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Survey of pharmacologic thromboprophylaxis in critically ill children*

Faustino, Edward Vincent S. MD; Patel, Sonya PharmD; Thiagarajan, Ravi R. MD, MPH; Cook, Deborah J. MD, MSc; Northrup, Veronika MPH; Randolph, Adrienne G. MD, MSc

doi: 10.1097/CCM.0b013e3182186ec0
Pediatric Critical Care

Objective: There is lack of evidence to guide thromboprophylaxis in the pediatric intensive care unit. We aimed to assess current prescribing practice for pharmacologic thromboprophylaxis in critically ill children.

Setting: Pediatric intensive care units in the United States and Canada with at least ten beds.

Design: Cross-sectional self-administered survey of pediatric intensivists using adolescent, child, and infant scenarios.

Participants: Pediatric intensive care unit clinical directors or section heads.

Interventions: None.

Measurements and Main Results: Physician leaders from 97 of 151 (64.2%) pediatric intensive care units or their designees responded to the survey. In mechanically ventilated children, 42.3% of the respondents would usually or always prescribe thromboprophylaxis for the adolescent but only 1.0% would prescribe it for the child and 1.1% for the infant. Considering all pediatric intensive care unit patients, 3.1%, 32.0%, and 44.2% of respondents would never prescribe thromboprophylaxis for the adolescent, child, and infant scenarios, respectively. These findings were significant (p < .001 for the adolescent vs. child and infant; p = .002 for child vs. infant). Other patient factors that increased the likelihood of prescribing prophylaxis to a critically ill child for all three scenarios were the presence of hypercoagulability, prior deep venous thrombosis, or a cavopulmonary anastomosis. Prophylaxis was less likely to be prescribed to patients with major bleeding or an anticipated invasive intervention. Low-molecular-weight heparin was the most commonly prescribed drug.

Conclusions: In these scenarios, physician leaders in pediatric intensive care units were more likely to prescribe thromboprophylaxis to adolescents compared with children or infants, but they prescribed it less often in adolescents than is recommended by evidence-based guidelines for adults. The heterogeneity in practice we documented underscores the need for rigorous randomized trials to determine the need for thromboprophylaxis in critically ill adolescents and children.

From the Department of Pediatrics (EVSF), Yale University School of Medicine, New Haven, CT; the Department of Pharmacy Services (SP), Yale-New Haven Hospital, New Haven, CT; Departments of Cardiology (RRT) and of Anesthesia, Perioperative and Pain Medicine (AGR), Children's Hospital Boston, Boston, MA; Departments of Medicine, Clinical Epidemiology and Biostatistics (DJC), McMaster University, Hamilton, Ontario, Canada; and the Yale Center for Analytical Sciences (VN), Yale University School of Medicine, New Haven, CT.

This publication was made possible by CTSA Grant Number UL1 RR024139 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH.

Information on Re-engineering the Clinical Research Enterprise can be obtained from the NIH Web site.

Biostatistical support provided by VN was funded through CTSA Grant Number UL1 RR024139. The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: vince.faustino@yale.edu

© 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins