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Chapter 16 - Prevention of VTE in Children

from Section 2 - Special considerations in pediatric patients

Published online by Cambridge University Press:  18 December 2014

By
Brian R. Branchford  and
Leslie Raffini
Edited by
Neil A. Goldenberg  and
Marilyn J. Manco-Johnson
Brian R. Branchford
Affiliation:
University of Colorado
Leslie Raffini
Affiliation:
University of Pennsylvania Perlman School of Medicine
Neil A. Goldenberg
Affiliation:
The Johns Hopkins University School of Medicine
Marilyn J. Manco-Johnson
Affiliation:
Hemophilia and Thrombosis Center, University of Colorado, Denver
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Summary

Introduction

In-hospital venous thromboembolism (VTE) represents a significant, yet preventable, public health burden, which was recognized in 2008 by the USA Surgeon General’s Call-to-Action [1]. Prophylactic anticoagulation for VTE prevention has been proven to be safe and effective, and has become standard care in hospitalized adults [2,3]. As providers become increasingly aware of the growing problem of VTE in hospitalized children, attention is starting to focus on prevention in this population.

The available data regarding utility and safety of primary prophylaxis is sparse, likely due to the relative infrequency of VTE in children compared to their adult counterparts. Since high-quality evidence in this area is lacking, clinical care is often formulated by expert consensus and extrapolation from adult studies. Two important considerations are clinician awareness of in-hospital VTE, and risk-stratified approaches to prevent unnecessary exposure of low-risk patients to potentially serious side effects. While this is an area expected to evolve greatly, this chapter provides a contemporary review of pertinent background information, risk factors for in-hospital VTE development, and existing recommendations for pharmacologic and non-pharmacologic VTE prophylaxis in children.

Although the incidence of in-hospital VTE is considerably lower in children than adults, it is an increasing problem particularly in pediatric tertiary care hospitals, with potential for severe consequences [4]. Possible explanations for the rising incidence include advances in tertiary care, prolonged survival of medically complex patients, increased utilization of central venous access devices (CVADs), improved imaging sensitivity, and increased awareness. Of children with VTE, 16% to 20% have objectively confirmed pulmonary embolism (PE) [5], and retrospective data from the Hospital for Sick Children indicates a VTE-specific mortality rate of 9% among pediatric PE cases [6]. The risks of long-term pulmonary insufficiency and chronic thromboembolic pulmonary hypertension following PE in children remain undefined.

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Pediatric Thrombotic Disorders , pp. 207 - 218
Publisher: Cambridge University Press
Print publication year: 2015

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References

United States Surgeon General’s Call-to-Action for Deep Vein Thrombosis 2008 [cited 2012]. Available from:
Sjalander, A, Bergqvist, D, Eriksson, H, Carlberg, B, Svensson, P. Efficacy and safety of anticoagulant prophylaxis to prevent venous thromboembolism in acutely ill medical inpatients: a meta-analysis. J Int Med. 2008;263(1):52–60.CrossRefGoogle ScholarPubMed
Dentali, F, Gianni, M, Lim, W, Crowther, M. Meta-analysis: Anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Annals Int Med. 2007;146(4):278–88.CrossRefGoogle ScholarPubMed
Raffini, L, Witmer, C, Feudtner, C. Dramatic increase in venous thromboembolism in children’s hospitals in the United States from 2001 to 2007. Pediatrics. 2009;124:1001–8.CrossRefGoogle ScholarPubMed
Journeycake, JM, Manco-Johnson, MJ. Thrombosis during infancy: what we know and what we do not know. Hematol Oncol Clin North Am. 2004;18:1315–38.CrossRefGoogle Scholar
Biss, TT, Kahr, WH, Chan, AK, Williams, S. Clinical features and outcome of pulmonary embolism in children. Br J Haem. 2008;142:808–18.CrossRefGoogle ScholarPubMed
Goldenberg, NA, Kahn, SR, Crowther, M, Nowak-Göttl, U, Manco-Johnson, MJ. Post thrombotic syndrome in children: a systematic review of frequency of occurrence, validity of outcome measures, and prognostic factors. Haematologica. 2010;95(11):1952–9.CrossRefGoogle ScholarPubMed
Kahn, S, Dunn, A, Cushman, M, Dentali, F, Akl, E, Cook, D, Balekian, A, et al. Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, 9th edn: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(Suppl 2):e195S–226S.CrossRefGoogle Scholar
Gould, M, Wren, S, Karanicolas, P, Arcelus, J, Heit, J, Samama, C. Prevention of VTE in Nonorthopedic Surgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th edn: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(Suppl 2):e2275–775.CrossRefGoogle Scholar
Falck-Ytter, Y, Johanson, N, Curley, C, Dahl, O, Schulman, S, Ortel, T, Pauker, S, Colwell, C. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th edn: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Chest. 2012;141(Suppl 2):e278–325.
Goldenberg, NA. Venous thromboembolism in children. Hematol Oncol Clin North Am. 2010;24(1):151–66.CrossRefGoogle ScholarPubMed
Monagle, Paul, Mahoney, Michael, Ali, Kaiser, Barnard, Dorothy, Bernstein, Mark, Brisson, Linda, David, Michele, Desai, Sunil, Scully, Marie-Francis, Halton, Jacqueline, Israels, Sara, Jardine, Lawrence, Leaker, Michael, McCusker, Patricia, Silva, Marianna, Wu, John, Anderson, Ron, Andrew, Maureen, Massicotte, M Patricia. Outcome of pediatric thromboembolic disease: a report from the Canadian Childhood Thrombophilia Registry. Pediatric Research. 2000;47(6):763–6.CrossRefGoogle ScholarPubMed
Revel-Vilk, S, Bauman, M, Massicotte, P. Prothrombotic conditions in an unselected cohort of children with venous thromboembolic disease. J Thromb Haemost. 2003;1:915–21.CrossRefGoogle Scholar
Andrew, M, Pencharz, P, Zlotkin, S, Burrows, P, Ingram, J, Adams, M, Filler, R. A cross-sectional study of catheter-related thrombosis in children receiving total parenteral nutrition at home. J Pediatr. 1995;126:358–63.CrossRefGoogle ScholarPubMed
Koksoy, C, Erden, I, Akkaya, A. The risk factors in central venous catheter-related thrombosis. Aust NZ J Surg. 1995;65:796–8.CrossRefGoogle ScholarPubMed
Male, C, Massicotte, P, Gent, M, Mitchell, L. Significant association with location of central venous line placement and risk of venous thrombosis in children. Thromb Haemost. 2005;94:516–21.Google ScholarPubMed
Stanley, A. Primary prevention of venous thromboembolism in medical and surgical oncology patients. Brit J Cancer. 2010;13(102 Suppl 1):S10–16.CrossRefGoogle Scholar
Elice, F. Hematologic malignancies and thrombosis. Thromb Research. 2012;129(3):360–6.CrossRefGoogle ScholarPubMed
