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Huerta CT, Ramsey WA, Rodriguez C, Parreco JP, Thorson CM, Sola JE, Perez EA. Uncovering Risk Factors and Outcomes of Pulmonary Embolism in a Nationwide Cohort of Hospitalized Children. Am Surg 2024; 90:998-1006. [PMID: 38059918 DOI: 10.1177/00031348231220590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
PURPOSE The incidence of pulmonary embolism (PE) in hospitalized children has increased in recent years. This study sought to characterize factors and outcomes associated with PE using a national pediatric cohort. METHODS The Nationwide Readmissions Database was queried (2016-2018) for patients (<18 years) with a diagnosis of PE. Index and prior hospitalizations (PHs) within 1 year were analyzed. A binary logistic regression utilizing 37 covariates (demographics, procedures, comorbidities, etc.) was constructed to examine a primary outcome of in-hospital mortality. RESULTS 3440 patients were identified (57% female) with the majority >12 years old (77%). One-third had a known deep vein thrombosis (69% lower and 31% upper extremity). Nineteen percent underwent central venous catheter (CVC) placement. Twenty-one percent had a PH within 1 year. Nine percent underwent an operation with the majority being cardiothoracic (5%). Overall mortality was 5%. Neurocranial surgery, cardiothoracic surgery, and CVC placement were associated with the highest odds of inpatient mortality after logistic regression. CONCLUSION Pediatric patients with PE have a high rate of PHs, CVC placement, and inpatient operations, which may be associated with higher mortality. This information can be utilized to improve screening measures and clinical suspicion for PE in hospitalized children.
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Affiliation(s)
- Carlos Theodore Huerta
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Walter A Ramsey
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Cindy Rodriguez
- Florida State University College of Medicine, Tallahassee, FL, USA
| | | | - Chad M Thorson
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan E Sola
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eduardo A Perez
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Cunha NSC, Malvea A, Sadat S, Ibrahim GM, Fehlings MG. Pediatric Spinal Cord Injury: A Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1456. [PMID: 37761417 PMCID: PMC10530251 DOI: 10.3390/children10091456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023]
Abstract
A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.
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Affiliation(s)
| | - Anahita Malvea
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON M5T 2S8, Canada;
| | - Sarah Sadat
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - George M. Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, ON M5G 1E8, Canada;
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON M5T 2S8, Canada;
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
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Papillon SC, Pennell CP, Master SA, Turner EM, Arthur LG, Grewal H, Aronoff SC. Derivation and Validation of a Machine Learning Algorithm for Predicting Venous Thromboembolism in Injured Children. J Pediatr Surg 2023; 58:1200-1205. [PMID: 36925399 DOI: 10.1016/j.jpedsurg.2023.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/10/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) causes significant morbidity in pediatric trauma patients. We applied machine learning algorithms to the Trauma Quality Improvement Program (TQIP) database to develop and validate a risk prediction model for VTE in injured children. METHODS Patients ≤18 years were identified from TQIP (2017-2019, n = 383,814). Those administered VTE prophylaxis ≤24 h and missing the outcome (VTE) were removed (n = 347,576). Feature selection identified 15 predictors: intubation, need for supplemental oxygen, spinal injury, pelvic fractures, multiple long bone fractures, major surgery (neurosurgery, thoracic, orthopedic, vascular), age, transfusion requirement, intracranial pressure monitor or external ventricular drain placement, and low Glasgow Coma Scale score. Data was split into training (n = 251,409) and testing (n = 118,175) subsets. Machine learning algorithms were trained, tested, and compared. RESULTS Low-risk prediction: For the testing subset, all models outperformed the baseline rate of VTE (0.15%) with a predicted rate of 0.01-0.02% (p < 2.2e-16). 88.4-89.4% of patients were classified as low risk by the models. HIGH-RISK PREDICTION All models outperformed baseline with a predicted rate of VTE ranging from 1.13 to 1.32% (p < 2.2e-16). The performance of the 3 models was not significantly different. CONCLUSION We developed a predictive model that differentiates injured children for development of VTE with high discrimination and can guide prophylaxis use. LEVEL OF EVIDENCE Prognostic, Level II. TYPE OF STUDY Retrospective, Cross-sectional.
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Affiliation(s)
- Stephanie C Papillon
- St. Christopher's Hospital for Children, Department of Pediatric General Thoracic, and Minimally Invasive Surgery, Philadelphia, PA 19134, USA.
| | - Christopher P Pennell
- St. Christopher's Hospital for Children, Department of Pediatric General Thoracic, and Minimally Invasive Surgery, Philadelphia, PA 19134, USA
| | - Sahal A Master
- St. Christopher's Hospital for Children, Department of Pediatric General Thoracic, and Minimally Invasive Surgery, Philadelphia, PA 19134, USA
| | - Evan M Turner
- Drexel University College of Medicine, 2900 W. Queen Lane, Philadelphia, PA 19129, USA
| | - L Grier Arthur
- St. Christopher's Hospital for Children, Department of Pediatric General Thoracic, and Minimally Invasive Surgery, Philadelphia, PA 19134, USA; Drexel University College of Medicine, 2900 W. Queen Lane, Philadelphia, PA 19129, USA
| | - Harsh Grewal
- St. Christopher's Hospital for Children, Department of Pediatric General Thoracic, and Minimally Invasive Surgery, Philadelphia, PA 19134, USA; Drexel University College of Medicine, 2900 W. Queen Lane, Philadelphia, PA 19129, USA
| | - Stephen C Aronoff
- Lewis Katz School of Medicine Temple University, Department of Pediatrics, 3223 N. Broad Street, Philadelphia, PA 19140, USA; St. Christopher's Hospital for Children, Section of Infectious Diseases, 160 E. Erie Avenue, Philadelphia, PA 19134, USA
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Thomas AX, Riviello JJ, Davila-Williams D, Thomas SP, Erklauer JC, Bauer DF, Cokley JA. Pharmacologic and Acute Management of Spinal Cord Injury in Adults and Children. Curr Treat Options Neurol 2022; 24:285-304. [PMID: 35702419 PMCID: PMC9184374 DOI: 10.1007/s11940-022-00720-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 11/26/2022]
Abstract
Purpose of Review This review provides guidance for acute spinal cord injury (SCI) management through an analytical assessment of the most recent evidence on therapies available for treating SCI, including newer therapies under investigation. We present an approach to the SCI patient starting at presentation to acute rehabilitation and prognostication, with additional emphasis on the pediatric population when evidence is available. Recent Findings Further studies since the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) demonstrated a potential functional outcome benefit with ultra-early surgical intervention ≤ 8 h post-SCI. Subsequent analysis of the National Acute Spinal Cord Injury Study (NASCIS) II and NASCIS III trials have demonstrated potentially serious complications from intravenous methylprednisolone with limited benefit. Newer therapies actively being studied have demonstrated limited or no benefit in preclinical and clinical trials with insufficient evidence to support use in acute SCI treatment. Summary Care for SCI patients requires a multi-disciplinary team. Immediate evaluation and management are focused on preventing additional injury and restoring perfusion to the affected cord. Rapid assessment and intervention involve focused neurological examination, targeted imaging, and surgical intervention when indicated. There are currently no evidence-based recommendations for pathomechanistically targeted therapies.
