Venous thromboembolism following inpatient pediatric surgery: Analysis of 153,220 patients

Abstract

Purpose: To evaluate venous thromboembolism (VTE) rates and risk factors following inpatient pediatric surgery.Methods: 153,220 inpatient pediatric surgical patients were selected from the 2012-2015 NSQIP-P database. Demographic and perioperative variables were documented. Primary outcome was VTE requiring treatment within 30 postoperative days. Secondary outcomes included length of stay (LOS) and 30-day mortality. Prediction models were generated using logistic regression. Mortality and time to VTE were assessed using Kaplan-Meier survival analysis.Results: 305 patients (0.20%) developed 296 venous thromboses and 12 pulmonary emboli (3 cooccurrences). Median time to VTE was 9 days. Most VTEs (81%) occurred pre-discharge. Subspecialties with highest VTE rates were cardiothoracic (0.72%) and general surgery (0.28%). No differences were seen for elective vs. urgent/emergent procedures (p=0.106). All-cause mortality VTE patients was 1.2% vs. 0.2% in patients without VTE (p<0.001). After stratifying by American Society of Anesthesiologists (ASA) class, no mortality differences remained when ASA < 3. Preoperative, postoperative, and total LOS were longer for patients with VTE (p<0.001 for each). ASA ≥ 3, preoperative sepsis, ventilator dependence, enteral/parenteral feeding, steroid use, preoperative blood transfusion, gastrointestinal disease, hematologic disorders, operative time, and age were independent predictors (C-statistic=0.83).Conclusions: Pediatric post-surgical patients have unique risk factors for developing VTE.

Venous thromboembolism in children undergoing surgery: incidence, risk factors and related adverse events

“…Patients undergoing cardiothoracic surgery, however, were found to be at higher risk of VTE when compared with patients receiving general surgery. This is consistent with previous literature in pediatric surgery, which finds higher rates of VTE after cardiothoracic procedures 38…”

“…Longer operative time was independently associated with VTE, while patients with VTE also had longer hospitalizations. An association between hospital length of stay and VTE risk in children had been reported previously,7 17 29 as with operative time 12 13 38. These findings are further corroborated in the literature around VTE in adults, where studies have found that longer operative times39 and longer hospital stays39 are associated with VTE.…”

The Developing Balance of Thrombosis and Hemorrhage in Pediatric Surgery: Clinical Implications of Age-Related Changes in Hemostasis

“…Bleeding and thrombosis in critically ill pediatric patients and those undergoing major surgery remains a complex clinical problem. 39 Increasingly, critically ill children and neonates are undergoing complex surgeries and interventions, but evidence-based, biology-informed guidelines for managing these patients are important. 79 Risk factors that can guide decision-making and therapeutic interventions in this population are scarce, 79 often largely extrapolated from adult practice, and do not account for special age-related changes.…”

“… 25 , 44 In an ACS National Surgical Quality Improvement Program–based study examining rates of venous thromboembolism (VTE) in pediatric surgery patients, Sherrod et al found that the highest VTE risk occurred in patients undergoing cardiothoracic or general surgical procedures, omphalocele repair, CSF-shunt creation, and complete colectomy via abdominal approach. 39 In a national study examining rates of femoral arterial thrombosis following cardiac catheterization in pediatric populations, we reported that infants aged 0 to 12 months have the highest rate of arterial thrombosis following cardiac catheterization of any pediatric age-group and that arterial thrombosis is associated with increased morbidity and cost when compared to children aged 1 to 18. 45 , 46 …”

“…However, with increased utilization of these procedures, rates of thrombosis and bleeding complications are also increasing. 3,39 Surgery itself alters coagulation by multiple mechanisms that include hyperadrenergic responses, hyperfibrinolysis, and consumptive coagulopathy. 43 In most routine surgical procedures on infants and children, the orchestration of procoagulant, anticoagulant, fibrinolytic, and vascular endothelial responses is sufficiently balanced to prevent pathological bleeding or thrombosis.…”