Update Course Rewind: DVT Prophylaxis 2024

GlobalCast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family, I'm Lizzie Lee from Cincinnati Children's Hospital Medical Center. Our 12th annual update course in pediatric surgery was held this past August. In this video series, we will recap the sessions and share the main highlights with you. This year we introduced a new approach to classify practice-changing ideas at our update course. Presentations now fall into three categories: Green circles for established practices, blue squares for promising newer practices, and black diamonds for early adopter practices only. Today we will talk about deep vein thrombosis or DVT prophylaxis in pediatric trauma with Doctors Regan Williams and Katy Russell. They brought us a case about a 15-year-old in a high-speed motor vehicle crash. This topic falls into the blue category of newer approaches. A 15-year-old who is in a high-speed motor vehicle crash is hemodynamically normal with a hematocrit of 28 in the trauma bay. She's got a 3-mm subdural hemorrhage that is stable on a CT scan 6 hours after injury. He had an operative pelvis fracture and he's going to be non-weight bearing for 6 weeks. When should we start chemical DVT prophylaxis in this patient? 24 hours. This is the the the big challenge is that the neurosurgical community is in large denial of the data. That says that it's safe to do and that if you don't do it, you have big complications. The literature is clear. Some hospitals have rewritten their protocol that the decision for DVT prophylaxis should be up to the trauma surgeon. The trauma surgeon decides if the patient's going to get DVT prophylaxis. You just ask the trauma surgeon and what the trauma surgeon says is what we do. A recent cohort study showed that chemical VTE prophylaxis was safe. It did not cause bleeding complications and should be done within 24 hours of admission to prevent development of VTE. They looked at a and found that in trauma patients, if you gave DVT prophylaxis within 24 hours of injury, they are much less likely to get a DVT. So I think our goal should be really to start within 24 hours. When should we avoid giving chemical DVT prophylaxis? You can absolutely give DVT prophylaxis in solid organ injuries. Pelvic injury? Once the patient's stable. In general, pediatric trauma patients with a low risk of bleeding with stable head, pelvic or solid organ injuries should receive chemical VTE prophylaxis. On the other hand, those with continued evidence of bleeding and unstable injuries should not receive chemical VTE prophylaxis. The EAST guidelines, which are the best data we have, would suggest that for adolescent patients with an ISS greater than 25, they need to get prophylaxis. The EAST, or Eastern Association for the Surgery of Trauma, has guidelines that recommend that you calculate the ISS, the injury severity score, which is the traumatic injury based on the worst injury of six body systems. If the ISS is less than 25 or they have a major risk of bleeding, avoid DVT prophylaxis. I think if the patient has a real risk of dying from bleeding, you should not give it. If you have a head injury that's unstable, that you're maybe going to put an ICP monitor, you're wondering if they need to get a crani or not, should probably not give it to them. Now, the patient is ready to go home. Which DVT prophylaxis should be prescribed for this patient to continue taking at home? Here in the hospital, you started Lovenox, but he's ready to go home. What are you going to send him on? Remember he's in a wheelchair for six weeks. Aspirin, Lovenox, Coumadin, some kind of a new generation DOAC. Let's see what the poll results showed for the different treatment options. About a quarter people are going to go aspirin, and about a quarter people DOAC, and then a lot of Lovenox. The downside to Lovenox is that it is an injection. There was a well-done adult study that was published in the New England Journal of Medicine. A randomized control trial was published in 2023 by the Major Extremity Trauma Research Consortium that included adult trauma patients with orthopedic injuries. They gave 6,000 of the adults aspirin and 6,000 of the adults Lovenox. What did they find? What they found is that aspirin was non-inferior to Lovenox in terms of DVT prophylaxis in that patient population. Although the study focused on adult patients, pediatric trauma surgeons are applying this to pediatric patients too and discharging them home on aspirin to take at home. That's most likely going to be followed way more than these Lovenox shots that we've been doing historically. We have started discharging kids on aspirin, realizing that taking some adult data that is not perfect, but it's effective and it's a lot better than Lovenox and a lot better than nothing. In conclusion, chemical DVT prophylaxis to start within 24 hours in pediatric trauma patients, even with stable pelvic or solid organ injuries, per the evidence and guidelines. Avoid chemical DVT prophylaxis if there is a high bleeding risk, such as unstable head injuries, according to the EAST guidelines. When patients are discharged home, aspirin is now commonly prescribed based on studies showing that it is as effective as Lovenox for DVT prevention, but easier to administer. GlobalCast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.