Low-molecular-weight heparin versus unfractionated heparin in pediatric traumatic brain injury

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  • 1 Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital;
  • 2 Department of Pediatric Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts; and
  • 3 Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
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OBJECTIVE

The incidence of venous thromboembolism (VTE) in patients with traumatic brain injury (TBI) has increased significantly. The Eastern Association for the Surgery of Trauma recommends using low-molecular-weight heparin (LMWH) over unfractionated heparin (UH) in pediatric patients requiring VTE prophylaxis, although this strategy is unsupported by the literature. In this study, the authors compare the outcomes of pediatric TBI patients receiving LMWH versus UH.

METHODS

The authors performed a 4-year (2014–2017) analysis of the pediatric American College of Surgeons Trauma Quality Improvement Program. All trauma patients (age ≤ 18 years) with TBI requiring thromboprophylaxis with UH or LMWH were potentially eligible for inclusion. Patients who had been transferred, had died in the emergency department, or had penetrating trauma were excluded. Patients were stratified into either the LMWH or the UH group on the basis of the prophylaxis they had received. Patients were matched on the basis of demographics, injury characteristics, vital signs, and transfusion requirements using propensity score matching (PSM). The study endpoints were VTE, death, and craniotomy after initiation of prophylaxis. Univariate analysis was performed after PSM to compare outcomes.

RESULTS

A total of 2479 patients met the inclusion criteria (mean age 15.5 ± 3.7 years and 32.0% female), of which 1570 (63.3%) had received LMWH and 909 (36.7%) had received UH. Before PSM, patients receiving UH were younger, had a lower Glasgow Coma Scale score, and had a higher Injury Severity Score. Patients treated in pediatric hospitals were more likely to receive UH (12.9% vs 9.0%, p < 0.001) than patients treated in adult hospitals. Matched patients receiving UH had a higher incidence of VTE (5.1% vs 2.9%, p = 0.03).

CONCLUSIONS

LMWH prophylaxis in pediatric TBI appears to be more effective than UH in preventing VTE. Large, multicenter prospective studies are warranted to confirm the superiority of LMWH over UH in pediatric patients with TBI. Moreover, outcomes of VTE prophylaxis in the very young remain understudied; therefore, dedicated studies to evaluate this population are needed.

ABBREVIATIONS ACS = American College of Surgeons; AIS = Abbreviated Injury Scale; DVT = deep vein thrombosis; ED = emergency department; GCS = Glasgow Coma Scale; ISS = Injury Severity Score; LMWH = low-molecular-weight heparin; PE = pulmonary embolism; pRBCs = packed red blood cells; PSM = propensity score matching; TBI = traumatic brain injury; TQIP = Trauma Quality Improvement Program; UH = unfractionated heparin; VTE = venous thromboembolism.

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Contributor Notes

Correspondence April E. Mendoza: Massachusetts General Hospital, Boston, MA. aemendoza@mgh.harvard.edu.

INCLUDE WHEN CITING Published online February 12, 2021; DOI: 10.3171/2020.9.PEDS20615.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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