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Affiliation(s)
- Ajay X. Thomas
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, Houston, TX USA
| | - James J. Riviello
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
| | - Daniel Davila-Williams
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
| | - Sruthi P. Thomas
- Division of Pediatric Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX USA
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Houston, TX USA
| | - Jennifer C. Erklauer
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
| | - David F. Bauer
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Houston, TX USA
| | - Jon A. Cokley
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Department of Pharmacy, Baylor College of Medicine, Houston, TX USA
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Mets EJ, Pathak N, Galivanche AR, McLynn RP, Frumberg DB, Grauer JN. Risk Factors for Venous Thromboembolism in Children Undergoing Orthopedic Surgery. Orthopedics 2022; 45:31-37. [PMID: 34846239 DOI: 10.3928/01477447-20211124-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Venous thromboembolism (VTE) is an uncommon but highly morbid and potentially preventable complication in children. This study aimed to characterize the incidence of, and risk factors for, VTE in children undergoing orthopedic surgery. A retrospective analysis was performed using the 2012 to 2017 American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database. Patient demographics, comorbidities, operative variables, and perioperative outcomes were compared between patients who did and did not develop a VTE. In total, 81,490 pediatric patients who underwent orthopedic surgery were identified. Of those, the mean±SD age was 9.7±4.8 years, and 50.1% were male. Sixty patients (0.07%) developed a postoperative VTE. On multivariate regression, demographic and surgical variables associated with a VTE were ages 16 to 18 years (P=.002; compared with ages 11 to 15 years), American Society of Anesthesiologists (ASA) classes III and V (P=.003; compared with ASA classes I and II), preoperative blood transfusion (P<.001), arthrotomy (P<.001), and femur fracture (P<.001). Postoperative adverse events occurring prior to a VTE were also assessed. Controlling for patient factors, independent risk factors for VTE included any adverse event (P<.001), major adverse events (P<.001), minor adverse events (P<.001), reoperation (P<.001), and readmission (P<.001). This study identified an incidence of VTE of 0.07% in a population of more than 80,000 children undergoing orthopedic surgery. The identification of risk factors for VTE in this patient population raises the issue of VTE prophylaxis for select high-risk subpopulations. [Orthopedics. 2022;45(1):31-37.].
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7
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McIntyre A, Sadowsky C, Behrman A, Martin R, Augutis M, Cassidy C, Betz R, Ertzgaard P, Mulcahey MJ. A Systematic Review of the Scientific Literature for Rehabilitation/Habilitation Among Individuals With Pediatric-Onset Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2022; 28:13-90. [PMID: 35521053 PMCID: PMC9009193 DOI: 10.46292/sci21-00046] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Objectives To conduct a systematic review to examine the scientific literature for rehabilitation/habilitation among individuals with pediatric-onset spinal cord injury (SCI). Methods A literature search of multiple databases (i.e., PubMed/MEDLINE, CINAHL, EMBASE, PsychINFO) was conducted and was filtered to include studies involving humans, published as full-length articles up to December 2020, and in English. Included studies met the following inclusion criteria: (1) ≥50% of the study sample had experienced a traumatic, acquired, nonprogressive spinal cord injury (SCI) or a nontraumatic, acquired, noncongenital SCI; (2) SCI onset occurred at ≤21 years of age; and (3) sample was assessed for a rehabilitation/habilitation-related topic. Studies were assigned a level of evidence using an adapted Sackett scale modified down to five levels. Data extracted from each study included author(s), year of publication, country of origin, study design, subject characteristics, rehabilitation/habilitation topic area, intervention (if applicable), and outcome measures. Results One hundred seventy-six studies were included for review (1974-2020) with the majority originating from the United States (81.3%). Most studies were noninterventional observational studies (n = 100; 56.8%) or noninterventional case report studies (n = 5; 2.8%). Sample sizes ranged from 1 to 3172 with a median of 26 (interquartile range [IQR], 116.5). Rehabilitation/habilitation topics were categorized by the International Classification of Functioning, Disability and Health (ICF); most studies evaluated ICF Body Function. There were 69 unique clinical health outcome measures reported. Conclusion The evidence for rehabilitation/habilitation of pediatric-onset SCI is extremely limited; nearly all studies (98%) are level 4-5 evidence. Future studies across several domains should be conducted with novel approaches to research design to alleviate issues related to sample sizes and heterogeneity.
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Affiliation(s)
- Amanda McIntyre
- Parkwood Institute Research, Parkwood Institute, London, Canada
| | - Cristina Sadowsky
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, John Hopkins University, Baltimore, Maryland
,International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, Maryland
| | - Andrea Behrman
- Department of Neurological Surgery, Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, Kentucky
,Kosair Charities Center for Pediatric Neurorecovery, Louisville, Kentucky
| | - Rebecca Martin
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, John Hopkins University, Baltimore, Maryland
,International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, Maryland
| | - Marika Augutis
- Department of Neurobiology, Care Sciences and Society, Division of Neurogeriatrics, Karolinska Institute, Solna, Sweden
| | - Caitlin Cassidy
- St. Joseph’s Health Care London, Parkwood Institute, London, Canada
| | - Randal Betz
- Institute for Spine and Scoliosis, Lawrenceville, New Jersey
,Department of Orthopedics, Mount Sinai Hospital, New York, New York
| | - Per Ertzgaard
- Department of Rehabilitation Medicine, Linköping University, Linköping, Sweden
| | - MJ Mulcahey
- Department of Occupational Therapy, Jefferson College of Rehabilitation Sciences, Thomas Jefferson University, Woodbury, New Jersey
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Panagopoulos D, Karydakis P, Noutsos G, Themistocleous M. Venous Thromboembolism Risk and Thromboprophylaxis in Pediatric Neurosurgery and Spinal Injury: Current Trends and Literature Review. Semin Thromb Hemost 2021; 48:318-322. [PMID: 34624914 DOI: 10.1055/s-0041-1733959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Although the entities of venous thromboembolism (VTE), deep venous thrombosis, pulmonary embolus, and thromboprophylaxis in adult patients undergoing brain tumor and spine surgery, traumatic brain injury and elective neurosurgical procedures are widely elucidated, the same is not valid when pediatric patients are under consideration. An attempt to review the peculiarities of these patients through a comprehensive bibliographic review is undertaken. We performed a narrative summary of the relevant literature dedicated to pediatric patients, centered on traumatic brain injury, the general incidence of thromboembolic disease in this patient population, the role of low molecular weight heparin (LMWH) in the treatment and prophylaxis of VTE, and its role in elective neurosurgical procedures, including spinal operations. Additionally, the risk of deep venous thrombosis in elective neurosurgical procedures is reviewed. Due to inherent limitations of the current studies, particularly a restricted number of patients, our data are underpowered to give a definitive protocol and guidelines for all the affected patients. Our current conclusions, based only on pediatric patients, argue that there is limited risk of VTE in pediatric patients suffering from brain tumors and that the possibility of VTE is very low in children undergoing elective neurosurgical procedures. There is no consensus regarding the exact incidence of VTE in traumatic brain injury patients. LMWH seems to be a safe and effective choice for the "at risk" pediatric patient population defined as being older than 15 years, venous catheterization, nonaccidental trauma, increased length of hospital stays, orthopaedic (including spinal) surgery, and cranial surgery.
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Affiliation(s)
| | | | - Georgios Noutsos
- Department of Anesthesiology, Pediatric Hospital of Athens, "Agia Sophia," Athens, Greece
| | - Marios Themistocleous
- Department of Neurosurgery, Pediatric Hospital of Athens, "Agia Sophia," Athens, Greece
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Lam Shin Cheung J, Lam Shin Cheung V, Athale U. Impact of ABO Blood Group on the Development of Venous Thromboembolism in Children With Cancer: A Systematic Review and Meta-Analysis. J Pediatr Hematol Oncol 2021; 43:216-223. [PMID: 33165187 DOI: 10.1097/mph.0000000000001996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/27/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few studies have evaluated the impact of ABO blood group on the risk of venous thromboembolism (VTE) in pediatric populations. We performed a systematic review to determine whether children (0 to 18 y old) with non-O blood group have an increased risk of developing VTE compared with those with O blood group. METHODS We searched Ovid Medline, Embase, PubMed, Cochrane, Web of Science, and CINAHL online databases from inception to December 2018 to find studies involving blood grouping and VTE. Data was collected regarding patients' underlying diseases, sex, age, ABO blood group, and VTE frequency. A meta-analysis using the random effect model was performed, and heterogeneity was assessed with the I2 value. RESULTS Among 1280 unique articles identified, 7 studies (3 conference abstracts, 4 peer-reviewed journal articles) involving 609 VTE cases were included in the systematic review. Six studies were eligible for a meta-analysis; all involved patients with cancer. Blood group O was protective against VTE (odds ratio, 0.56; 95% confidence interval, 0.43-0.79). Findings were similar across sensitivity analyses. CONCLUSIONS This systematic review has documented that O blood group is protective against new-onset VTE in children with cancer. Larger studies across different ethnic backgrounds and disease categories are needed to confirm these findings.
