American Society of Hematology 2018 Guidelines for management of venous thromboembolism: treatment of pediatric venous thromboembolism

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Abstract

<div class="section"> <a class="named-anchor" id="d3096864e400">  </a> <h5 class="section-title" id="d3096864e401">Background:</h5> <p id="d3096864e403">Despite an increasing incidence of venous thromboembolism (VTE) in pediatric patients in tertiary care settings, relatively few pediatric physicians have experience with antithrombotic interventions. </p> </div><div class="section"> <a class="named-anchor" id="d3096864e405">  </a> <h5 class="section-title" id="d3096864e406">Objective:</h5> <p id="d3096864e408">These guidelines of the American Society of Hematology (ASH), based on the best available evidence, are intended to support patients, clinicians, and other health care professionals in their decisions about management of pediatric VTE. </p> </div><div class="section"> <a class="named-anchor" id="d3096864e410">  </a> <h5 class="section-title" id="d3096864e411">Methods:</h5> <p id="d3096864e413">ASH formed a multidisciplinary guideline panel that included 2 patient representatives and was balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews (up to April of 2017). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. </p> </div><div class="section"> <a class="named-anchor" id="d3096864e415">  </a> <h5 class="section-title" id="d3096864e416">Results:</h5> <p id="d3096864e418">The panel agreed on 30 recommendations, covering symptomatic and asymptomatic deep vein thrombosis, with specific focus on management of central venous access device–associated VTE. The panel also addressed renal and portal vein thrombosis, cerebral sino venous thrombosis, and homozygous protein C deficiency. </p> </div><div class="section"> <a class="named-anchor" id="d3096864e420">  </a> <h5 class="section-title" id="d3096864e421">Conclusions:</h5> <p id="d3096864e423">Although the panel offered many recommendations, additional research is required. Priorities include understanding the natural history of asymptomatic thrombosis, determining subgroup boundaries that enable risk stratification of children for escalation of treatment, and appropriate study of newer anticoagulant agents in children. </p> </div>

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Systems for grading the quality of evidence and the strength of recommendations I: Critical appraisal of existing approaches The GRADE Working Group

David Atkins, Martin Eccles, Signe Flottorp … (2004)

Background A number of approaches have been used to grade levels of evidence and the strength of recommendations. The use of many different approaches detracts from one of the main reasons for having explicit approaches: to concisely characterise and communicate this information so that it can easily be understood and thereby help people make well-informed decisions. Our objective was to critically appraise six prominent systems for grading levels of evidence and the strength of recommendations as a basis for agreeing on characteristics of a common, sensible approach to grading levels of evidence and the strength of recommendations. Methods Six prominent systems for grading levels of evidence and strength of recommendations were selected and someone familiar with each system prepared a description of each of these. Twelve assessors independently evaluated each system based on twelve criteria to assess the sensibility of the different approaches. Systems used by 51 organisations were compared with these six approaches. Results There was poor agreement about the sensibility of the six systems. Only one of the systems was suitable for all four types of questions we considered (effectiveness, harm, diagnosis and prognosis). None of the systems was considered usable for all of the target groups we considered (professionals, patients and policy makers). The raters found low reproducibility of judgements made using all six systems. Systems used by 51 organisations that sponsor clinical practice guidelines included a number of minor variations of the six systems that we critically appraised. Conclusions All of the currently used approaches to grading levels of evidence and the strength of recommendations have important shortcomings.

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Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise.

Holger Schünemann, Wojtek Wiercioch, Itziar Etxeandia … (2014)

Although several tools to evaluate the credibility of health care guidelines exist, guidance on practical steps for developing guidelines is lacking. We systematically compiled a comprehensive checklist of items linked to relevant resources and tools that guideline developers could consider, without the expectation that every guideline would address each item. We searched data sources, including manuals of international guideline developers, literature on guidelines for guidelines (with a focus on methodology reports from international and national agencies, and professional societies) and recent articles providing systematic guidance. We reviewed these sources in duplicate, extracted items for the checklist using a sensitive approach and developed overarching topics relevant to guidelines. In an iterative process, we reviewed items for duplication and omissions and involved experts in guideline development for revisions and suggestions for items to be added. We developed a checklist with 18 topics and 146 items and a webpage to facilitate its use by guideline developers. The topics and included items cover all stages of the guideline enterprise, from the planning and formulation of guidelines, to their implementation and evaluation. The final checklist includes links to training materials as well as resources with suggested methodology for applying the items. The checklist will serve as a resource for guideline developers. Consideration of items on the checklist will support the development, implementation and evaluation of guidelines. We will use crowdsourcing to revise the checklist and keep it up to date.

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Dramatic increase in venous thromboembolism in children's hospitals in the United States from 2001 to 2007.

C Witmer, Chris Feudtner, Leslie Raffini … (2009)

The goals were to determine whether there has been an increase in the rate of venous thromboembolism (VTE) in pediatric tertiary care hospitals and to evaluate the use of anticoagulants in the treatment of hospitalized pediatric patients with VTE. A retrospective cohort study of patients or =1 coexisting chronic complex medical condition. Pediatric malignancy was the medical comorbid condition associated most strongly with recurrent VTE (P < .001). The proportion of children with VTE who were treated with enoxaparin increased from 29% to 49% during this time period (P < .001); the use of warfarin decreased slightly from 11.4% to 9.6% (P= .02). Increasing age was associated with increased likelihood of patients with VTE being treated with either enoxaparin or warfarin. This multicenter study demonstrates a dramatic increase in the diagnosis of VTE at children's hospitals from 2001 to 2007.

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Author and article information

Journal

Title: Blood Advances

Abbreviated Title: Blood Adv

Publisher: American Society of Hematology

ISSN (Print): 2473-9529

ISSN (Electronic): 2473-9537

Publication date Created: November 27 2018

Publication date (Electronic): November 27 2018

Publication date (Print): November 27 2018

Volume: 2

Issue: 22

Pages: 3292-3316

Article

DOI: 10.1182/bloodadvances.2018024786

PMC ID: 6258911

PubMed ID: 30482766

SO-VID: 386267d1-cd47-4267-adc2-027d1a586a09

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