Development of a perioperative venous thromboembolism prophylaxis algorithm for pediatric orthopedic surgical patients

Incidence of venous thromboembolism in pediatric orthopedics: A systematic review

BACKGROUNDS

Children undergoing orthopedic procedures often present numerous risk factors for thromboembolism. A recent survey, conducted by the Pediatric Orthopaedic Society of North America (POSNA), indicates that pediatric orthopedic surgeons are unaware of venous thromboembolism (VTE) prevention protocols and feel that certain procedures should require thromboprophylaxis. The aim of this systematic review was to properly assess the incidence of VTE in pediatric orthopedics. By using a thorough and broad search of the literature, the incidence according to different subspecialties of pediatric orthopedics was evaluated.

METHODS

A systematic review on VTE in pediatric orthopedics was conducted. Four databases were searched for articles reporting these events. Three major search concepts: "pediatrics", "orthopedic surgery/trauma" and "VTE complications" were used and broken down in MeSH, EmTree and their free vocabulary synonyms for proper literature review. Two independent authors screened 8467 titles and abstracts. Seventy articles reporting VTE in children treated by orthopedic surgeons were selected for data extraction. We reported median incidences by orthopedic subtypes and by study characteristics with a semi-quantitative review model.

RESULTS

The 70 articles yielded a total of 845,010 participants. Spine articles (33/70) provided 25,2% of the children included in the review. Trauma studies (16/70) accounted for 47.5% of the participants. The overall VTE median incidence was 0.16% [95% CI: 0.0-1.01%]. Musculoskeletal infections had a noticeably higher median incidence of 3.5% [CI: 0.0-13.8%]. Small variations were seen for the other subtypes: trauma, spine and elective surgeries. Subgroups by article characteristics did not differ significantly either.

CONCLUSION

Thrombotic complications are rare events in pediatric orthopedics, but knowledge epidemiologic is important because its potential severity. In this review, VTE median incidence for all orthopedic subtypes was around 0.16% [CI: 0.0-1.01%]. According to subspecialty assessment, musculoskeletal infections were associated with greater risk of VTE occurrence.

LEVEL OF EVIDENCE

III - Systematic review.

Prophylaxis of Venous Thromboembolism in Children: A Systematic Review

Venous thromboembolism (VTE) in children is a rare but serious event. Current guidance on pharmacological thromboprophylaxis in children is mostly based on adult studies and expert opinions. The aim of this systematic review was to examine under which conditions children (age ≤ 18 years) would benefit from pharmacological thromboprophylaxis with low molecular weight heparin or unfractionated heparin. Eligible studies included children, who did not receive pharmacological thromboprophylaxis as comparator, and VTE events were radiologically verified. MEDLINE and Embase were searched up to October 3, 2021. Ten studies were included presenting data for 976 children receiving pharmacological thromboprophylaxis. We divided the studies into three categories based on the population studied: children in the intensive care unit (n = 2), children with fractures and/or undergoing surgery (n = 5), and children with systemic disease (n = 3). A lower incidence of VTE was found when pharmacological thromboprophylaxis was used compared with no prophylaxis in children in intensive care unit with central venous catheter and mechanical ventilation (7/27 vs. 13/24), children in the intensive care unit admitted after trauma with a very high risk of VTE based on several risk factors (0/21 vs. 13/96), and children with acute lymphoblastic leukemia treated with L-asparaginase concomitant with steroid and presence of central venous catheter (0/82 vs. 8/121). Pharmacological thromboprophylaxis was not associated with an increased bleeding risk. In conclusion, pharmacological thromboprophylaxis in children is sparsely investigated. Only children with several risk factors for VTE are likely to benefit from pharmacological thromboprophylaxis.

Venous Thromboembolism After Pelvic Osteotomy in Adolescent Patients: A Database Study Characterizing Rates and Current Practices

BACKGROUND

Current risks and practices in medical prophylaxis of venous thromboembolism (VTE) after major elective lower extremity surgeries such as pelvic osteotomies have not been well-defined in the pediatric population. The purpose of this study was to (1) evaluate population rates of VTE in adolescents undergoing pelvic osteotomies, and (2) characterize current practices on types of VTE prophylaxis being utilized after pelvic osteotomies.

METHODS

The study evaluated the Pediatric Health Information System database between October 1, 2015 and January 1, 2020 for patients between 10 and 18 years of age meeting selected ICD-10 procedure and diagnosis codes relating to pelvic osteotomies. The rate of VTE was calculated within 90 days of index procedure. Types of pharmacologic prophylaxis were characterized. Continuous variables were compared with 2-sample t tests; proportions and categorical variables were compared with Fisher exact or χ2 tests, all with 2-tailed significance <0.05.

RESULTS

Of 1480 included patients, 9 were diagnosed with VTE within 90 days of surgery (VTE rate: 0.61%). Four of 9 (44.4%) had received pharmacologic prophylaxis postoperatively. There were no differences in baseline demographics or length of stay between patients that did or did not develop VTE (P>0.05). Overall, 52.0% received at least one form of pharmacologic prophylaxis postoperatively. The most common pharmacologic prophylaxis used was aspirin (47.6%), of which 64.4% received 81 mg dosing. There was no difference in VTE rates in those with or without prophylaxis (0.52% vs. 0.70%, P=0.75). However, those prescribed prophylaxis were significantly older (15.2±2.3 vs. 13.6±2.4 y, P<0.0001) and had a higher proportion of females (71.8% vs. 54.6%, P<0.01).

CONCLUSIONS

The overall rate of VTE in pediatric patients after pelvic osteotomies is non-negligible. There is heterogeneity in the type of anticoagulant utilized; however, VTE prophylaxis is most commonly prescribed in older adolescents and female patients. Guidelines for medical prevention of deep venous thrombosis and pulmonary embolism in the pediatric population are warranted after hip preservation surgery.

LEVEL OF EVIDENCE

Level IV, case series.

Optimizing pharmacologic thromboprophylaxis use in pediatric orthopedic surgical patients through implementation of a perioperative venous thromboembolism risk screening tool

BACKGROUND

Although rare, venous thromboembolic events (VTE) are a significant challenge in pediatric orthopedic surgical patients (POSP). A VTE thromboprophylaxis screening tool was developed and implemented in POSPs at the IWK Health Centre since October 2016.

OBJECTIVES

This retrospective cohort study was designed to evaluate and assess the impact of the VTE thromboprophylaxis screening tool in terms of use of thromboprophylaxis in POSP.

METHODS

Using the tool, POSPs were screened and were categorized into risk groups. Patient groups were compared and spearman correlation analysis was performed to show the strength of association between risk factors and thromboprophylaxis. Retrospective screening of pre-algorithm patients who received thromboprophylaxis was done to further assess the screening tool.

RESULTS

After the implementation of the VTE thromboprophylaxis screening tool in POSPs, there was a 47.9% reduction in the use of thromboprophylaxis (P = 0.046) as compared with before. Neither VTE nor significant bleeding complications occurred before or after screening tool implementation. Compliance with the screening tool was excellent (100% of patients in the high-risk category received thromboprophylaxis). High-risk patients were more likely to have body mass index  > 30 (35.7%), limited/altered mobility (57.1%), and to be undergoing a complicated/repeat surgery (64.3%).

CONCLUSIONS

The present study demonstrates successful implementation of a VTE thromboprophylaxis screening tool that resulted in significant reduction in use of thromboprophylaxis in POSPs with no increase in VTE or change in bleeding complications.