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Pediatric Venous Thromboembolism Prevention

By Suzan Miller-Hoover, DNP, RN, CCNS, CCRN, Contributor
Pediatric Venous Thromboembolism Prevention
In 2008, the U. S. Department of Health and Human Services published “The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis.” In this call to action, the Surgeon General outlined a framework called CARE: Communication, Action, Research and Evaluation. These key framework elements were intended to reach into the healthcare systems, communities, and government councils (Galston & U. S. Department of Health and Human Services (DHHS), 2008).

Current research indicates that the healthcare system has embraced the need for venous thromboembolism prophylaxis (VTE) in the adult population. There are national guidelines and standards of care which call for both mechanical and pharmacologic prophylaxis during the hospitalization -- regardless of diagnosis. The practice of VTE prophylaxis is incorporated in adult hospitals during the admission process.

This is NOT the case for pediatric patients. A paucity of research on this topic and the mistaken view that children do not get VTEs has delayed the development of standardized guidelines for the pediatric patient.

In 2009, Raffini, Huang, Witmer, and Feudtner published the results of a seven year retrospective study utilizing the Pediatric Health Information System. This report showed a statistically significant increase in the rate of VTE (P <0.001) by 70% or from 34 to 58 cases per 10,000 hospital admissions. The study indicated that the increases were applicable to children of all ages (neonates through age 18 years) (Raffini, Huang, Witmer, et al., 2009). Since that time, the number of diagnosed VTE in children has continued to grow.

Due to the increasing survival rates of children with increasingly complex medical issues (leading to longer lengths of stay in the hospital), VTE in children has been gaining attention. Additionally, medical providers have been empowered to adopt VTE prophylaxis guidelines and protocols as means of identification, has increased awareness of the condition’s immediate and long-term complications. The immediate complications of VTE include loss of limb, organ or life, while up to 50% of children with VTE experience a chronic, debilitating condition called post-thrombotic syndrome (PTS) (Sharathkumar, Mahajerin, Heidt, et al., 2012).

The most readily available guideline is from Cincinnati Children’s Hospital. These guidelines are part of the Best Evidence Statement program (BESt). Published February 18, 2014, Cincinnati Children’s Venous Thromboembolism (VTE) Prophylaxis in Children and Adolescents, BESt 181, has been available to healthcare organizations across the nation at no charge. As with the CHOP document published in 2011, these recommendations are generalizable to all hospitalized patients aged 10-18 years (Raffini, Trimarchi, Beliveau, et al., 2011; Cincinnati Children’s Hospital, 2014).

The recommendations are:
1. All patients who are expected to have a surgical procedure lasting at least 60 minutes have sequential compression devices (SCD) placed at induction of anesthesia unless there are contraindications to mechanical prophylaxis.
2. All patients age 10 to 17 years are assessed for VTE risk factors on admission and reassessed at 48 to 72 hours of hospitalization and the risk category is to be assigned.
3. Mechanical VTE prophylaxis is administered based on risk category as soon as feasible but within 24 hours of assessment, unless there are contraindications.
4. When planning to initiate pharmacologic prophylaxis: obtain hematology consultation when considering pharmacologic agents.

Contraindications include:
1. Suspected or existing VTE.
2. Acute fracture or trauma to lower extremity.
3. Skin conditions affecting the lower extremity (dermatitis, eczema, arterial insufficiency).
4. Lower extremity used for peripheral intravenous access.

Additional risk factors include:
1. Obesity (>95th percentile of BMI for age).
2. Central venous catheters.
3. History of venous thrombosis.
4. Inflammation diseases.
5. Estrogen containing medication usage.
6. Oncologic diagnosis.
7. Trauma or surgery to abdomen or lower extremities.
8. Altered mobility for greater than 48 hours.

It is important to note that each healthcare institution must determine which combination of risk factors should be included in which risk category (low, moderate, or high). This determination should be based on the individual facility’s VTE rate and causes. However, a general rule of thumb is: altered mobility plus one additional risk factor places the patient at moderate risk, and altered mobility plus two additional risk factors places the patient at high risk.

Adding pharmacologic prophylaxis is a much discussed practice. This is because of the bleeding risk associated with heparin use in an injectable form, as in the case of pediatrics. The medical team must determine the best medication and the type of patients who would benefit from pharmacologic prophylaxis.

In adults, the guidelines are quite simple, everyone older than 18 years who is admitted to the hospital will receive mechanical and pharmacologic prophylaxis. However, preventing VTE is not so simple.

• Do you use puberty as the starting point (children at this point in their maturity have clotting systems similar to adults), or do you start earlier? Some pediatric facilities are starting at age 10 years. ?
• Do you place SCDs on everyone older than 10 years, or only those at moderate or high risk?
• When do you start pharmacologic prophylaxis and what medication do you choose?

As with all things pediatric, the answer is not simple. If any research is available, it is rarely supported by a wide variety of study. However, to do nothing preventative is not a viable answer. STOP THE CLOT before it begins! Children do get VTE and can be affected for the rest of their lives from complications arising from a VTE event.

Get more information on venous thromboembolism with the RN.com CE course, “DVT: A Life-Threatening Condition.”


References:
Cincinnati Children’s Hospital (2014). Venous thromboembolism (VTE) prophylaxis in children and adolescents. Best Evidence Statement. Retrieved from https://www.guideline.gov/content.aspx?id=47904

Galson, S. K., & U.S. Department of Health and Human Services. (2008). The Surgeon General's call to action to prevent deep vein thrombosis and pulmonary embolism. Call to Action: 1-49, (5). Retrieved from http://www.accpstorage.org/chest08/bestOF/SurgeonGeneralsReport.pdf

Raffini, L., Huang, Y., Witmer, C., & Feudtner, C. (2009). Dramatic increase in venous thromboembolism in children’s hospitals in the United States from 2001 to 2007. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19736261

Raffini, L, Trimarchi, T., Beliveau, J., & Davis, D. (2011). Thromboprohylaxis in a pediataric hospital: A patient-safety and quality-improvement initiative. Pediatrics, 127 (5). Retrieved from http://pediatrics.aappublications.org/content/127/5/e1326

Sharathkumar, A., Mahajerin, A., Heidt, L., …Rademaker, A. (2012). Risk-prediction tool for identifying hospitalized children with a predisposition for development of venous thromboembolism: Peds-Clot clinical decision rule. Journal of Thrombosis and Haemostasis. 10, (7). 1326–1334.

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Biography:
Dr. Miller-Hoover is a certified Acute and Critical Care Pediatric Clinical Nurse Specialist and has worked in nursing for more than 30 years. Her nursing career has taken her from the bedside, to education and leadership in critical care units where she has cared for patients of all ages. Dr. Miller-Hoover is a published author in peer-reviewed nursing journals and has been accepted for various poster and podium presentations at national conferences.