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Affiliation(s)
- Jeffrey Lam Shin Cheung
- Division of Hematology/Oncology, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton
| | | | - Uma Athale
- Division of Hematology/Oncology, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton
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Georgeades C, Van Arendonk K, Gourlay D. Venous thromboembolism prophylaxis after pediatric trauma. Pediatr Surg Int 2021; 37:679-694. [PMID: 33462655 DOI: 10.1007/s00383-020-04855-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 11/24/2022]
Abstract
In recent years, there has been an increased focus on developing and validating venous thromboprophylaxis guidelines in the pediatric trauma population. We review the current literature regarding the incidence of and risk factors for venous thromboembolism (VTE) and the use of prophylaxis in the pediatric trauma population. Risk factors such as age, injury severity, central venous catheters, mental status, injury type, surgery, and comorbidities can lead to a higher incidence of VTE. Risk stratification tools have been developed to determine whether mechanical and/or pharmacologic prophylaxis should be implemented depending on the degree of VTE risk. When VTE risk is high, pharmacologic prophylaxis, such as with low molecular weight heparin, is often initiated. However, the timing and duration of VTE prophylaxis is dependent on patient factors including ambulatory status and contraindications such as bleeding. In addition, the utility of screening ultrasound for VTE surveillance has been evaluated and though they are not widely recommended, no formal guidelines exist. While more research has been done in recent years to assess the most appropriate type, timing, and duration of VTE prophylaxis, further studies are warranted to create optimal guidelines for decreasing the risk of VTE after pediatric trauma.
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Affiliation(s)
- Christina Georgeades
- Division of Pediatric Surgery, Children's Wisconsin, 999 N 92nd Street, Suite 320, Milwaukee, WI, 53226, USA. .,Department of Surgery, Medical College of Wisconsin, 8701 W. Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Kyle Van Arendonk
- Division of Pediatric Surgery, Children's Wisconsin, 999 N 92nd Street, Suite 320, Milwaukee, WI, 53226, USA
| | - David Gourlay
- Division of Pediatric Surgery, Children's Wisconsin, 999 N 92nd Street, Suite 320, Milwaukee, WI, 53226, USA
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Ibrahim W, Mushtaq F. Consideration of pulmonary thromboembolism in paediatric patients presenting to the emergency department with abdominal pain. BMJ Case Rep 2021; 14:14/5/e239175. [PMID: 33975833 PMCID: PMC8118077 DOI: 10.1136/bcr-2020-239175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Venous thromboembolism (VTE) is a recognised complication of lower limb trauma in adult patients and classically presents with cardiopulmonary symptoms. However, the risk of VTE and its presenting signs and symptoms are less well documented in the paediatric population. We report the case of a child who presented to our emergency department with abdominal pain 2 weeks after lower limb fracture, who was subsequently found to have a pulmonary thromboembolism (PTE). This case report highlights the importance of having a high index of suspicion for VTE in the paediatric population if there are predisposing risk factors and to consider PTE as a differential cause of abdominal pain. To the authors' knowledge, no case has been described in which a child presenting with abdominal pain was consequently found to have a pulmonary embolism.
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Affiliation(s)
- Wasyla Ibrahim
- Emergency Department, University Hospital Hairmyres, East Kilbride, UK
| | - Farhat Mushtaq
- Emergency Department, NHS Lanarkshire, East Kilbride, UK
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12
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van Erp IA, Gaitanidis A, El Moheb M, Kaafarani HMA, Saillant N, Duhaime AC, Mendoza AE. Low-molecular-weight heparin versus unfractionated heparin in pediatric traumatic brain injury. J Neurosurg Pediatr 2021; 27:469-474. [PMID: 33578391 DOI: 10.3171/2020.9.peds20615] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The incidence of venous thromboembolism (VTE) in patients with traumatic brain injury (TBI) has increased significantly. The Eastern Association for the Surgery of Trauma recommends using low-molecular-weight heparin (LMWH) over unfractionated heparin (UH) in pediatric patients requiring VTE prophylaxis, although this strategy is unsupported by the literature. In this study, the authors compare the outcomes of pediatric TBI patients receiving LMWH versus UH. METHODS The authors performed a 4-year (2014-2017) analysis of the pediatric American College of Surgeons Trauma Quality Improvement Program. All trauma patients (age ≤ 18 years) with TBI requiring thromboprophylaxis with UH or LMWH were potentially eligible for inclusion. Patients who had been transferred, had died in the emergency department, or had penetrating trauma were excluded. Patients were stratified into either the LMWH or the UH group on the basis of the prophylaxis they had received. Patients were matched on the basis of demographics, injury characteristics, vital signs, and transfusion requirements using propensity score matching (PSM). The study endpoints were VTE, death, and craniotomy after initiation of prophylaxis. Univariate analysis was performed after PSM to compare outcomes. RESULTS A total of 2479 patients met the inclusion criteria (mean age 15.5 ± 3.7 years and 32.0% female), of which 1570 (63.3%) had received LMWH and 909 (36.7%) had received UH. Before PSM, patients receiving UH were younger, had a lower Glasgow Coma Scale score, and had a higher Injury Severity Score. Patients treated in pediatric hospitals were more likely to receive UH (12.9% vs 9.0%, p < 0.001) than patients treated in adult hospitals. Matched patients receiving UH had a higher incidence of VTE (5.1% vs 2.9%, p = 0.03). CONCLUSIONS LMWH prophylaxis in pediatric TBI appears to be more effective than UH in preventing VTE. Large, multicenter prospective studies are warranted to confirm the superiority of LMWH over UH in pediatric patients with TBI. Moreover, outcomes of VTE prophylaxis in the very young remain understudied; therefore, dedicated studies to evaluate this population are needed.
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Affiliation(s)
- Inge A van Erp
- 1Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital.,2Department of Pediatric Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts; and.,3Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Apostolos Gaitanidis
- 1Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital
| | - Mohamad El Moheb
- 1Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital
| | - Haytham M A Kaafarani
- 1Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital
| | - Noelle Saillant
- 1Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital
| | - Ann-Christine Duhaime
- 2Department of Pediatric Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts; and
| | - April E Mendoza
- 1Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital
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13
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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:e375-e379. [PMID: 31821246 DOI: 10.1097/bpo.0000000000001483] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The incidence of venous thromboembolism (VTE) after elective surgery in children with mobility impairments, including those with a neuromuscular complex chronic condition (NCCC), is unknown. Therefore, our objectives were to assess the incidence of VTE after elective spine and lower-extremity surgery in children with NCCC. METHODS A retrospective analysis of children with NCCC undergoing elective lower-extremity and/or spinal surgeries from 2005 to 2009 included in the Pediatric Health Information Systems Plus (PHIS+) database. VTE during hospitalization for surgery was assessed through abstraction and review of ultrasound (U/S) and computed tomography results by 2 independent reviewers. VTEs related to pre-existing central venous catheters were excluded. RESULTS There were 4,583 children with NCCC who underwent orthopaedic surgery during the study period at 6 centers. Most were male (56.3%), non-Hispanic whites (72.7%), and had private insurance (52.2%). The most common NCCC diagnoses were cerebral palsy (46.7%), brain and spinal cord malformations (31.1%), and central nervous system degenerative conditions (14.5%). Forty children (0.9%) underwent U/S to assess VTE. Eighteen children (0.4%) underwent computed tomography to assess VTE. Four children (with cerebral palsy) had a positive U/S for a lower-extremity VTE (10-18 y of age), yet 2 had their VTE before surgery. Therefore, the adjusted VTE rate for children with NCCC undergoing orthopaedic lower-extremity or spine surgery was 4 per 10,000 (2 cases per 4583 surgeries). Each of the 2 cases had a known coagulation disorder preoperatively. Only 10% of the cohort used compression devices, 3% enoxaparin, and 1.6% aspirin for prophylaxis. CONCLUSION The rate of non-central-venous-catheter-related VTE associated with orthopaedic surgery in children with NCCC is very low and lower than rates reported in healthy children. SIGNIFICANCE To our knowledge, this is the first multi-institutional study reporting the incidence of VTE in children with NCCCs undergoing elective hip and spine surgery. These data support no additional prophylaxis is required in children with NCCC undergoing elective hip and spine surgery unless other known risk factors are also present.
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Cushman M, Barnes GD, Creager MA, Diaz JA, Henke PK, Machlus KR, Nieman MT, Wolberg AS. Venous Thromboembolism Research Priorities: A Scientific Statement From the American Heart Association and the International Society on Thrombosis and Haemostasis. Circulation 2020; 142:e85-e94. [PMID: 32776842 DOI: 10.1161/cir.0000000000000818] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Venous thromboembolism is a major cause of morbidity and mortality. The impact of the US Surgeon General's The Surgeon General's Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism in 2008 has been lower than expected given the public health impact of this disease. This scientific statement highlights future research priorities in venous thromboembolism, developed by experts and a crowdsourcing survey across 16 scientific organizations. At the fundamental research level (T0), researchers need to identify pathobiological causative mechanisms for the 50% of patients with unprovoked venous thromboembolism and to better understand mechanisms that differentiate hemostasis from thrombosis. At the human level (T1), new methods for diagnosing, treating, and preventing venous thromboembolism will allow tailoring of diagnostic and therapeutic approaches to individuals. At the patient level (T2), research efforts are required to understand how foundational evidence impacts care of patients (eg, biomarkers). New treatments, such as catheter-based therapies, require further testing to identify which patients are most likely to experience benefit. At the practice level (T3), translating evidence into practice remains challenging. Areas of overuse and underuse will require evidence-based tools to improve care delivery. At the community and population level (T4), public awareness campaigns need thorough impact assessment. Large population-based cohort studies can elucidate the biological and environmental underpinnings of venous thromboembolism and its complications. To achieve these goals, funding agencies and training programs must support a new generation of scientists and clinicians who work in multidisciplinary teams to solve the pressing public health problem of venous thromboembolism.
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Cushman M, Barnes GD, Creager MA, Diaz JA, Henke PK, Machlus KR, Nieman MT, Wolberg AS. Venous thromboembolism research priorities: A scientific statement from the American Heart Association and the International Society on Thrombosis and Haemostasis. Res Pract Thromb Haemost 2020; 4:714-721. [PMID: 32685877 PMCID: PMC7354403 DOI: 10.1002/rth2.12373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 12/27/2022] Open
Abstract
Venous thromboembolism (VTE) is a major cause of morbidity and mortality. The impact of the Surgeon General's Call to Action in 2008 has been lower than expected given the public health impact of this disease. This scientific statement highlights future research priorities in VTE, developed by experts and a crowdsourcing survey across 16 scientific organizations. At the fundamental research level (T0), researchers need to identify pathobiologic causative mechanisms for the 50% of patients with unprovoked VTE and better understand mechanisms that differentiate hemostasis from thrombosis. At the human level (T1), new methods for diagnosing, treating, and preventing VTE will allow tailoring of diagnostic and therapeutic approaches to individuals. At the patient level (T2), research efforts are required to understand how foundational evidence impacts care of patients (eg, biomarkers). New treatments, such as catheter-based therapies, require further testing to identify which patients are most likely to experience benefit. At the practice level (T3), translating evidence into practice remains challenging. Areas of overuse and underuse will require evidence-based tools to improve care delivery. At the community and population level (T4), public awareness campaigns need thorough impact assessment. Large population-based cohort studies can elucidate the biologic and environmental underpinings of VTE and its complications. To achieve these goals, funding agencies and training programs must support a new generation of scientists and clinicians who work in multidisciplinary teams to solve the pressing public health problem of VTE.
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Affiliation(s)
- Mary Cushman
- Department of MedicineDepartment of Pathology and Laboratory MedicineLarner College of Medicine at the University of VermontBurlingtonVTUSA
| | | | - Mark A. Creager
- Heart and Vascular CenterDartmouth‐Hitchcock Medical Center Geisel School of Medicine at DartmouthLebanonNHUSA
| | - Jose A. Diaz
- Division of Surgical ResearchVanderbilt University Medical CenterNashvilleTNUSA
| | - Peter K. Henke
- Department of SurgeryUniversity of MichiganAnn ArborMIUSA
| | | | - Marvin T. Nieman
- Department of PharmacologyCase Western Reserve UniversityClevelandOHUSA
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory MedicineUNC Blood Research CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Mets EJ, McLynn RP, Grauer JN. Venous thromboembolism in children undergoing surgery: incidence, risk factors and related adverse events. WORLD JOURNAL OF PEDIATRIC SURGERY 2020; 3:e000084. [DOI: 10.1136/wjps-2019-000084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 02/07/2023] Open
Abstract
BackgroundAlthough less common in adults, venous thromboembolism (VTE) in children is a highly morbid, preventable adverse event. While VTE has been well studied among pediatric hospitalized and trauma patients, limited work has been done to examine postoperative VTE in children undergoing surgery.MethodsUsing data from National Surgical Quality Improvement Project Pediatric database (NSQIP-P) from 2012 to 2016, a retrospective cohort analysis was performed to determine the incidence of, and risk factors for, VTE in children undergoing surgery. Additionally, the relationships between VTE and other postoperative adverse outcomes were evaluated.ResultsOf 361 384 pediatric surgical patients, 378 (0.10%) were identified as experiencing postoperative VTE. After controlling for patient and surgical factors, we found that American Society of Anesthesiologists (ASA) class of II or greater, aged 16–18 years, non-elective surgery, general surgery (compared with several other surgical specialties), cardiothoracic surgery (compared with general surgery) and longer operative time were significantly associated with VTE in pediatric patients (p<0.001 for each comparison). Furthermore, a majority of adverse events were found to be associated with increased risk of subsequent VTE (p<0.001).ConclusionIn a large pediatric surgical population, an incidence of postoperative VTE of 0.10% was observed. Defined patient and surgical factors, and perioperative adverse events were found to be associated with such VTE events.
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Benmelouka A, Shamseldin LS, Nourelden AZ, Negida A. A Review on the Etiology and Management of Pediatric Traumatic Spinal Cord Injuries. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2019; 4:e28. [PMID: 32322796 PMCID: PMC7163256 DOI: 10.22114/ajem.v0i0.256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
CONTEXT Pediatric traumatic spinal cord injury (SCI) is an uncommon presentation in the emergency department. Severe injuries are associated with devastating outcomes and complications, resulting in high costs to both the society and the economic system. EVIDENCE ACQUISITION The data on pediatric traumatic spinal cord injuries has been narratively reviewed. RESULTS Pediatric SCI is a life-threatening emergency leading to serious outcomes and high mortality in children if not managed promptly. Pediatric SCI can impose many challenges to neurosurgeons and caregivers because of the lack of large studies with high evidence level and specific guidelines in terms of diagnosis, initial management and of in-hospital treatment options. Several novel potential treatment options for SCI have been developed and are currently under investigation. However, research studies into this field have been limited by the ethical and methodological challenges. CONCLUSION Future research is needed to investigate the safety and efficacy of the recent uprising neurodegenerative techniques in SCI population. Owing to the current limitations, there is a need to develop novel trial methodologies that can overcome the current methodological and ethical limitations.
