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A Multinational Study of Thromboprophylaxis Practice in Critically Ill Children*

Faustino, Edward Vincent S. MD1; Hanson, Sheila MD, MS2; Spinella, Philip C. MD3; Tucci, Marisa MD4; O’Brien, Sarah H. MD, MSc5; Nunez, Antonio Rodriguez MD, PhD6; Yung, Michael MD7; Truemper, Edward MD, MS8; Qin, Li PhD9; Li, Simon MD, MPH10; Marohn, Kimberly MD1; G. Randolph, Adrienne MD, MSc11; on behalf of the PROphylaxis against ThRombosis prACTice (PROTRACT) Study Investigators of the PALISI BloodNet

doi: 10.1097/CCM.0000000000000147
Pediatric Critical Care

Objectives: Although critically ill children are at increased risk for developing deep venous thrombosis, there are few pediatric studies establishing the prevalence of thrombosis or the efficacy of thromboprophylaxis. We tested the hypothesis that thromboprophylaxis is infrequently used in critically ill children even for those in whom it is indicated.

Design: Prospective multinational cross-sectional study over four study dates in 2012.

Setting: Fifty-nine PICUs in Australia, Canada, New Zealand, Portugal, Singapore, Spain, and the United States.

Patients: All patients less than 18 years old in the PICU during the study dates and times were included in the study, unless the patients were 1) boarding in the unit waiting for a bed outside the PICU or 2) receiving therapeutic anticoagulation.

Interventions: None.

Measurements and Main Results: Of 2,484 children in the study, 2,159 (86.9%) had greater than or equal to 1 risk factor for thrombosis. Only 308 children (12.4%) were receiving pharmacologic thromboprophylaxis (e.g., aspirin, low-molecular-weight heparin, or unfractionated heparin). Of 430 children indicated to receive pharmacologic thromboprophylaxis based on consensus recommendations, only 149 (34.7%) were receiving it. Mechanical thromboprophylaxis was used in 156 of 655 children (23.8%) 8 years old or older, the youngest age for that device. Using nonlinear mixed effects model, presence of cyanotic congenital heart disease (odds ratio, 7.35; p < 0.001) and spinal cord injury (odds ratio, 8.85; p = 0.008) strongly predicted the use of pharmacologic and mechanical thromboprophylaxis, respectively.

Conclusions: Thromboprophylaxis is infrequently used in critically ill children. This is true even for children at high risk of thrombosis where consensus guidelines recommend pharmacologic thromboprophylaxis.

1Department of Pediatrics, Yale School of Medicine, New Haven, CT.

2Department of Pediatrics, Children’s Hospital of Wisconsin, Milwaukee, WI.

3Department of Pediatrics, Washington University at St. Louis School of Medicine, St. Louis, MO.

4Department of Pediatrics, CHU Sainte-Justine University of Montreal, Montreal, QC, Canada.

5Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH.

6Pediatric Intensive Care Unit, University of Santiago de Compostela, Santiago de Compostela, Spain.

7Pediatric Intensive Care Unit, Women’s and Children’s Hospital, Adelaide, South Australia, Australia.

8Department of Pediatrics, Children’s Hospital and Medical Center, Omaha, NE.

9Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT.

10Department of Pediatrics, New York Medical College Maria Fareri Children’s Hospital, Valhalla, NY.

11Department of Anesthesia, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, MA.

* See also p. 1317.

This work was performed at Akron Children’s Hospital; Alberta Children’s Hospital; Baylor College of Medicine; Baystate Medical Center; Boston Children’s Hospital; Centre Hospitalier Universitaire de Sherbrooke; Centre mere-enfant Soleil du CHU de Quebec; Centro Hospitalar Lisboa Norte; Children’s Hospital and Medical Center, Omaha and Nebraska Medical Center; Children’s Hospital and Research Center Oakland; Children’s Hospital at Westmead; Children’s Hospital of Philadelphia; Children’s Hospital of Wisconsin; Children’s Hospitals and Clinics of Minnesota; CHU Sainte-Justine University of Montreal; Cohen Children’s Medical Center of New York; Complexo Hospitalario Universitario A Coruna; Connecticut Children’s Medical Center; Dell Children’s Medical Center of Central Texas; Doernbecher Children’s Hospital; Duke University Medical Center; Gregorio Maranon General University Hospital; Helen DeVos Children’s Hospital; Hospital Clinico Universitario de Santiago; Hospital Dona Estefania; Hospital Infantil Universitario Miguel Servet; Hospital Infantil Universitario Niño Jesus; Hospital Pediatrico Coimbra; Hospital Regional Universitario Materno Infantil Carlos Haya; Hospital Sao Joao; Hospital Universitario Materno Infantil Las Palmas de Gran Canaria; Joseph M Sanzani Children’s Hospital at Hackensack University Medical Center; KK Women’s and Children’s Hospital; Mater Children’s Hospital; Montreal Children’s Hospital; Nationwide Children’s Hospital; Nuestra Senora de Candelaria Hospital; Penn State Children’s Hospital; Princess Margaret Hospital; Riley Hospital for Children; Royal Children’s Hospital Brisbane; Royal Children’s Hospital Melbourne; Sant Joan de Deu Hospital; St. Louis Children’s Hospital; Starship Children’s Hospital; Stony Brook University Medical Center; Sydney Children’s Hospital; University Hospital of Salamanca; University of California at San Francisco; University of Rochester Medical Center; University of Virginia; Women’s and Children’s Hospital, Adelaide; and Yale-New Haven Children’s Hospital.

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Dr. Faustino received funding from Clinical and Transitional Science Award (CTSA) (grant numbers UL1 TR000142 and KL2 TR000140) from the National Institutes of Health (NIH). His institution received grant support from the NIH. Dr. Spinella is a consultant of TerumoBCT and is employed by Washington University in St. Louis. Dr. O’Brien is a consultant of Bristol-Myers Squibb. Dr. O’Brien served as a board member for American Thrombosis and Hemostasis Network, consulted for Bristol Myers (Venous Thromboembolism in Peds: Apixaban), and provided expert testimony for Katie Crott Walsh (for trial). Her institution received grant support from Hemostasis and Thrombosis Research Society and American Diabetes Association. Dr. Yung is employed by the Women’s and Children’s Hospital. Dr. Truemper is employed by Children’s Specialty Physicians. Dr. Qin received funding from CTSA (grant number UL1 TR000142). Dr. Marohn is employed by the Yale New Haven Hospital. REDCap from Washington University at St. Louis School of Medicine, which was used as the study’s data collection tool, was funded through CTSA (grant number UL1 TR000448). The remaining authors have disclosed that they do not have any potential conflicts of interest.

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

© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins