2. Venous Thromboembolism Prophylaxis in High-Risk Pediatric Trauma Patients

Venous Thromboembolism Prophylaxis in High-Risk Pediatric Trauma Patients

Recommendations for VTE Prophylaxis – Lovenox (for patients with CrCl>30 ml/min)

Patient < 60 kg

  • 0.5 mg/kg/dose sub-Q every 12 hours

Patient > 60 kg

  • 30 mg sub-Q every 12 hours

For patients with epidural bleed or ICP monitor who are > 60 kg

  • 40 mg sub-Q every 24 hours

For patients with CrCl<30, consider SQ heparin.

  • >60kg: 5000 units sub-Q every 8 hours
  • <60kg: discuss on case-by-case basis

Administer at 0900 and 2100 and check Anti-Xa level at 1pm following the 3rd dose. Goal anti-xa is 0.2-0.4.

For Patients >60 kg, if Anti-Xa is low, increase by 10 mg BID and repeat after 3 more doses.

For patients <60 kg, If Anti-Xa is low, increase by 0.2mg/kg and repeat after 3 more doses

If Anti-Xa is high, decrease similarly and re-check.

Timing of initiation of cVTE optimal within 12 hours of admission.

Any patient who is high risk but not on chemical DVT prophylaxis should be on mechanical (SCD) DVT prophylaxis as long as there are no contraindications.

Patients who are discharged and remain high risk/immobile should be transitioned to Aspirin 3-5mg/kg, max dose 325mg.

High risk patient = Unable to ambulate within 48 hours post injury

AND

> 8 years old w/ 1 high risk criteria

OR

< 8 years old w/ 2 or more high risk criteria

High risk Criteria:

  • Central venous line (CVL)
  • Spinal Cord Injury
  • Moderate to Severe TBI
  • NWB fracture
  • Vascular injury
  • ICU stay expected > 48 hours
  • Hx of shock (needs transfusion, CPR or inotropic support)
  • Major thoracoabdominal operation
  • Hx of VTE
  • Hx of chronic inflammatory disease (IBD, vasculitis, nephrotic syndrome)
  • Use of estrogen
  • Family history of VTE (first degree relative)
  • Obesity (BMI > 95th percentile)

Exceptions:

  • Do not hold routinely for operative or IR intervention except as below
  • Traumatic brain injury: start 24 hours after stable head CT or 24 hours after craniotomy.
    • Hold 12 hours prior to placement and removal for EVD or ICP monitor. While EVD or ICP monitor is in place, may change to daily dosing. (40 mg daily if >60 kg, and 0.5mg/kg daily if <60 kg).  Check Anti-Xa after 3rd dose fi still on daily dosing.)
  • Spine Injury:
    • operative spine injuries- hold VTE prophylaxis in AM on day of surgery. After surgery, if fixation only (no dural procedure) start at next dosing time.  If decompression, laminectomy, dural procedure, hold for 24 hours post op.  Q2 neuro checks after VTE prophylaxis re-started (24 hours)
    • Non-operative spine injuries – start VTE prophylaxis per protocol. Delay 24 hours if epidural/subdural hematoma present
  • Solid organ injury (non-op): Start DVT prophylaxis within 12 hours of hospital arrival. Hold only for active hemorrhage, transfusion requirement or if abdomen is packed for hemostasis
  • Epidural anesthesia: hold 12 hours prior to placement and removal. While epidural in place, may change to daily dosing.
  • Other relative contraindications: (1) ongoing blood loss, (2) coagulopathy, (3) thrombocytopenia, (4) history of heparin induced thrombocytopenia
  • Surgeon discretion / concern for risk of bleeding with prophylaxis