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Affiliation(s)
| | | | | | - Ahmed Negida
- Medical Research Group of Egypt, Egypt
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
- Neurosurgery Department, Bahçeşehir University, Istanbul, Turkey
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Audu CO, Wakefield TW, Coleman DM. Pediatric deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2019; 7:452-462. [DOI: 10.1016/j.jvsv.2018.12.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 12/16/2018] [Indexed: 12/14/2022]
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Sherrod BA, McClugage SG, Mortellaro VE, Aban IB, Rocque BG. Venous thromboembolism following inpatient pediatric surgery: Analysis of 153,220 patients. J Pediatr Surg 2019; 54:631-639. [PMID: 30361075 PMCID: PMC6451662 DOI: 10.1016/j.jpedsurg.2018.09.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 09/19/2018] [Accepted: 09/20/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate venous thromboembolism (VTE) rates and risk factors following inpatient pediatric surgery. METHODS 153,220 inpatient pediatric surgical patients were selected from the 2012-2015 NSQIP-P database. Demographic and perioperative variables were documented. Primary outcome was VTE requiring treatment within 30 postoperative days. Secondary outcomes included length of stay (LOS) and 30-day mortality. Prediction models were generated using logistic regression. Mortality and time to VTE were assessed using Kaplan-Meier survival analysis. RESULTS 305 patients (0.20%) developed 296 venous thromboses and 12 pulmonary emboli (3 cooccurrences). Median time to VTE was 9 days. Most VTEs (81%) occurred predischarge. Subspecialties with highest VTE rates were cardiothoracic (0.72%) and general surgery (0.28%). No differences were seen for elective vs. urgent/emergent procedures (p = 0.106). All-cause mortality VTE patients was 1.2% vs. 0.2% in patients without VTE (p < 0.001). After stratifying by American Society of Anesthesiologists (ASA) class, no mortality differences remained when ASA < 3. Preoperative, postoperative, and total LOSs were longer for patients with VTE (p < 0.001 for each). ASA ≥ 3, preoperative sepsis, ventilator dependence, enteral/parenteral feeding, steroid use, preoperative blood transfusion, gastrointestinal disease, hematologic disorders, operative time, and age were independent predictors (C-statistic = 0.83). CONCLUSIONS Pediatric postsurgical patients have unique risk factors for developing VTE. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Brandon A Sherrod
- Department of Neurosurgery, Division of Pediatric Neurosurgery, The University of Alabama at Birmingham and Children's Hospital of Alabama, Birmingham, AL.
| | - Samuel G McClugage
- Department of Neurosurgery, Division of Pediatric Neurosurgery, The University of Alabama at Birmingham and Children's Hospital of Alabama, Birmingham, AL
| | - Vincent E Mortellaro
- Department of Surgery, Division of Pediatric Surgery, The University of Alabama at Birmingham and Children's Hospital of Alabama, Birmingham, AL
| | - Inmaculada B Aban
- Department of Biostatistics, The University of Alabama at Birmingham, School of Public Health, Birmingham, AL
| | - Brandon G Rocque
- Department of Neurosurgery, Division of Pediatric Neurosurgery, The University of Alabama at Birmingham and Children's Hospital of Alabama, Birmingham, AL
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Amos LE, Silvey M, Hall M, Witmer CM, Carpenter SL. Primary thromboprophylaxis in hospitalized children: A multi-center retrospective analysis. Thromb Res 2019; 176:1-7. [DOI: 10.1016/j.thromres.2019.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/25/2019] [Accepted: 02/01/2019] [Indexed: 10/27/2022]
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Lensing AWA, Male C, Young G, Kubitza D, Kenet G, Patricia Massicotte M, Chan A, Molinari AC, Nowak-Goettl U, Pap ÁF, Adalbo I, Smith WT, Mason A, Thelen K, Berkowitz SD, Crowther M, Schmidt S, Price V, Prins MH, Monagle P. Rivaroxaban versus standard anticoagulation for acute venous thromboembolism in childhood. Design of the EINSTEIN-Jr phase III study. Thromb J 2018; 16:34. [PMID: 30598642 PMCID: PMC6302520 DOI: 10.1186/s12959-018-0188-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/19/2018] [Indexed: 12/03/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a relatively rare condition in childhood with treatment mainly based on extrapolation from studies in adults. Therefore, clinical trials of anticoagulation in children require novel approaches to deal with numerous challenges. The EINSTEIN-Jr program identified pediatric rivaroxaban regimens commencing with in vitro dose finding studies followed by evaluation of children of different ages through phase I and II studies using extensive modeling to determine bodyweight-related doses. Use of this approach resulted in drug exposure similar to that observed in young adults treated with rivaroxaban 20 mg once-daily. Methods EINSTEIN-Jr phase III is a randomized, open-label, study comparing the efficacy and safety of rivaroxaban 20 mg-equivalent dose regimens with those of standard anticoagulation for the treatment of any types of acute VTE in children aged 0–18 years. A total of approximately 500 children are expected to be included during the 4-year study window. Flexibility of treatment duration is allowed with study treatment to be given for 3 months with the option to continue treatment in 3-month increments, up to a total of 12 months. However, based on most common current practice, children younger than 2 years with catheter-related thrombosis will have a main treatment period of 1 month with the option to prolong treatment in 1-month increments, up to a total of 3 months. Conclusions EINSTEIN-Jr will compare previously established 20 mg-equivalent rivaroxaban dosing regimens with standard anticoagulation for the treatment of VTE in children. Demonstration of similarity of disease, as well as equivalent rivaroxaban exposure and exposure-response will enable extrapolation of efficacy from adult trials, which is critical given the challenges of enrollment in pediatric anticoagulation trials. Trial registration Clinicaltrials.gov NCT02234843, registered on 9 September 2014.
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Affiliation(s)
- Anthonie W A Lensing
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Christoph Male
- 2Department of Paediatrics, Medical University of Vienna, Wien, Austria
| | - Guy Young
- 3Children's Hospital Los Angeles, Los Angeles, USA
| | - Dagmar Kubitza
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Gili Kenet
- 4Sheba Medical Center, TelHashomer, Israel
| | | | - Anthony Chan
- 6Department of Pediatrics, McMaster University, Hamilton, Canada
| | | | | | - Ákos F Pap
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Ivet Adalbo
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - William T Smith
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Amy Mason
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Kirstin Thelen
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Scott D Berkowitz
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Mark Crowther
- 9Department of Medicine, Hematology and Thromboembolism McMaster University, Hamilton, ON Canada
| | - Stephan Schmidt
- 10Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics University of Florida, Orlando, FL USA
| | - Victoria Price
- 11Department of Pediatrics, Division of Pediatric Hematology-Oncology Dalhousie University, Halifax, Canada
| | - Martin H Prins
- 12Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Paul Monagle
- Royal Children's Hospital, University of Melbourne, Murdoch Childrens Research Institute, Melbourne, Australia
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Prophylaxis against venous thromboembolism in pediatric trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society. J Trauma Acute Care Surg 2017; 82:627-636. [PMID: 28030503 DOI: 10.1097/ta.0000000000001359] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the increasing incidence of venous thromboembolism (VTE) in hospitalized children, the risks and benefits of VTE prophylaxis, particularly for those hospitalized after trauma, are unclear. The Pediatric Trauma Society and the Eastern Association for the Surgery of Trauma convened a writing group to develop a practice management guideline on VTE prophylaxis for this cohort of children using the Grading of Recommendations Assessment, Development, and Evaluation framework. METHODS A systematic review of MEDLINE using PubMed from January 1946 to July 2015 was performed. The search retrieved English-language articles on VTE prophylaxis in children 0 to 21 years old with trauma. Topics of investigation included pharmacologic and mechanical VTE prophylaxis, active radiologic surveillance for VTE, and risk factors for VTE. RESULTS Forty-eight articles were identified and 14 were included in the development of the guideline. The quality of evidence was low to very low because of the observational study design and risks of bias. CONCLUSIONS In children hospitalized after trauma who are at low risk of bleeding, we conditionally recommend pharmacologic prophylaxis be considered for children older than 15 years old and in younger postpubertal children with Injury Severity Score (ISS) greater than 25. For prepubertal children, even with ISS greater than 25, we conditionally recommend against routine pharmacologic prophylaxis. Second, in children hospitalized after trauma, we conditionally recommend mechanical prophylaxis be considered for children older than 15 years and in younger postpubertal children with ISS greater than 25 versus no prophylaxis or in addition to pharmacologic prophylaxis. Lastly, in children hospitalized after trauma, we conditionally recommend against active surveillance for VTE with ultrasound compared with routine daily physical examination alone for earlier detection of VTE. The limited pediatric data and paucity of high-quality evidence preclude providing more definitive recommendations and highlight the need for clinical trials of prophylaxis. LEVEL OF EVIDENCE Systematic review/meta-analysis, level III.
