Venous Thromboembolism Prophylaxis In Trauma Patients: Practice Gap...

All right, who was and just so you guys know, we have a lot of comments from the audience too, and I don't, we want to move forward, but it's interesting people in different regions of the world are giving their employees. Well, I was going to say we've stolen a lot from the airline industry in terms of how they manage safety and maybe we need to steal from the police department and how they manage officer involved shootings that they can't just go back to work the next day. They have a whole program for that stuff anyway, that's amazing. Good comment. OK, so moving on to something completely different, as Monty Python says. This is an obese 8-year-old admitted to the ICU after a motor vehicle crash, required chest compressions, and he has a grade 3 liver laceration, a comminuted displaced tibia fracture, a severe brain injury with subdural hemorrhage requiring norepinephrine to maintain his cerebral perfusion pressure, and his GCS is 8 on post-injury day 3. And this question is about prophylaxis for venous thromboembolism. The most appropriate post-traumatic venous thromboembolism prophylaxis in this patient is sequential compression devices until he is ambulatory, and, and the choices are a screening ultrasound and follow-up in the ICU, presuming he's still there on day 7, daily screening ultrasounds, starting low molecular weight heparin with antithrombin 10A. Level titrated to 0.2 to 0.4 international units per mL and then low molecular weight heparin with a little bit higher dose and lastly, aspirin. So this just as a way of background is another thing that's significantly changed, I would say over the last 10 to 20 years where uh the general teaching some time ago was that kids just didn't get this problem and it didn't exist and you didn't really need to worry about it to perhaps the pendulum swung to where it's much more widely recognized maybe it's over swung we see kids getting inguinal hernia repairs with sequential compression devices being brought to the operating room. Uh, for a 30 minute procedure, I'm not sure they need, but clearly it's much more recognized than it used to be, and it's not something that pediatric surgeons have a history of being used to dealing with. Should I go on to the, so Todd, can I ask a, you know, Chuck raised an interesting point. Can I ask a question? Do, does everyone at this table, does their hospital have uh protocols for the use of the sequential compression devices for patients going to the operating room? I'm working on one at our place right now. Our, our hospitals are women's and children's hospital, and so we have a tendency to put on too many sequential compression stockings because the nurses put them on all the women and so you walk in to do a routine case and there, there they are. So, uh, we're currently working on something to, to hit it, hit the sweet spot. Midwest Pediatric Surgery Consortium is taking on a standardized protocol and studying it at 11 different centers. Um, actually, not all of them are going to be involved, but, but the most of them, and it involves chemoprophylaxis with antithrombin 1A and, and uh as well as uh compression devices, um, and it's following a protocol and then also looking at ultrasound, um. Uh, evaluation on a, on a daily basis to, to evaluate for the present. So I, I hope within a short time, next couple of years we'll have an answer as to what a really great, um, uh, protocol is and how effective it is and, and whether in fact it's, it's preventing DVTs. The problem with this area is the number of DVTs is actually a number of complications from DVTs is very small and so, and so, um. It's not insignificant, but it's, it's small. But the complication itself is if it happens, when it happens catastrophic, we track all our our DVTs. The vast majority seem to occur around central lines. In fact, if you look close enough, all central lines have a fibrin sheath. So are we going to prevent all fibrine sheaths, which I don't think we can. Are we going to track the clots around it? What if it's a clot that is non-obstructive versus obstructive around a central line? And that's the lines are do the answer. Do you want to analyze the poll results? Yeah, they're almost, yeah, oh wait. Why don't you say it because somehow it just went away. 5 answers. Almost exactly. So this is all are the same. So this is appropriate. Yes, it's a difficult question. So the theoretically correct answer is getting a screening ultrasound on ICU day 7, and the reason the anticoagulant, the pharmacologic prevention is not indicated is because the kid had a significant head bleed, and so he's probably not a good candidate to anticoagulate him, yet he is a high risk child. I would refer people to the references to this article at the end. There's a lot of good articles, but there's a really nice 2017 seminars summary by the Dr. Perry, who's the current chair of the Abstinence trauma Committee. On this very topic that really nicely summarizes it and probably we got some of these here. So this, this is based, this data presented here is based on one particular schema used to predict risk for venous thromboembolism and trauma patients. There are other schemas. They tend