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Variability in Guidelines for Venous Thromboembolism Prophylaxis After Pediatric Trauma

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Variability in Guidelines for Venous Thromboembolism Prophylaxis After Pediatric Trauma
Sheila J. Hanson, MD, MS1, E. Vince Faustino, MD2, Arash Mahajerin, MD3, A. Jill Thompson, PharmD4, Sarah O'Brien, MD5, Christian J. Streck6, MD, John K. Petty, MD7, 1Medical College of Wisconsin, Children's Hospital of Wisconsin, Critical Care; 2Yale University School of Medicine, Pediatric Critical Care; 3University of California- Irvine, Children's Hospital of Orange County, Hematology; 4Medical University of South Carolina, Pharmacy; 5Nationwide Children's Hospital, Hematology, 6Medical University of South Carolina, Pediatric Surgery; 7Wake Forest University, Brenner Children's Hospital, Pediatric Surgery

Objective: Objective: To describe current guidelines for venous thromboembolism (VTE) prophylaxis following pediatric trauma.
Methods: Guidelines for VTE prophylaxis were requested from members of Pediatric Trauma Society institutions in October, 2013.
Results: Twenty-four institutions responded. Thirty-three percent (8/24) of centers had no guidelines for VTE prophylaxis. Thirteen centers had trauma guidelines for VTE prophylaxis (10 specific for pediatric trauma, 3 centers used adult trauma guidelines), while 3 centers used VTE guidelines for hospitalized children. Age cutoffs for prophylaxis ranged from 10-18 years. Six centers recommended prophylaxis for children younger than the initial age cutoff if additional risk factors were present. All 10 pediatric trauma guidelines stratified by number of risk factors. Most common risk factors (9/10) were presence of CVC, complex lower extremity fracture, pelvic fracture, and spinal cord injury. Sequential compression devices and low molecular weight heparin (LMWH) use were recommended in all. LMWH dose of 0.5mg/kg q12h was recommended by 10/11 of the pediatric guidelines where dose was specified, with a maximum dose ranging 30-70mg. Monitoring of LMWH under specific conditions, most commonly renal insufficiency, was recommended in 5/13 pediatric guidelines. Routine monitoring of LMWH level was recommended in only one guideline. Unfractionated heparin was an option in 1 general pediatric guideline and none of the pediatric trauma guidelines. Conclusions: Significant variability exists in guidelines for VTE prophylaxis following pediatric trauma. Though local guidelines are present in 66% of responding institutions, the criteria for prophylaxis varies by age of at-risk patients and additional risk factors. LMWH is consistently the agent of choice for prophylaxis. Development of consensus guidelines for VTE prophylaxis after pediatric trauma would aid in standardizing trauma care.
Objective: Discuss the variability of current local guidelines for venous thromboembolism after pediatric trauma.Objective Content: Recognize the implications of variability in pediatric guidelines for venous thromboembolism.


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