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Cullis PS, Gudlaugsdottir K, Andrews J. A systematic review of the quality of conduct and reporting of systematic reviews and meta-analyses in paediatric surgery. PLoS One 2017; 12:e0175213. [PMID: 28384296 PMCID: PMC5383307 DOI: 10.1371/journal.pone.0175213] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 03/22/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Our objective was to evaluate quality of conduct and reporting of published systematic reviews and meta-analyses in paediatric surgery. We also aimed to identify characteristics predictive of review quality. BACKGROUND Systematic reviews summarise evidence by combining sources, but are potentially prone to bias. To counter this, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was published to aid in reporting. Similarly, the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) measurement tool was designed to appraise methodology. The paediatric surgical literature has seen an increasing number of reviews over the past decade, but quality has not been evaluated. METHODS Adhering to PRISMA guidelines, we performed a systematic review with a priori design to identify systematic reviews and meta-analyses of interventions in paediatric surgery. From 01/2010 to 06/2016, we searched: MEDLINE, EMBASE, Cochrane, Centre for Reviews and Dissemination, Web of Science, Google Scholar, reference lists and journals. Two reviewers independently selected studies and extracted data. We assessed conduct and reporting using AMSTAR and PRISMA. Scores were calculated as the sum of reported items. We also extracted author, journal and article characteristics, and used them in exploratory analysis to determine which variables predict quality. RESULTS 112 articles fulfilled eligibility criteria (53 systematic reviews; 59 meta-analyses). Overall, 68% AMSTAR and 56.8% PRISMA items were reported adequately. Poorest scores were identified with regards a priori design, inclusion of structured summaries, including the grey literature, citing excluded articles and evaluating bias. 13 reviews were pre-registered and 6 in PRISMA-endorsing journals. The following predicted quality in univariate analysis:, word count, Cochrane review, journal h-index, impact factor, journal endorses PRISMA, PRISMA adherence suggested in author guidance, article mentions PRISMA, review includes comparison of interventions and review registration. The latter three variables were significant in multivariate regression. CONCLUSIONS There are gaps in the conduct and reporting of systematic reviews in paediatric surgery. More endorsement by journals of the PRISMA guideline may improve review quality, and the dissemination of reliable evidence to paediatric clinicians.
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Affiliation(s)
- Paul Stephen Cullis
- Department of Surgical Paediatrics, Royal Hospital for Children, Glasgow, United Kingdom
- School of Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Katrin Gudlaugsdottir
- Department of Surgical Paediatrics, Royal Hospital for Children, Glasgow, United Kingdom
| | - James Andrews
- Department of Surgical Paediatrics, Royal Hospital for Children, Glasgow, United Kingdom
- School of Medicine, University of Glasgow, Glasgow, United Kingdom
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Abstract
Although venous thromboembolism (VTE) occurs in less than 1% of hospitalized pediatric trauma patients, care providers must make decisions about VTE prophylaxis on a daily basis. The consequences of VTE are significant; the risks of developing VTE are variable; and the effectiveness of prophylaxis against VTE is not conclusive in children. While the value of VTE prophylaxis is well defined in adult trauma care, it is unclear how this translates to the care of injured children. This review evaluates the incidence and risks of VTE in pediatric trauma and assesses the merits of prophylaxis in children. Pharmacologic prophylaxis against VTE is a reasonable strategy in critically injured adolescent trauma patients. Further study is needed to establish the risks and benefits of VTE prophylaxis across the spectrum of injured children.
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Affiliation(s)
- John K Petty
- Section of Pediatric Surgery, Department of General Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157.
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Chima RS, Hanson SJ. Venous Thromboembolism in Critical Illness and Trauma: Pediatric Perspectives. Front Pediatr 2017; 5:47. [PMID: 28349046 PMCID: PMC5346591 DOI: 10.3389/fped.2017.00047] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/24/2017] [Indexed: 11/13/2022] Open
Abstract
Critically ill children and those sustaining severe traumatic injuries are at higher risk for developing venous thromboembolism (VTE) than other hospitalized children. Multiple factors including the need for central venous catheters, immobility, surgical procedures, malignancy, and dysregulated inflammatory state confer this increased risk. As well as being at higher risk of VTE, this population is frequently at an increased risk of bleeding, making the decision of prophylactic anticoagulation even more nuanced. The use of pharmacologic and mechanical prophylaxis remains variable in this high-risk cohort. VTE pharmacologic prophylaxis is an accepted practice in adult trauma and intensive care to prevent VTE development and associated morbidity, but it is not standardized in critically ill or injured children. Given the lack of pediatric specific guidelines, prevention strategies are variably extrapolated from the successful use of mechanical and pharmacologic prophylaxis in adults, despite the differences in developmental hemostasis and thrombosis risk between children and adults. Whether the burden of VTE can be reduced in the pediatric critically ill or injured population is not known given the lack of robust data. There are no trials in children showing efficacy of mechanical compression devices or prophylactic anticoagulation in reducing the rate of VTE. Risk stratification using clinical factors has been shown to identify those at highest risk for VTE and allows targeted prophylaxis. It remains unproven if such a strategy will mitigate the risk of VTE and its potential sequelae.
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Affiliation(s)
- Ranjit S Chima
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine , Cincinnati, OH , USA
| | - Sheila J Hanson
- Medical College of Wisconsin, Children's Hospital of Wisconsin , Milwaukee, WI , USA
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Jaffray J, Bauman M, Massicotte P. The Impact of Central Venous Catheters on Pediatric Venous Thromboembolism. Front Pediatr 2017; 5:5. [PMID: 28168186 PMCID: PMC5253371 DOI: 10.3389/fped.2017.00005] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 01/09/2017] [Indexed: 12/12/2022] Open
Abstract
The use of central venous catheters (CVCs) in children is escalating, which is likely linked to the increased incidence of pediatric venous thromboembolism (VTE). In order to better understand the specific risk factors associated with CVC-VTE in children, as well as available prevention methods, a literature review was performed. The overall incidence of CVC-VTE was found to range from 0 to 74%, depending on the patient population, CVC type, imaging modality, and study design. Throughout the available literature, there was not a consistent determination regarding whether a particular type of central line (tunneled vs. non-tunneled vs. peripherally inserted vs. implanted), catheter material, insertion technique, or insertion location lead to an increased VTE risk. The patient populations who were found to be most at risk for CVC-VTE were those with cancer, congenital heart disease, gastrointestinal failure, systemic infection, intensive care unit admission, or involved in a trauma. Both mechanical and pharmacological prophylactic techniques have been shown to be successful in preventing VTE in adult patients, but studies in children have yet to be performed or are underpowered. In order to better determine true CVC-VTE risk factors and best preventative techniques, an increase in large, prospective pediatric trials needs to be performed.
