevertheless, the AAP guidelines found that early ambulation and mechanical prophylaxis were adequate for the prevention of VTE following most pediatric orthopaedic operations. However, they do list certain high-risk scenarios where chemical prophylaxis must be considered. These include patients with a history of prior VTE, obesity, immobility, and trauma. Similarly, recommendations on effective risk-stratification models have been provided by the Association of Pediatric Anesthetists of Great Britain and Ireland13.
In conclusion, the utilization of existing risk stratification tools and prediction algorithms may help delineate which patients are at an increased risk of VTE following orthopaedic procedures14–16.
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. 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
5. 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
6. 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
7. 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
8. 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
9. 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
10. 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
11. 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
12. 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
13. 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
14. Cunningham AJ, Dewey E, Hamilton NA, Schreiber MA, Krishnaswami S, Jafri MA. Validation of a venous thromboembolism prediction algorithm for pediatric trauma: A national trauma data bank (NTDB) analysis. J Pediatr Surg. 2020;55(6):1127-1133. doi:10.1016/j.jpedsurg.2020.02.032
15. Connelly CR, Laird A, Barton JS, et al. A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients. JAMA Surg. 2016;151(1):50-57. doi:10.1001/jamasurg.2015.2670
16. Atchison CM, Arlikar S, Amankwah E, et al. Development of a new risk score for hospital-associated venous thromboembolism in noncritically ill children: findings from a large single-institutional case-control study. J Pediatr. 2014;165(4):793-798. doi:10.1016/j.jpeds.2014.05.053