to have a lot of common overlap, and what they look for are what are the risk factors. So being a trauma patient in general is a risk factor for thromboembolism. It's a bigger risk factor in adults than it is in kids. The estimates in kids are all over the map when you try to find out what the incidence of this is, and his summary suggests that it's somewhere between 0.16 and 1%. So a pretty wide range there, but overall it's probably on the order of 1% or less in general. In adult trauma patients, if I remember the numbers right, it's about 3 to 5%. In adult neuro trauma patients, it's significantly higher, like 10 or 15%. But the risk factors in kids, a bunch of them are listed here. I don't think I need to read all these off, including central catheters, central lines. Another one Craig mentioned earlier is inflammatory bowel disease, and it's listed here under chronic inflammatory states. Blood transfusion, blood transfusion should be another one. I don't know if it's on this list. And then obesity, which this child had as well. This is all from a patient. by Landish from Milwaukee that had their own sort of risk factors and according to their schema, the patient, uh, you can use the pointer, by the way, on that thing, the top button button pointer. OK. Oh, there we go. So the first thing is he's a high risk patient. What makes him a high risk patient if they're greater than 12 and they just have one or more risk factors or they're less than 12 and they have more than 4 risk factors. And then the second aspect is whether you're concerned about their bleeding risk and obviously as we mentioned with him, you are. So if you're not worried about it, then you treat them with low molecular weight heparin and sequential compression devices until they're ambulatory. But if they're not a candidate for pharmacologic prophylaxis, they get the STDs until they're ambulatory and then a screening ultrasound on day 7. And so that was the correct. So you think that low molecular heparin would actually increase the risk of Bleeding in the head with with head trauma. I think that that's what you're arguing is the risks of a DVT with embolism versus the risks of intracerebral bleeding on both. Rob, I don't know what the risk of, I don't know if anybody does know the risk of low molecular weight heparin in that scenario is, but, uh, but you do know what the benefit of and his risk factors probably low enough for a major complication from it that that you're not going to get enough benefit out of giving it that what would you do if you find a DVT on post-op day 7? Um, I guess it would depend on what his general status was. He may be far enough out at that point in time with his neuro injury. I don't know the answer to that off the top of my head. I don't know if there is an answer. I'm just, I don't know if he had a. sizable DVT and didn't have hemorrhages, you'd heronize them, treat them like a DVD. I mean one's prophylaxis, the other is treatment, right? Yeah. So Troy, do you have a, do you have a comment? I just had a question. So in the operating room for an elective procedure, is it still imperative to activate the STDs prior to induction of anesthesia, because that was always what I was taught was that those were supposed to be on before the patient was put to sleep. And at least at our hospital, it's kind of challenging to make sure that that always happens. And so I was curious to see what your practices were. Are your, are your STDs put on in the holding area and then they are not, or are they putting on in the operating? They're put on usually in the operating room after the patient's asleep, and I'm always griping that that's probably the wrong thing to do put on in the preoperative area and then and then the patient. Taken to the operating room, but, but if not, if the nurse, as soon as the patient hits the table, those could go on, but that can take, that can take, I mean, but they are supposed to be on prior to induction, right, right, right. And again that that happens every day, so it does, that can work too. But yes, they're supposed to be on and working. Before the patient, so at our place they're on in the holding area or pre-op area. The patient's transported and then they're connected and then they get their circumcision and go home and then they get at what age do you guys start doing that? So what's the big, what's the change in practice? What is the headline here for this? So the headline for this is. To be aware that it's a real thing in kids and there's a variety of different schemas out there, but you ought to have one available, be familiar with on age and risk factors, based on age and either STDs or low molecular or yeah, yeah, I think this this landish article, David Gourlay's article is actually probably Uh, I'll go out on a limb and say it's probably the best, um, you know, protocol that we have. That's the one that's the basis for your Midwest Consortium. That's the MWPSC, um, you guys that's the testing, um, at, at multiple centers, but it's, but, but what it, it suggests is that, um, when you should use, um, you know, STDs versus chemo prophylaxis and so on, and it's a good start. And she was a fellowship applicant in the last round, the lead author, yes. FYI. All right, next.