Takemoto, CM. Venous thromboembolism in cystic fibrosis. Pediatr Pulmonology. 2012;47(2):105–12.CrossRefGoogle ScholarPubMed
Higgerson, RA, Christie, LM, Brown, AM, McArthur, JA, Totapally, BR, Hanson, SJ. National Association of Children’s Hospitals and Related Institutions Pediatric Intensive Care Unit FOCUS group. Incidence and risk factors associated with venous thrombotic events in pediatric intensive care unit patients. Pediatr Crit Care Med. 2011;12(6):628–34.CrossRefGoogle Scholar
Male, C, Ginsberg, JS, Hanna, K, Andrew, M, Halton, J, et al. Comparison of venography and ultrasound for the diagnosis of asymptomatic deep vein thrombosis in the upper body in children: results of the PARKAA study. Thromb Haemost. 2002;87:593–8.CrossRefGoogle Scholar
Male, C, Andrew, M, Hanna, K, Julian, J, Mitchell, L; PARKAA Investigators. Central venous line-related thrombosis in children: association with central venous line location and insertion technique. Blood. 2003;101(11):4273–8.CrossRefGoogle ScholarPubMed
Dollery, CM, Bauraind, O, Bull, C, Milla, PJ. Thrombosis and embolism in long-term central venous access for parenteral nutrition. Lancet. 1994;344(8929):1043–5.CrossRefGoogle ScholarPubMed
Derish, MT, Frankel, LR. Venous catheter thrombus formation and pulmonary embolism in children. Pediatr Pulmonology. 1995;20(6):349–54.CrossRefGoogle ScholarPubMed
Randolph, A, Gonzales, C, Andrew, M. Benefit of heparin in peripheral venous and arterial catheters: systematic review and meta-analysis of randomised controlled trials. BMJ. 1998;316:969–75.CrossRefGoogle ScholarPubMed
Dillon, PW, Bagnall-Reeb, HA, Buckley, JD, Wiener, ES, Haase, GM. Prophylactic urokinase in the management of long-term venous access devices in children: a Children’s Oncology Group study. J Clin Oncol. 2004;22(13):2718–23.CrossRefGoogle ScholarPubMed
Raad, I, Khalil, S, Costerton, J, Lam, C, Bodey, G. The relationship between the thrombotic and infectious complications of central venous catheters. JAMA. 1884;271(13):1014–16.CrossRefGoogle Scholar
Massicotte, P, Gent, M, Shields, K, Marzinotto, V, Szechtman, B, Chan, A, Andrew, M. An open-label randomized controlled trial of low molecular weight heparin for the prevention of central venous line-related thrombotic complications in children: the PROTEKT trial. Thromb Res. 2003;109(2–3):101–8.CrossRefGoogle ScholarPubMed
Schroeder, AR, Silverman, NH, Rubesova, E, Merkel, E, Roth, SJ. A continuous heparin infusion does not prevent catheter-related thrombosis in infants after cardiac surgery. Pediatr Crit Care Med. 2010;11(4):489–95.Google Scholar
Newall, FH, Savoia, HF, Campbell, J, Monagle, P. Warfarin therapy in children requiring long-term total parenteral nutrtion (TPN). Pediatrics. 2003;112(5):e386.CrossRefGoogle Scholar
Ruud, E, De Lange, C, Hogstad, EM, Wesenberg, F. Low-dose warfarin for the prevention of central line-associated thrombosis in children with malignancies: a randomized, controlled study. Acta Paediatr. 2006;95:1053–9.CrossRefGoogle ScholarPubMed
Young, A, Begum, G, Kerr, D, Hughes, A, Rea, D, Shepherd, S, Stanley, A, et al. Warfarin thromboprophylaxis in cancer patients with central venous catheters (WARP): an open-label randomised trial. The Lancet. 2009;373(9663):567–74.CrossRefGoogle ScholarPubMed
Toker, S, Morgan, SJ. Deep vein thrombosis prophylaxis in trauma patients. Thrombosis. 2011;9(1):7–9.Google Scholar
O’Brien, SH. In the absence of a central venous catheter, risk of venous thromboembolism is low in critically injured children, adolescents, and young adults: Evidence from the National Trauma Data Bank. Pediatr Crit Care Med. 2011;12(3):251–6.CrossRefGoogle Scholar
Cyr, C, Pettersen, G, David, M, Brossard, J. Venous thromboembolism after severe injury in children. Acta Haematol. 2006;115(3–4):198–200.CrossRefGoogle ScholarPubMed
Monagle, P, Goldenberg, N, Ichord, R, Journeycake, J, Nowak-Gottl, U, Vesely, S. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th edn. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e737S–801S.CrossRefGoogle Scholar
