Enric Castellet, Míriam Basagaña-Farrés.
Response/Recommendation: Gender does not influence the choice of venous thromboembolism (VTE) prophylaxis. However, high-risk pediatric patients ³ 13-years old may benefit from the administration of VTE prophylaxis.
Strength of Recommendation: Strong.
Rationale: Several clinical practice guidelines (CPG) have repeatedly identified adolescence as an independent risk factor for the development of VTE. Conversely, patient gender has not been recognized as a risk factor for the development of VTE. Most studies refer to skeletal maturity as chronologic age. Terminology such as “puberty” and “adolescence” is also used by some authors1-6. Unlike in adults, there is a scarcity of evidence on the risks and benefits of VTE prophylaxis in children. In addition, most of the existing studies were carried out in pediatric patients who sustained traumatic injuries21-24, with very few evaluating patients undergoing elective orthopaedic procedures25-28.
Interventions to prevent VTE include early postoperative ambulation, mechanical prophylaxis, and pharmacologic prophylaxis. The VTE risk threshold for administration of prophylaxis must evaluate both the harm of a VTE event, as well as the possible adverse side effects brought on by the prophylactic agent itself29-38.
Most studies evaluating the incidence of VTE in pediatric patients showed no difference in risk with respect to gender39-47. Some isolated studies identified female gender as a contributing factor; however, the level of risk contribution was negligible compared to other risk factors48-49.
The precise age at which pediatric patients are at highest risk of VTE remains unknown. The evidence to date currently suggests that in pediatric patients undergoing orthopaedic procedures, children ³ 13-years old are at the highest risk of VTE development50-51.
Due to the low incidence of VTE in the pediatric orthopaedic surgical patients, and the considerable risks associated with thromboprophylaxis administration, universal thromboprophylaxis cannot be recommended44. The age at which a pediatric patient is considered at significant risk for VTE development remains a contentious issue. Age cut-offs for VTE risk tend to range from 9 to 15. The ambivalence towards age and risk is best reflected in a national multidisciplinary consensus study on VTE in pediatric trauma. They found that the risk of VTE appears augment in early adolescence and continues to increase into young adulthood44.
A survey of pediatric trauma practices indicated that 13% of trauma centres described their utilization of low-molecular-weight heparin (LMWH) prophylaxis in patients aged 11 to 15 as “often” or “always.” Additionally, the incidence increased to 57% in patients aged 16 to 204.
In 2017 the Pediatric Trauma Society (PTS), in conjunction with the Eastern Association of Surgery for Trauma (EAST), conducted a systematic review and published CPG on prophylaxis against VTE in pediatric trauma53. They recommended that pharmacologic and/or mechanical thromboprophylaxis be considered in all pediatric trauma patients ³ 15 years-old who are at low risk of bleeding. However, due to the inadequacies of available data, the significance of these CPG was limited. Additionally, there is no evidence to support routine surveillance with ultrasound screening for VTE in injured children54.
In one study, Hanson et al.51, concluded that despite the low incidence of VTE, emerging data indicates that critically injured adolescent patients are at significant risk of developing VTE. As the risk of bleeding with prophylactic doses of LMWH is quite low, critically injured adolescent patients is one population that stands to benefit greatly from the implementation of a protocol for VTE prophylaxis. In conjunction with mechanical prophylaxis, LMWH is appropriate for many critically injured adolescent patients who have a low risk of bleeding. CPG on early and aggressive postoperative mobilization have helped drastically reduce VTE occurrence and must continue to be part of the standard of care.
In a recent meta-analysis of studies on VTE risk factors and VTE risk-assessment models, Mahajerin et al.53, found that in children with a low risk of bleeding who are hospitalized for a traumatic injury, pharmacologic prophylaxis should be considered for those > 15 years old and in younger post-pubertal children with injury severity score (ISS) > 25. Furthermore, we recommend against the use of routine pharmacologic prophylaxis in pre-pubertal children, even those with ISS >25. Similarly, current EAST guidelines state that pharmacologic prophylaxis should only be used in either children ³ 15-years old, or post-pubertal children under the age of 15 with an ISS greater than 25. However, these guidelines are not definitive due to the lack of supportive data and overall low quality of evidence.
Despite the paucity of evidence supporting reliable treatment algorithms, CPG on the management of VTE in pediatrics have been established. In general, they have all identified adolescence and older age as independent risk factors and identified particular age cut-offs for the administration of specific VTE prophylactic agents55-56. While the overall incidence of VTE in pediatric patients remains low, the identification of a prophylactic agent that is both safe and effective remains a challenge. Currently, a reliable treatment algorithm for the management of VTE in pediatric patients is non-existent, further clinical trials with innovative study designs are required to aid in its development.
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