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Moving forward: advancing venous thromboembolism knowledge in pediatric trauma.

Deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively known as venous thromboembolism (VTE), affect approximately 900,000 people in the United States annually and result in hundreds of thousands of hospitalizations and deaths. Recently, a national workgroup recommended that 1) improved utilization in clinical practice of existing, proven-effective preventive measures is critical to reducing the disease burden from VTE; 2) systematic surveillance of DVT and PE is needed to provide nationally representative data on the prevalence and annual incidence of DVT and PE; 3) tracking and documenting changes in the incidence of DVT and PE through systematic surveillance will be important to enhance prevention efforts, and 4) the Centers for Disease Control should convene a second group of experts to advise the agency in detail on the strengths, weaknesses, and feasibility of possible approaches to systematic surveillance for DVT and PE (1). Pertaining to pediatric data on incidence and treatment, Raffini et al (2) in 2009 reported a dramatic increase in the diagnosis of VTE from 2001 to 2007 among patients 18 yrs of age discharged from 35–40 children’s hospitals by using the Pediatric Health Information System administrative database. During the 7-yr study period, in which 11,337 hospitalized patients were diagnosed with VTE, the annual rate of VTE significantly increased by 70%, from 34 to 58 cases per 10,000 hospital admissions. This increase was observed across the pediatric age spectrum (neonates, infants, children, and adolescents), and the majority (63%) of children with VTE had at least one or more coexisting chronic complex medical condition. Pediatric malignancy was the medical comorbid condition associated most strongly with recurrent VTE (2). Injured adults are a group well recognized to be at special risk for VTE; established risk factors are spinal cord injury, traumatic brain injury, and the presence of central venous catheters (CVCs). The risk of VTE in the injured pediatric population has been previously estimated from large multicenter studies to be .08% (3–5). In previous studies, older age, craniotomy, injury severity, and presence of CVCs has emerged as risk factors (3, 6). In this issue of Pediatric Critical Care Medicine, Drs. O’Brien and Candrilli (7) examine the incidence of VTE in 135,000 patients whose records were entered into the National Trauma Coma Data Bank, reports findings similar to that previously reported: 1) VTE rates (six per 1,000 cases) were overall low, and 2) older age and CVC were risk factors for VTE (7). Furthermore, similar to the limitations of the previous work (3), these authors were also not able to shed light on the location of CVC, VTE prophylaxis, or duration of CVC, once again precluding recommendations regarding VTE prophylaxis in this population. However, recently, Hanson et al (8) reported that among nine of 144 (6.2%) children admitted to the pediatric intensive care unit after trauma who developed VTE, VTE was diagnosed at a median of 9 days after admission, with six of nine (67%) occurrences of VTE located at the site of previous or existing CVCs. Locations of CVCs were femoral in the majority of cases reported. However, other significant risk factors for thrombosis were also identified such as parenteral nutrition, deep sedation neuromuscular blockade, inotropic support, and recombinant factor VIIa administration. Logistic analysis found a 7.9-fold increase in the odds of developing VTE for each additional CVC (p .005), a three-fold increase with each additional risk factor present (p .009), and a 1.3-fold increase for an increase in injury severity (p .03). In this study, VTE was not associated with sepsis, spinal cord injury, fracture, or elevated D-dimer level. This latter study suggests that most critically ill children developing thrombosis have multiple risk factors that include poor perfusion, immobility, as well as the presence of a CVC (8). These data and others, including the present study by Drs. O’Brien and Candrilli (7), reveal that certain subgroups of injured children might benefit from screening for VTE and VTE prophylaxis but that, at a minimum, formal study of the relationship among CVC location, duration of indwelling CVC, and development of VTE is warranted, especially among critically ill and injured children with multiple risk factors for VTE. The American College of Chest Physicians Evidence Based Clinical Practice Guidelines recommend that all major trauma patients receive pharmacologic prophylaxis with low molecular weight heparin, barring risk of or active bleeding (9). However, both screening for and treatment of VTE among adult trauma patients is controversial. One recent study showed that in trauma patients, subcutaneous heparin dosed three times a day may be as effective as standarddosed enoxaparin for prophylaxis of VTE without increased complications. Heparin three times a day for VTE prophylaxis was associated with significant pharmaceutical cost savings (10). In the largest pediatric study to date on this topic, Raffini et al (2) reported on the use of anticoagulants among hospitalized children. The proportion of children with VTE who were treated with enoxaparin increased from 29% to 49% during 2001– 2007, and the use of warfarin decreased from 11.4% to 9.6%. Increasing age was associated with increased likelihood of patients with VTE being treated with either enoxaparin or warfarin (2). Despite this recent information on utilization, there are no specific pediatric data re*See also p. 251.