Monagle, P, Cochrane, A, Roberts, R, Manlhiot, C, Weintraub, R, Szechtman, B, et al. A multicenter, randomized trial comparing heparin/warfarin and acetylsalicylic acid as primary thromboprophylaxis for 2 years after the Fontan procedure in children. J Am Coll Cardiol. 2011;58(6):645–51.CrossRefGoogle ScholarPubMed
Grace, RF, Neuberg, D, Sallan, SE, Connors, JM, Neufeld, EJ, Deangelo, DJ, Silverman, LB. The frequency and management of asparaginase-related thrombosis in paediatric and adult patients with acute lymphoblastic leukaemia treated on Dana-Farber Cancer Institute consortium protocols. Brit J Haematol. 2011;152(4):452–9.CrossRefGoogle ScholarPubMed
Raetz, EA. Tolerability and efficacy of L-asparaginase therapy in pediatric patients with acute lymphoblastic leukemia. J Pediatr Hematol/Oncol. 2010;32(7):554–63.CrossRefGoogle ScholarPubMed
Hirota-Kawadobora, M, Ishikawa, S, Fujihara, N, Wakabayashi, S, Kamijo, Y, Yamauchi, K, et al. Analysis of hypofibrinogenemias found on routine coagulation screening tests and identification of heterozygous dysfibrinogenemia or fibrinogen deficiency. Rinsho byori: The Japanese Journal of Clinical Pathology. 2007;55(11):989–95.Google ScholarPubMed
Mitchell, LAndrew, M, Hanna, K, Abshire, T, Halton, J, Wu, J, Anderson, R, Cherrick, I, Desai, S, Mahoney, D, McCusker, P, Chait, P, Abdolell, M, deVeber, G, Mikulis, D. Trend to efficacy and safety using antithrombin concentrate in prevention of thrombosis in children receiving L-asparaginase for acute lymphoblastic leukemia. Results of the PAARKA study. Thromb Haemost. 2003;90(2):235–44.Google ScholarPubMed
Nowak-Gottl, U, Manner, D, Kenet, G. Thrombophilia testing in neonates and infants with thrombosis. Semin Fetal Neonatal Med. 2011;16(6):345–8.CrossRefGoogle ScholarPubMed
Young, G, Bonduel, M, Brandao, L, Chan, A, Friedrichs, F, Goldenberg, NA, Grabowski, E, Heller, C, Journeycake, J, Kenet, G, Krumpel, A, Kurnik, K, Lubetsky, A, Male, C, Manco-Johnson, M, Matthew, P, Monagle, P, van Ommen, H, Simoni, P, Svirirn, P, Tormene, D, Nowak Gottl, U. Impact of inherited thrombophilia on venous thromboembolism in children: a systematic review and meta-analysis of observational studies. Circulation. 2008;118(13):1373–82.CrossRefGoogle ScholarPubMed
Faustino, E, Thiagarajan, R, Cook, D, Northrup, V, Randolph, A. Survey of parmacologic thromboprophylaxis in critically ill children. Critical Care Medicine. 2011;39(7):1773–8.CrossRefGoogle Scholar
, MA A-F. Obesity and venous thrombosis: a review. SeminThromb Hemost. 2011;37(8):903–7.CrossRefGoogle Scholar
Wang, YC MK, Marsh, T, Gortmaker, S, Brown, M. Health and economic burden of the projected obesity trends in the USA and the UK. The Lancet. 2011;378(9793):815–27.CrossRefGoogle ScholarPubMed
Gerotziafas, GT. Risk factors for venous thromboembolism in children. International Angiology: A Journal of the International Union of Angiology. 2004;23(3):195–205.Google ScholarPubMed
Sandoval, JA, Sheehan, MP, Stonerock, CE, Shafique, S, Rescorla, FJ, Dalsing, MC. Incidence, risk factors, and treatment patterns for deep venous thrombosis in hospitalized children: an increasing population at risk. J Vasc Surg: Official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 2008;47(4):837–43.CrossRefGoogle ScholarPubMed
Gonazalez, B, Mahoney, D, Hulten, K, Edwards, R, Lamberth, L, Hammerman, W, Mason, E, Kaplan, S. Venous thrombosis associated with staphylococcal osteomyelitis in children. Pediatrics. 2006;117(5):1673–9.CrossRefGoogle Scholar
Koster, T, Lieuw-A-Len, DD, Kroes, ACM, Emmerich, JD, Van Dissel, JT. Chlamydia pneumoniae IgG seropositivity and risk of deep-vein thrombosis. Lancet. 2000;355:1694–5.CrossRefGoogle ScholarPubMed
Emmerich, J. Infection and venous thrombosis. Pathophysiol Haemost Thromb. 2002;32:346–8.CrossRefGoogle ScholarPubMed