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Affiliation(s)
- Julie Jaffray
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine , Los Angeles, CA , USA
| | - Mary Bauman
- University of Alberta, Stollery Children's Hospital , Edmonton, AB , Canada
| | - Patti Massicotte
- University of Alberta, Stollery Children's Hospital , Edmonton, AB , Canada
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Dreyfus J, Flood A, Cutler G, Ortega H, Kreykes N, Kharbanda A. Comparison of pediatric motor vehicle collision injury outcomes at Level I trauma centers. J Pediatr Surg 2016; 51:1693-9. [PMID: 27160431 DOI: 10.1016/j.jpedsurg.2016.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/04/2016] [Accepted: 04/10/2016] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Examine the association of American College of Surgeons Level I pediatric trauma center designation with outcomes of pediatric motor vehicle collision-related injuries. METHODS Observational study of the 2009-2012 National Trauma Data Bank, including n=28,145 patients <18years directly transported to a Level I trauma center. Generalized estimating equations estimated odds ratios (ORs) for injury outcomes, comparing freestanding pediatric trauma centers (PTCs) with adult centers having added Level I pediatric qualifications (ATC+PTC) and general adult trauma centers (ATC). Models were stratified by age following PTC designation guidelines, and adjusted for demographic and clinical risk factors. RESULTS Analyses included n=16,643 children <15 and n=11,502 adolescents 15-17years. Among children, odds of laparotomy (OR=1.88, 95% CI 1.28-2.74) and pneumonia (OR=2.13, 95% CI 1.32-3.46) were greater at ATCs vs. freestanding PTCs. Adolescents treated at ATC+PTCs or ATCs experienced greater odds of death (OR=2.18, 95% CI 1.30-3.67; OR=1.98, 95% CI 1.37-2.85, respectively) and laparotomy (OR=4.33, 95% CI 1.56-12.02; OR=5.11, 95% CI 1.92-13.61, respectively). CONCLUSIONS Compared with freestanding PTCs, children treated at general ATCs experienced more complications; adolescents treated at ATC+PTCs or general ATCs had greater odds of death. Identification and sharing of best practices among Level I trauma centers may reduce variation in care and improve outcomes for children.
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Affiliation(s)
- Jill Dreyfus
- Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404.
| | - Andrew Flood
- Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404
| | - Gretchen Cutler
- Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404
| | - Henry Ortega
- Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404
| | - Nathan Kreykes
- Department of Pediatric Surgery, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404
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Recommendations for venous thromboembolism prophylaxis in pediatric trauma patients: A national, multidisciplinary consensus study. J Trauma Acute Care Surg 2016; 80:695-701. [PMID: 26881487 DOI: 10.1097/ta.0000000000000962] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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When children become adults and adults become most hypercoagulable after trauma: An assessment of admission hypercoagulability by rapid thrombelastography and venous thromboembolic risk. J Trauma Acute Care Surg 2016; 80:778-82. [PMID: 26886005 DOI: 10.1097/ta.0000000000000985] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Thrombelastography (TEG) maximal amplitude (mA) has also been shown to reflect hypercoagulability and increased venous thromboembolism (VTE) risk in adult trauma patients. Based on these previous works, we sought to identify when children become adults with respect to TEG mA values and whether this correlated with VTE risk. METHODS We evaluated all trauma patients admitted from January 2010 to December 2013 who were highest-level activations. Age was evaluated as a continuous variable, followed by a categorical evaluation. TEG mA values were evaluated as continuous and dichotomous (hypercoagulable, mA ≥ 65 mm). Logistic regression was then constructed controlling for age categories, sex, and injury severity to assess the association with TEG mA values and VTE risk. RESULTS A total of 7,194 Level 1 trauma patients were admitted during this time frame (819 were <18 years of age). The likelihood of mA equal to or greater than 65 mm remained at 35% to 37% through age 30 years with significant increases observed at ages 31 years to 35 years (45%) and 46 years to 50 years (49%), both p < 0.01. When controlling for injury severity, race, and sex, logistic regression demonstrated that every 5-year increase in age (after age 30 years) was associated with a 16% increased likelihood of hypercoagulability at admission. Beginning with age 1 year, VTE risk remained at 1.5% or less until age 13 years where it increased to 2.3%, increasing again at age 15 years to 5.1%. Two additional significant increases were identified between ages 31 years and 35 years (5.5%) as well as 46 years and 50 years (7.6%), both p < 0.001. Logistic regression demonstrated a 3.4-fold increased risk for VTE among those aged 31 years to 50 years compared with those who are younger than 30 years. The same model noted a 2.3-fold increased risk compared with those who are older than 50 years. CONCLUSION Beginning at age 13 years, children transition toward adult hypercoagulability, as evidenced by elevated TEG mA values and VTE risk. However, the greatest VTE risk (and highest likelihood of hypercoagulable mA) is among those adults 31 years to 50 years of age. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Risk factors and co-morbidities in adolescent thromboembolism are different than those in younger children. Thromb Res 2016; 141:178-82. [DOI: 10.1016/j.thromres.2016.03.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/10/2016] [Accepted: 03/16/2016] [Indexed: 01/19/2023]
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Halvorson EE, Ervin SE, Russell TB, Skelton JA, Davis S, Spangler J. Association of Obesity and Pediatric Venous Thromboembolism. Hosp Pediatr 2016; 6:22-26. [PMID: 26675300 PMCID: PMC9161240 DOI: 10.1542/hpeds.2015-0039] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND The incidence of venous thromboembolism (VTE) is increasing among pediatric patients in the United States. Previous studies on obesity as a risk factor have produced mixed results. METHODS We completed a retrospective chart review of patients aged 2 to 18 years with VTE identified by using International Classification of Diseases, Ninth Revision, codes and confirmed by imaging. Patients were admitted between January 2000 and September 2012. Control subjects were matched on age, gender, and the presence of a central venous catheter. Data were collected on weight, height, and risk factors, including bacteremia, ICU admission, immobilization, use of oral contraceptives, and malignancy. Underweight patients and those without documented height and weight data were excluded. Independent predictors of VTE risk were identified by using univariate and multivariate analyses. RESULTS We identified 88 patients plus 2 matched control subjects per case. The majority of cases were nonembolic events (77%) of the lower extremity (25%) or head and neck (22%) confirmed by ultrasound (43%) or computed tomography scan (41%). A statistically significant association was found between VTE and increased BMI z score (P = .002). In multivariate analysis, BMI z score (odds ratio [OR]: 3.1; P = .007), bacteremia (OR: 4.9; P = .02), ICU stay (OR: 2.5; P = .02), and use of oral contraceptives (OR: 17.4; P < .001) were significant predictors. CONCLUSIONS In this single-institution study, the diagnosis of VTE was significantly associated with overweight and obesity. Further study is needed to fully define this association.
