Summary
Venous thromboembolic events (VTE) occur in children at the time of surgery. Few guidelines about how to assess the risk and provide prophylaxis have been developed and published so far. It is uncertain if any of these guidelines have been adopted into clinical practice. The article discusses the specific differences of the haemostatic system throughout childhood, risk assessment, choice and dosing of antithrombotic agents, difficulties in drug monitoring and side effects of treatment including HIT. Current available recommendations and guidelines are summarized. Current evidence on which to base risk stratification and prevention of VTE for children undergoing surgery consists mainly of cohort studies, case series, case reports and expert opinion. Many suggestions are merely extrapolated from results from clinical trials in adults. Primary healthy children who undergo minor surgery including circumcision, herniotomy and appendectomy do not need antithrombotic prophylaxis. Children with multiple risk factors for VTE including severe underlying conditions and long-term immobilization, children with central venous lines and children with a history of VTE should be considered to receive VTE prophylaxis. Older children (Tanner II+) should be treated following adult guidelines. Standard unfractionated heparin and low molecular heparin are the most frequently recommended antithrombotic drugs. Decision for VTE prophylaxis must widely be based on individual risk assessment by experienced physicians. Newly developed scores and guidelines may provide assistance. Well designed clinical studies in children that provide proper evidence on risk assessment for VTE at the time of surgery and investigate safety and efficacy of antithrombotic prophylaxis/treatment are urgently needed.
Zusammenfassung
Perioperative venöse Thromboembolien (VTE) können auch Kinder betreffen. Bisher wurden nur wenige Leitlinien zur Risikoeinschätzung und Prophylaxe entwickelt und publiziert. Es ist unbekannt, ob diese in der klinischen Praxis angewendet werden. Der Artikel beschäftigt sich mit den Unterschieden der Hämostase des heranwachsenden Kindes, der Risikoeinschätzung, Wahl und Dosierung einer antithrombotischen Behandlung sowie den Schwierigkeiten beim Monitoring und Nebenwirkungen der Therapie einschließlich HIT. Weiters werden die aktuellen Leitlinien besprochen. Aktuell basiert die Risikostratifizierung und perioperative VTE-Prophylaxe hauptsächlich auf Kohortenstudien, Fallserien, Fallberichten und Expertenmeinungen. Viele Empfehlungen beruhen lediglich auf den Ergebnissen von klinischen Studien bei Erwachsenen. Primär gesunde Kinder, die sich kleineren chirurgischen Eingriffen, wie einer Zirkumzision, Herniotomie oder Appendektomie, unterziehen müssen, benötigen keine antithrombotische Prophylaxe. Kinder mit mehreren Risikofaktoren, wie schweren Grunderkrankungen, Langzeitimmobilisierung, zentralvenösen Kathetern (ZVK), und Kinder, die schon einmal eine VTE erlitten haben, sollten eine VTE-Prophylaxe erhalten. Ältere Kinder (Tanner II+) sollen entsprechend den Leitlinien für Erwachsene behandelt werden. Standard Heparin/unfraktioniertes Heparin und niedermolekulares Heparin sind die am häufigsten empfohlenen Antikoagulantien. Die Entscheidung zur VTE-Prophylaxe hängt ganz wesentlich von der Einschätzung des Risikos durch einen erfahrenen Arzt ab. Risiko Scores und Behandlungsleitlinien können die Entscheidung unterstützen. Es braucht dringend kontrollierte klinische Studien, die in Zukunft eine auf Evidenz basierende Entscheidung für das perioperative VTE-Risiko und die Sicherheit und Wirksamkeit einer antithrombotischen Prophylaxe/Therapie für Kinder erlauben.
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Abbreviations
- HIT:
-
Heparin- induzierte Thrombopenie
- PTS:
-
Postthrombotisches Syndrom
- SH/UFH:
-
Standardheparin/Unfraktioniertes Heparin
- VTE:
-
Venöse Thromboembolie
- ZVK:
-
Zentralvenöser Katheter
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Streif, W. Perioperative Thromboseprophylaxe bei Kindern. Wien Med Wochenschr 159, 481–486 (2009). https://doi.org/10.1007/s10354-009-0712-6
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DOI: https://doi.org/10.1007/s10354-009-0712-6