Prophylaxis against venous thromboembolism in pediatric trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society Arash Mahajerin, MD, MSCr, John K. Petty, MD, Sheila J. Hanson, MD, MS, A. Jill Thompson, PharmD, Sarah H. O’Brien, MD, Christian J. Streck, MD, Toni M. Petrillo, MD, and E. Vincent S. Faustino, MD, MHS, Orange, California BACKGROUND: Despite the increasing incidence of venous thromboembolism (VTE) in hospitalized children, the risks and benefits of VTE prophylaxis, particularly for those hospitalized after trauma, are unclear. The Pediatric Trauma Society and the Eastern Association for the Surgery of Trauma convened a writing group to develop a practice management guideline on VTE prophylaxis for this cohort of children using the Grading of Recommendations Assessment, Development, and Evaluation framework. METHODS: A systematic review of MEDLINE using PubMed from January 1946 to July 2015 was performed. The search retrieved English- language articles on VTE prophylaxis in children 0 to 21 years old with trauma. Topics of investigation included pharmacologic and mechanical VTE prophylaxis, active radiologic surveillance for VTE, and risk factors for VTE. RESULTS: Forty-eight articles were identified and 14 were included in the development of the guideline. The quality of evidence was low to very low because of the observational study design and risks of bias. CONCLUSIONS: In children hospitalized after trauma who are at low risk of bleeding, we conditionally recommend pharmacologic prophylaxis be considered for children older than 15 years old and in younger postpubertal children with Injury Severity Score (ISS) greater than 25. For prepubertal children, even with ISS greater than 25, we conditionally recommend against routine pharmacologic prophy- laxis. Second, in children hospitalized after trauma, we conditionally recommend mechanical prophylaxis be considered for chil- dren older than 15 years and in younger postpubertal children with ISS greater than 25 versus no prophylaxis or in addition to pharmacologic prophylaxis. Lastly, in children hospitalized after trauma, we conditionally recommend against active surveillance for VTE with ultrasound compared with routine daily physical examination alone for earlier detection of VTE. The limited pedi- atric data and paucity of high-quality evidence preclude providing more definitive recommendations and highlight the need for clinical trials of prophylaxis. (J Trauma Acute Care Surg. 2017;82: 627–636. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Systematic review/meta-analysis, level III. KEY WORDS: Deep vein thrombosis; injury severity score; intensive care; pediatric; wounds and injuries. I n the past decade, the incidence of venous thromboembolism (VTE) in hospitalized children increased by nearly 70%, likely because of advancements in the care of critically ill children, in- creased awareness, and better detection methods. 1 In the short term, VTE in children is associated with prolonged hospi- talization, pulmonary embolism, paradoxical embolic stroke, and even death, whereas in the long term, it is associated with prolonged anticoagulation, recurrence of VTE, and postthrom- boticsyndrome with limb swelling and pain due to venous insufficiency. 2 Venous thromboembolism is also associated with excess inpatient costs ranging from $12,000 to $28,000 per hospitalization. 3,4 Although the incidence of VTE in children is low, children hospitalized after trauma, similar to adults, are at increased risk of VTE. 1,5,6 Of the nearly one quarter of a million children hospitalized after trauma annually in the United States, 0.1% to 0.8% develop VTE. 3,7 Given the rising incidence of VTE in children and the resultant morbidity and excess cost, there is growing impetus for hospitals to institute local pediatric guidelines on VTE prophylaxis, particularly in high-risk popula- tions, such as those hospitalized after trauma. Unlike in adults, there is paucity of evidence on the risks and benefits of VTE prophylaxis in children. 2,5 As local pediat- ric guidelines on VTE prophylaxis are developed, it is impera- tive to evaluate the current state of evidence to determine what recommendations can be made. The Grading of Recommen- dations Assessment, Development, and Evaluation (GRADE) methodology provides guidance for rating evidence quality and Submitted: October 17, 2016, Revised: November 29, 2016, Accepted: December 6, 2016, Published online: December 28, 2016. Division of Hematology, Department of Pediatrics, University of California Irvine School of Medicine, Orange, California (A.M.); Division of Pediatric Surgery, De- partment of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (J.K.P.); Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (S.J.H.); Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina (A.J.T.); Division of Hematology and Oncology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio (S.H.O.); Division of Pediatric Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina (C.J.S.); Division of Critical Care, Department of Pediatrics Emory School of Medicine, Atlanta, Georgia (T.M.P.); and Section of Pediatric Critical Care, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut (E.V.S.F.). This study was presented at the 29th annual meeting of the Eastern Association for the Surgery of Trauma, January 12–16, 2016, in San Antonio, Texas. Address for reprints: Arash Mahajerin, MD, MSCr, Division of Hematology, Depart- ment of Pediatrics, University of California Irvine School of Medicine, 1201 W La Veta Ave, Orange, CA 92868; email: amahajerin@choc.org. DOI: 10.1097/TA.0000000000001359 GUIDELINES J Trauma Acute Care Surg Volume 82, Number 3 627 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.