Venous thromboembolic risk stratification in pediatric trauma: A Pediatric Trauma Society Research Committee multicenter analysis

Abstract

BACKGROUND:Venous thromboembolism (VTE) in injured children is rare, but its consequences are significant. Several risk stratification algorithms for VTE in pediatric trauma exist with little consensus, and all are hindered in development by relying on registry data with known inaccuracies. We performed a multicenter review to evaluate trauma registry fidelity and confirm the effectiveness of one established algorithm across diverse centers. METHODS:Local trauma registries at 10 institutions were queried for all patients younger than 18 years admitted between 2009 and 2018. Additional chart review was performed on all "VTE" cases and random non-VTE controls to assess registry errors. Corrected data were then applied to our prediction algorithm using 10 real-time variables (Glasgow Coma Scale, age, sex, intensive care unit admission, transfusion, central line placement, lower extremity/pelvic fracture, major surgery) to calculate VTE risk scores. Contingency table classifiers and the area under a receiver operator characteristic curve were calculated. RESULTS:Registries identified 52,524 pediatric trauma patients with 99 episodes of VTE; however, chart review found that 13 cases were misclassified for a corrected total of 86 cases (0.16%). After correction, the algorithm still displayed strong performance in discriminating VTE-fated encounters (sensitivity, 69%; area under the receiver operating characteristic curve, 0.96). Furthermore, despite wide institutional variability in VTE rates (0.04-1.7%), the algorithm maintained a specificity of >91% and a negative predictive value of >99.7% across centers. Chart review also revealed that 54% (n = 45) of VTEs were directly associated with a central line, usually femoral (n = 34, p < 0.001 compared with upper extremity), and that prophylaxis rates were underreported in the registries by about 50%; still, only 19% of the VTE cases had been on prophylaxis before diagnosis. CONCLUSION:The VTE prediction algorithm performed well when applied retrospectively across 10 diverse pediatric centers using corrected registry data. These findings can advance initiatives for VTE screening/prophylaxis guidance following pediatric trauma and warrant prospective study.

Venous thromboembolic screening in pediatric trauma: A prospective cohort study of risk-stratified ultrasonography

“…Several factors limit these results. Our VTE prediction algorithm was developed from NTDB data, the use of which has well-described drawbacks 12 . We have recently validated the algorithm via institutional trauma registry review and direct chart investigation with controls, but the retrospective nature of these data remains a limitation 12 .…”

“…Our VTE prediction algorithm was developed from NTDB data, the use of which has well-described drawbacks 12 . We have recently validated the algorithm via institutional trauma registry review and direct chart investigation with controls, but the retrospective nature of these data remains a limitation 12 . In addition, existing VTE prediction algorithms are based on the risk of symptomatic VTE, which we have demonstrated underestimates the risk of all VTE 4,15 .…”

“… 4 Each variable was weighted according to a point system with a total of 797 possible points conferring a maximum VTE risk of 12.7%. The algorithm was subsequently recalibrated and validated in a population of 52,524 pediatric trauma patients and demonstrated a sensitivity of 69%, specificity of 97%, and negative predictive value of 99% 12,13 …”

“…The algorithm was subsequently recalibrated and validated in a population of 52,524 pediatric trauma patients and demonstrated a sensitivity of 69%, specificity of 97%, and negative predictive value of 99%. 12,13…”

“…4,11 The algorithm was subsequently validated in a multicenter retrospective analysis. 12 The objective of this study was to prospectively evaluate the effectiveness of risk-based VTE screening at our level 1 pediatric trauma center. We hypothesized that risk-based screening would detect VTE at a rate predicted by our algorithm and identify a subset of pediatric trauma patients who might benefit from prophylactic anticoagulation.…”