Global Cast 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.
Diamonds 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 porphylaxis in pediatric trauma with doctors Regan Williams and Katie 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. He's got a three-millimeter subdural hemorrhage that is stable on a CT scan six hours after injury. He had an operative pelvis fracture and he's going to be non-weight-bearing for six weeks. When should we start chemical DVT porphylaxis in this patient? 24 hours.
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 porphylaxis should be up to the trauma surgeon. The trauma surgeon decides if the patient is going to get DVT porphylaxis. You just ask the trauma surgeon and what the trauma surgeon says is what we do.
A recent cohort study showed that chemical VTE porphylaxis 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 it and found that in trauma patients, if you gave DVT porphylaxis 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 porphylaxis?
You can absolutely give DVT porphylaxis in solid organ injuries. In general, pediatric trauma patients with a low risk of bleeding with stable head, pelvic or solid organ injuries should receive chemical VTE porphylaxis. On the other hand, those with continued evidence of bleeding and unstable injuries should not receive chemical VTE porphylaxis.
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 porphylaxis. 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 porphylaxis.
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 cranny or not, you should probably not give it to them. Now the patient is ready to go home. Which DVT porphylaxis should be prescribed for this patient to continue taking at home? 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 of people are going to go aspirin and about a quarter of 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 controlled 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.