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Risk-stratified Thromboprophylaxis decreases High Incidence of VTE in patients with Long-Gap EA
Sigrid Bairdain MD MPH*; Daniel P. Kelly MD*; David Zurakowski, PhD; Brenda Dodson PharmD; Kathy M.Harney RN,C-PNP; Russell W. Jennings MD; Cameron C. Trenor III MD,MMSc
Boston Children’s Hospital, Harvard Medical School, Boston, MA

Background: To determine the safety and efficacy of a thromboprophylaxis protocol in reducing venous thromboembolic events (VTEs) and identify factors associated with increased risk of VTE in Long-Gap Esophageal Atresia (LGEA) patients.

Methods: Retrospective review between 2005 and 2014 of all LGEA patients treated in the ICU at Boston Children’s Hospital. Patients with symptomatic VTE with radiographic confirmation were defined as events. The anticoagulation protocol was initiated in July 2012. Univariate and multivariate analysis evaluated factors associated with VTE, including age, weight, preoperative gap length, primary versus secondary Foker process (FP), days of pharmacologic paralysis, number of paralytic episodes, central venous catheters (CVCs) and invasive procedures, ventilator days, and exposure to thromboprophylaxis treatment

Results: Fifty-seven LGEA patients with median age of 4 months (28 females, 29 males) were identified. Overall, 15 had a VTE (26%). VTE incidence was 33% (13/40) prior to and 11% (2/17) following the protocol, representing a 22% absolute reduction. The 15 cases with VTEs had a significantly higher median number of paralysis episodes (4 vs. 1, P = 0.004), number of CVCs (4 vs. 2, P = 0.019), thoracotomies (6 vs. 3, P = 0.023), and, the percentage of secondary FP was higher among VTE cases (80% vs. 36%, P = 0.006). Multivariable logistic regression identified number of episodes of paralysis as the only significant, independent risk factor for increased likelihood of VTE, with an estimated 2.5 times higher odds of VTE with each additional episode (OR: 2.5, 95% CI: 1.5-3.7, P < 0.001). No bleeding complications occurred and there was no thrombosis-related mortality.

Conclusion: The incidence of symptomatic VTE decreased by 22% after implementation of a standardized thromboprophylaxis protocol in this series of patients with LGEA and appeared safe as no bleeding complications occurred. Prospective evaluation of this risk-stratified of thromboprophylaxis approach is in progress.

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