Lozinguez, O, Belec, L, Nicaud, V, Alhenc-Gelas, M, Fiessinger, JN, Aiach, M, Emmerich, J. Demonstration of an association between Chlamydia pneumoniae infection and venous thromboembolic disease. Thromb Haemost. 2000;83:887–91.CrossRefGoogle ScholarPubMed
Fridlender, Z, Leitersdorf, E. Association between cytomegalovirus infection and venous thromboembolism. Am J Med Sci. 2007;334(2):111–14.CrossRefGoogle ScholarPubMed
Matta, F, Stein, P. Human immunodeficiency virus infection and risk of venous thormboembolism. Am J Med Sci. 2008;336(5):402–6.CrossRefGoogle Scholar
Branchford, B, Bajaj, L, Manco-Johnson, M, Wang, M, Goldenberg, NA. Risk factors for in-hospital venous thromboembolism in children: a case-control study employing diagnostic validation. Haematologica. 2011. 2012 Apr;97(4):509–15.CrossRefGoogle ScholarPubMed
Jackson, PC, Morgan, JM. Perioperative thromboprophylaxis in children: development of a guideline for management. Pediatr Anesthes. 2008;18:478–87.CrossRefGoogle ScholarPubMed
Raffini, L, Beliveau, J, Davis, D. Thromboprophylaxis in a pediatric hospital: A patient safety and quality improvement initiative. Pediatrics. 2011;127:e1326–32.CrossRefGoogle Scholar
Amin, A, Dobesh, P, Shorr, A, Hussein, M, Mozaffari, E, Benner, JS. Are hospitals delivering appropriate VTE prevention? The venous thromboembolism study to assess the rate of thromboprophylaxis (VTE start). J Thromb Thrombolysis. 2010;29:326–39.CrossRefGoogle Scholar
Beck, M, Todoric, K, Lehman, E, Sciamanna, C. Reliability of a point-based VTE risk assessment tool in the hands of medical residents. J Hosp Med. 2011;6(4):195–201.CrossRefGoogle ScholarPubMed
Amarigiri, S. Elastic compression stockings for prevention of deep vein thrombosis. Cochr Database Syst Rev. 2010;7.Google Scholar
Chalmers, E, Ganesen, V, Liesner, R, Maroo, S, Nokes, T, Saunders, D, et al. Guideline on the investigation, management and prevention of venous thrombosis in children. Brit J Haematol. 2011;154(2):196–207.CrossRefGoogle ScholarPubMed
Guyatt, G, Gutterman, D, Baumann, M, Addrizzo-Harris, D, Hylek, E, Phillips, B, Raskob, G, Zelman Lewis, S, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: Report from an American College of Chest Physicians Task Force. Chest. 2006;129(1):174–81.CrossRefGoogle ScholarPubMed
Moruf, A, Spyropoulos, AC, Schardt, TQ, Gibson, E, Manco-Johnson, MJ, Wang, M, et al. Peri-procedural bridging with low molecular weight heparin in patients receiving warfarin for venous thromboembolism: a pediatric experience. Thromb Res. 2012;130(4):612–15.CrossRefGoogle ScholarPubMed
Sharathkumar, AA, Mahajerin, A, Heidt, L, Doerfer, K, Heiny, M, Vik, T, et al. Risk-prediction tool for identifying hospitalized children with a predisposition for development of venous thromboembolism: Peds-Clot Clinical Decision Rule. J Thromb Haemost. 2012;10(7):1326–34.CrossRefGoogle ScholarPubMed
Wright, JM, Watts, RG. Venous thromboembolism in pediatric patients: epidemiologic data from a pediatric tertiary care center in Alabama. J Pediatr Hematol Oncol. 2011;33(4):261–4.CrossRefGoogle ScholarPubMed
Oschman, A, Kuhn, RJ. Venous thromboembolism in the pediatric population. Orthopedics. 2010;33(3):180–4.CrossRefGoogle ScholarPubMed
Anderson, FA, Spencer, FA. Risk factors for venous thromboembolism. Circulation. 2003;107(23 Suppl 1):19–16.CrossRefGoogle ScholarPubMed
Hanson, SJ, Punzalan, RC, Greenup, RA, Liu, H, Sato, TT, Havens, PL. Incidence and risk factors for venous thromboembolism in critically ill children after trauma. J Trauma. 2010;68(1):52–6.CrossRefGoogle ScholarPubMed
Spentzouris, G, Scriven, RJ, Lee, TK, Labropoulos, N. Pediatric venous thromboembolism in relation to adults. Journal of Vascular Surgery: Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 2012;55(6):1785–93.CrossRefGoogle ScholarPubMed

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