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Affiliation(s)
| | | | | | - Joseph A Skelton
- Departments of Pediatrics, Brenner FIT (Families in Training), Brenner Children's Hospital, Winston-Salem, North Carolina Epidemiology and Prevention, Division of Public Health Sciences, and
| | - Stephen Davis
- Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - John Spangler
- Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
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Venous Thromboembolic Disease in Children and Adolescents. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:149-165. [DOI: 10.1007/5584_2016_113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Arlikar SJ, Atchison CM, Amankwah EK, Ayala IA, Barrett LA, Branchford BR, Streiff MB, Takemoto CM, Goldenberg NA. Development of a new risk score for hospital-associated venous thromboembolism in critically-ill children not undergoing cardiothoracic surgery. Thromb Res 2015; 136:717-22. [DOI: 10.1016/j.thromres.2015.04.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/24/2015] [Accepted: 04/27/2015] [Indexed: 10/23/2022]
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Abstract
PURPOSE Research on venous thromboembolism events (VTE), such as deep venous thrombosis (DVT) and pulmonary embolism (PE), in pediatric orthopaedic trauma patients is sparse. We describe the incidence in the USA of VTE associated with pediatric lower extremity orthopaedic trauma, and characterize injury patterns and VTE treatment methods. METHODS The Pediatric Health Information System (PHIS) was queried from 2004 to 2013 using ICD-9 codes for lower extremity fractures (pelvis, femur, tibia, ankle, foot) and dislocations (hip, knee, ankle, subtalar) and VTE. Records were queried for age, diagnoses, and VTE treatment. RESULTS During the study period 285,611 clinical encounters reported lower extremity trauma. Of those, 167 patients were simultaneously coded with VTE (99 DVT, 50 PE, 18 combined DVT/PE), to give an incidence of VTE associated with pediatric lower extremity trauma of 0.058 %. Patients were from 39 centers, with an average age of 12.9 years (range 0-19). There were 249 fractures and 21 dislocations, with 25 (15 %) patients sustaining more than one lower extremity injury. The most common fracture locations were the femur/femoral neck (95), tibia/ankle (92), and pelvis (44). 72 % (121/167) of patients were treated with anticoagulation medication, of which the most common was low-molecular-weight heparin (111/167, 66 %). CONCLUSIONS The incidence of VTE events associated with lower extremity orthopaedic trauma is 0.058 %. Adolescents and polytrauma patients with injuries of the femur/femoral neck, tibia/ankle, and pelvis are more commonly affected. Low-molecular-weight heparin is commonly used to treat VTE in pediatric and adolescent patients.
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Gonda DD, Fridley J, Ryan SL, Briceño V, Lam SK, Luerssen TG, Jea A, Jea A. The safety and efficacy of use of low-molecular-weight heparin in pediatric neurosurgical patients. J Neurosurg Pediatr 2015; 16:329-34. [PMID: 26067336 DOI: 10.3171/2015.1.peds14489] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Low-molecular-weight heparins (LMWHs), mainly enoxaparin, offer several advantages over standard anticoagulation therapies such as unfractionated heparin and warfarin, including predictable pharmacokinetics, minimal monitoring, and subcutaneous administration. The purpose of this study was to determine the safety and efficacy of LMWHs in pediatric neurosurgical patients. METHODS A retrospective study was performed with patients 18 years old or younger who were admitted to the Pediatric Neurosurgery Service at Texas Children's Hospital and treated with LMWH for either therapeutic or prophylactic purposes between March 1, 2011, and December 30, 2013. Demographic and clinical features and outcomes were recorded. RESULTS LMWH was administered for treatment of venous thromboembolic events (VTEs) in 17 children and for prophylaxis in 24 children. Clinical resolution of VTEs occurred in 100% (17 of 17) of patients receiving therapeutic doses of LMWH. No patient receiving prophylactic doses of LMWH developed a new VTE. Major or minor bleeding complications occurred in 18% (3 of 17 children) and 4% (1 of 24 children) of those receiving therapeutic and prophylactic doses, respectively. All 4 patients who experienced hemorrhagic complications had other bleeding risk factors-i.e., coagulopathies and antiplatelet medications. CONCLUSIONS LMWH seems to be safe and efficacious for both management and prophylaxis of VTEs in pediatric neurosurgery. However, pediatric practitioners should be aware of higher risk for bleeding complications with increasing doses of LMWH, especially in patients with preexisting bleeding disorders or concurrent use of antiplatelet agents.
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Affiliation(s)
- David D Gonda
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jared Fridley
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sheila L Ryan
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Valentina Briceño
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi K Lam
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Thomas G Luerssen
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Andrew Jea
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Lemley K, Bauer P. Pediatric Spinal Cord Injury: Recognition of Injury and Initial Resuscitation, in Hospital Management, and Coordination of Care. J Pediatr Intensive Care 2015; 4:27-34. [PMID: 31110847 DOI: 10.1055/s-0035-1554986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Spinal cord injury is uncommon in the pediatric population with a lifelong impact for the patient and family. Knowledge of spine embryology, mechanisms of injury that lead to specific injuries, appropriate utilization of radiographic imaging based on suspected injury, prehospital and hospital management of various spinal cord injuries is essential for providers attending to traumatically injured patients. In addition to patients who present with soft tissue and bony injuries diagnosed with clinical examination and confirmed with computed tomography or magnetic resonance imaging, it is important to note that the pediatric population is at a higher risk for spinal cord injury without radiographic abnormality than the adult population. Patients who survive the acute phase of injury face long-term rehabilitation and have an increased risk of depression and mortality. Understanding the long-term sequelae of spinal cord injuries is also an essential management component of traumatically injured children. A program that provides long-term rehabilitation, psychosocial and spiritual support, and adaptive environmental supports gives patients and their families the best opportunity for long-term recovery. A review of the current literature on the diagnosis, management, and follow-up of pediatric spinal cord injury is presented.
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Affiliation(s)
- Kyle Lemley
- Department of Pediatric Critical Care, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
| | - Paul Bauer
- Department of Pediatric Critical Care, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
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Luchtman-Jones L. Venous thromboembolism and anticoagulation safety: who is watching the children? Pediatr Blood Cancer 2014; 61:1916-7. [PMID: 25053292 DOI: 10.1002/pbc.25145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 05/19/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Lori Luchtman-Jones
- Division of Hematology, Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, District of Columbia; George Washington University School of Medicine, Washington, District of Columbia
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Intra-abdominal venous thrombosis after colectomy in pediatric patients with chronic ulcerative colitis: incidence, treatment, and outcomes. J Pediatr Surg 2014; 49:614-7. [PMID: 24726123 DOI: 10.1016/j.jpedsurg.2013.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 10/08/2013] [Accepted: 10/09/2013] [Indexed: 01/06/2023]
Abstract
PURPOSE Children with chronic ulcerative colitis (CUC) are at increased risk for venous thromboembolism, especially after colectomy procedures. We aim to review our patients with CUC who underwent a colectomy and suffered intra-abdominal thrombosis; moreover we wanted to define thrombotic incidence and outcomes METHODS In this is IRB approved retrospective study, we reviewed our patients who underwent colectomy for CUC from January 1999 to December 2011 for development of intra-abdominal thrombosis. RESULTS Of 366 patients with CUC who underwent colectomy, 15 (4%) were diagnosed with a venous thromboembolism. All patients presented with acute abdominal pain. The locations of thrombus formation varied: 13 (87%) developed thrombi in the portal vein, 4 (27%) in the splenic vein, 2 (13%) in the superior mesenteric vein, 1 (7%) in the hepatic vein, and 1 (7%) in the hepatic artery. The mean number of post-operative days at diagnosis of thrombus was 38.7 days (range 3-180 days). Fourteen patients (93%) underwent anticoagulation for treatment. The mean number of days of anticoagulant therapy until documented resolution of thrombus on imaging was 96.3 days (range 14-364 days). All thrombi resolved with therapy. There was no mortality during follow-up. CONCLUSIONS Four percent of our pediatric patients with chronic ulcerative colitis who underwent colectomy developed symptomatic intra-abdominal venous thromboembolism. 3 to 6 months of anticoagulant therapy is adequate treatment in almost all patients. Practitioners should have a high index of suspicion for intra-abdominal venous thrombus when these patients complain of abdominal pain postoperatively. Based on our experience, prophylactic anticoagulation should be strongly considered peri-operatively in this population.
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