Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma.
BACKGROUND
Historically, 6% of critically ill children developed clinically apparent venous thromboembolism (VTE) after trauma at our Level I pediatric trauma center. We hypothesized that implementation of clinical guidelines for thrombosis prophylaxis incorporating both VTE risk and bleeding risk would reduce VTE incidence without increased bleeding.


METHODS
VTE, both clinically apparent and those only detected by guideline-directed screening, were prospectively identified for all children admitted to the intensive care unit after trauma during three time periods: preimplementation of guidelines for VTE thromboprophylaxis (PRE; April 1, 2006-June 30, 2007), the intervening period (ROLL OUT; July 1, 2007-November 4, 2008), and postguideline implementation (POST; November 5, 2008-June 1, 2010). For patients classified as high risk for VTE, anticoagulation was recommended. For those patients at high risk of VTE with high risk of bleeding, anticoagulation was deferred and screening ultrasound performed.


RESULTS
Fourteen of 546 subjects developed VTE. There was a decrease in total VTE (p = 0.041) and clinical VTE (p = 0.001) after guideline implementation. The nine VTE PRE (5.2%) were clinically symptomatic, while the three VTE POST (1.8%) were detected by guideline-directed screening ultrasound. Implementation of guidelines did not increase overall thromboprophylaxis, with decreased anticoagulation in patients at low risk of VTE. No bleeding complications occurred. No patients classified by the guidelines as low risk for VTE developed VTE.


CONCLUSIONS
The incidence of clinical VTE and total VTE decreased after implementation of clinical guidelines for thromboprophylaxis in critically ill children after trauma. This decrease in VTE was not associated with increased prophylactic anticoagulation nor increased bleeding. The guidelines were predictive in identifying patients at low risk for VTE.


METHODS
II, therapeutic study.
Department of Pediatrics, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin 5322, USA. shanson@mcw.edu
Sheila J
SJ
Hanson
Rowena C
RC
Punzalan
Marjorie J
MJ
Arca
Pippa
P
Simpson
Melissa A
MA
Christensen
Sydney K
SK
Hanson
Ke
K
Yan
Kristin
K
Braun
Peter L
PL
Havens
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D016638:Critical Illness / Q000453:epidemiology / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D008297:Male; D017410:Practice Guidelines as Topic; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology; D020246:Venous Thrombosis / Q000453:epidemiology / Q000517:prevention & control*; D014947:Wounds and Injuries / Q000150:complications* / Q000453:epidemiology / Q000628:therapy; D055815:Young Adult