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Abstract
BACKGROUND Acute pulmonary embolism is a life-threatening condition and rarely occurs in children. In adults, catheter-directed therapy emerges as a potentially safer and effective therapeutic option. However, there is a paucity of data on the safety and efficacy of catheter-directed therapy for pulmonary embolism in children. We report a single-centred experience of catheter-directed therapy for acute pulmonary embolism in children. METHODS This is a retrospective study of children who had no CHD and underwent catheter-directed therapy at Detroit Medical Center during a 12-year period from 2005 to 2017. Demographic and clinical data associated with pulmonary embolism were collected along with the outcome. RESULTS A total of nine patients of median age 16 years with the range from 12 to 20 received catheter-directed therapy for sub-massive (n = 6) and massive pulmonary embolism (n = 3). Among nine patients, one patient received Angiojet thrombectomy and balloon angioplasty, whereas eight patients received catheter-directed thrombolysis using tissue plasminogen activator through infusion catheters (n = 3) or EkoSonic ultrasound-accelerated thrombolysis system (n = 5). In four out of five patients treated with EkoSonic, significant clinical improvement was noticed within 24 hours. Among seven patients who survived, two patients had minor gastrointestinal bleeding with median hospital stay of 8 days with the range from 5 to 24 days, and two patients with massive pulmonary embolism died possibly due to delayed institution of catheter-directed therapy. CONCLUSION Catheter-directed therapy with/without EkoSonic is an emerging alternative therapy for sub-massive and massive pulmonary embolism in children. A timely institution of catheter-directed therapy appeared important to improve the outcome.
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Pelland-Marcotte MC, Tucker C, Klaassen A, Avila ML, Amid A, Amiri N, Williams S, Halton J, Brandão LR. Outcomes and risk factors of massive and submassive pulmonary embolism in children: a retrospective cohort study. LANCET HAEMATOLOGY 2019; 6:e144-e153. [DOI: 10.1016/s2352-3026(18)30224-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/03/2018] [Accepted: 12/10/2018] [Indexed: 01/13/2023]
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Abstract
Pulmonary embolism is an uncommon but potentially life-threatening event in children. There has been increasing awareness of pulmonary embolism in children with improved survival in children with systemic disease and advancements in diagnostic modalities. However, literature regarding pulmonary embolism in children is sparse, and thus current guidelines for management of pulmonary embolism in children are extrapolated from adult literature and remain controversial. This article reviews the background and pathophysiology of venous thromboembolism, as well as current diagnostic approach and recommended management of pulmonary embolism in children.
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Fukuda A, Isoda T, Sakamoto N, Nakajima K, Ohta T. Lessons from a patient with cardiac arrest due to massive pulmonary embolism as the initial presentation of Wilms tumor: a case report and literature review. BMC Pediatr 2019; 19:39. [PMID: 30704433 PMCID: PMC6354414 DOI: 10.1186/s12887-019-1413-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 01/21/2019] [Indexed: 02/08/2023] Open
Abstract
Background Finding an abdominal mass or hematuria is the initial step in diagnosing Wilms tumor. As the first manifestation of Wilms tumor, it is exceedingly rare for pulmonary tumor embolism to present with cardiac arrest. A case of a patient whose sudden cardiac arrest due to massive pulmonary tumor embolism of Wilms tumor was not responsive to resuscitation is presented. Case presentation The patient was a five-year-old girl who collapsed suddenly during activity in nursery school and went into cardiac arrest in the ambulance. Unfortunately, she was not responsive to conventional resuscitation. A judicial autopsy conducted at the local police department showed the main cause of her sudden cardiac arrest was attributed to multiple pulmonary tumor embolisms of stage IV Wilms tumor. Conclusions Except for one reported case, treatments were not successful in all eight cardiac arrest cases with pulmonary tumor embolism of Wilms tumor. These results indicate that it is challenging not only to make an accurate diagnosis, but also to provide proper specific treatment in the cardiac arrest setting. We propose that flexible triage and prompt transfer to a tertiary hospital are necessary as an oncologic emergency to get such patients to bridging therapy combined with extracorporeal membrane oxygenation or immediate surgical intervention under cardiopulmonary bypass.
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Affiliation(s)
- Atsuna Fukuda
- Department of Pediatrics, JA Toride Medical Center, 2-1-1, Hongo, Toride, Ibaraki, Japan
| | - Takeshi Isoda
- Department of Pediatrics, JA Toride Medical Center, 2-1-1, Hongo, Toride, Ibaraki, Japan. .,Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, 1-5-45, Bunkyo-ku, Tokyo, Japan.
| | - Naoya Sakamoto
- Department of Pediatric Surgery, JA Toride Medical Center, 2-1-1, Hongo, Toride, Ibaraki, Japan
| | - Keisuke Nakajima
- Department of Pediatrics, JA Toride Medical Center, 2-1-1, Hongo, Toride, Ibaraki, Japan
| | - Tetsuya Ohta
- Department of Pediatrics, JA Toride Medical Center, 2-1-1, Hongo, Toride, Ibaraki, Japan
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Sharaf N, Sharaf VB, Mace SE, Nowacki AS, Stoller JK, Carl JC. D-dimer in Adolescent Pulmonary Embolism. Acad Emerg Med 2018; 25:1235-1241. [PMID: 30010232 DOI: 10.1111/acem.13517] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/11/2018] [Accepted: 06/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND D-dimer is used to aid in diagnosing adult pulmonary embolism (PE). D-dimer has not been validated in adolescents. Clinicians must balance the risk of overtesting with that of a missed PE. D-dimer may be useful in this context. This study evaluates D-dimer in PE-positive and PE-negative adolescents. METHODS PE-positive patients < 22 years were diagnosed with PE by computed tomography (CT) or high-probability ventilation/perfusion, seen at emergency departments (EDs)/hospitals within a 16-hospital system across two states, January 1998 through December 2016. Of the 189 PE-positive patients, 88 (46.5%) had a D-dimer and were matched 1:1 by age, sex, and race to patients suspected of PE but confirmed negative by CT angiogram. RESULTS Ages of PE-positive patients ranged from 13 to 21 years, 64 (73%) were female, and 52 (60%) were Caucasian. Mean D-dimer was significantly higher (3,256 ng/mL, 95% confidence interval [CI] = 2,505-4,006 ng/mL) in PE-positive versus PE-negative patients (1,244 ng/mL, 95% CI = 493-1,995 ng/mL; p < 0.001). Mean D-dimer was higher in patients with massive or submassive PE (8,742 ng/mL, 95% CI = 5,994-11,491 ng/mL), followed by PE in central (4,795 ng/mL [95% CI = 3,465-6,125 ng/mL), lobar (3,758 ng/mL [95% CI = 1,841-5,676), and distal (2,327 ng/mL [95% CI = 1,273-3,381 ng/mL]) arteries. When comparing thresholds of positive D-dimer (≥500, ≥750, and ≥1,000 ng/mL), D-dimer had sensitivities of 90, 82, and 67% and specificities of 16, 53, and 67%, respectively. Negative predictive values were 61, 75, and 71% while positive likelihood ratios were 1.1, 1.8, and 2.2, respectively. CONCLUSIONS This study represents the largest available cohort of adolescent patients examining the diagnostic value of D-dimer for PE. Our results indicate that depending on the threshold selected, D-dimer can be a sensitive test for PE in adolescents and that discriminative value is higher for a cutoff of 750 ng/mL than that for 500 ng/mL. Prospective studies investigating the diagnostic value of D-dimer and a clinical decision rule for PE in pediatrics are needed.
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Affiliation(s)
- Nematullah Sharaf
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic Cleveland OH
| | - Victoria B. Sharaf
- Case Western Reserve University School of Medicine Cleveland Clinic Cleveland OH
| | - Sharon E. Mace
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic Cleveland OH
- Cleveland Clinic Emergency Services Institute Cleveland Clinic Cleveland OH
| | - Amy S. Nowacki
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic Cleveland OH
- Department of Quantitative Health Sciences Lerner Research Institute Cleveland Clinic Cleveland OH
| | - James K. Stoller
- Education and Respiratory Institutes Cleveland Clinic Cleveland OH
| | - John C. Carl
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic Cleveland OH
- Children's Hospital Cleveland OH
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Abstract
The diagnosis of pulmonary thromboembolism (PE) is often delayed because it is usually misdiagnosed as pneumonia or deep vein thrombosis. We report an unusual case of PE misdiagnosed as viral pleuritis on the first arrival at the emergency department (ED) in our hospital. A 14-year-old girl with no previous significant medical history was referred to the ED with pleuritic and chest pain with low-grade fever 4 days before admission. Echography showed a small amount of left pleural effusion. A 12-lead electrocardiogram was normal. She received a diagnosis of viral pleuritis. Two days before admission, she revisited ED with dyspnea and exacerbated pain. Echography showed slight increase in left pleural effusion. She had the same diagnosis. The chest pain remained at the same level. On the day of admission, she presented to ED with vomiting, watery diarrhea, abdominal pain, chest pain, and respiratory distress. Laboratory findings showed hypoalbuminemia and proteinuria. Echography showed a moderate amount of pleural effusion on both sides and no dilatation of the right cardiac ventricle. Contrast-enhanced chest computed tomography was performed to search the cause of the respiratory distress, which showed filling defects with contrast material in pulmonary arteries. A 12-lead electrocardiogram showed an S1Q3T3 pattern. She received a diagnosis of PE caused by nephrotic syndrome. Pulmonary thromboembolism can mimic infectious pleuritis and lead to misdiagnosis and/or delayed diagnosis. Thus, risk factors of PE should be considered in pediatric patients presenting with symptoms suggesting infectious pleuritis.
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Kanis J, Pike J, Hall CL, Kline JA. Clinical characteristics of children evaluated for suspected pulmonary embolism with D-dimer testing. Arch Dis Child 2018; 103:835-840. [PMID: 29117964 DOI: 10.1136/archdischild-2017-313317] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 10/25/2017] [Accepted: 10/30/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND We sought to determine clinical variables in children tested for suspected pulmonary embolism (PE) that predict PE+ outcome for the development of paediatric PE prediction rule. METHODS Data were collected by query of a laboratory database for D-dimer from January 2004 to December 2014 for a large multicentre hospital system and the radiology database for pulmonary vascular imaging in children aged 5-17. Using explicit, predefined methods, trained abstractors, determined if D-dimer was sent in the evaluation of PE and then recorded predictor data which was tested for association with PE+ outcome using univariate techniques. RESULTS D-dimer was ordered in 526 children for clinical suspicion of PE. Thirty-four of 526 were PE+ (6.4%, 95% CI 4.3% to 8.7%). The radiology database identified 17 additional patients with PE (n=51 PE+ total). Children evaluated for PE were primarily in the ED setting (80%), teenagers (88%) and 2:1 female:male. Children with PE had higher mean heart and higher respiratory rate and a lower pulse oximetry and haemoglobin concentration. On univariate analysis, five conditions were more frequent in PE+ compared with no PE: surgery, central line, limb immobility, prior PE or deep vein thrombosis and cancer. CONCLUSIONS The rate of PE diagnosis in children with D-dimer was 6.4%, similar to that seen in adults; most children with PE are over 13 years and had clinical predictors known to increase probability of PE in symptomatic adults. Future studies should use these criteria to develop a clinical decision rule for PE in children.
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Affiliation(s)
- Jessica Kanis
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan Pike
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Cassandra L Hall
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Evaluation of the pulmonary embolism rule out criteria (PERC rule) in children evaluated for suspected pulmonary embolism. Thromb Res 2018; 168:1-4. [DOI: 10.1016/j.thromres.2018.05.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 04/17/2018] [Accepted: 05/21/2018] [Indexed: 12/20/2022]
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59
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Abstract
Pulmonary embolism (PE) in children is a rare condition with potential for high mortality. PE incidence is increasing owing to increased survival of children with predisposing conditions, increased use of central venous catheters, and improved awareness and recognition. Although pediatric PE is distinct from adult PE, management guidelines in children are extrapolated from the adult data. Treatment includes thrombolysis or thrombectomy, and pharmacologic anticoagulation. Ongoing clinical trials are evaluating the use of direct oral anticoagulants in children. Further research is required to develop pediatric-specific evidence-based guidelines for diagnosis and management of PE.
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Affiliation(s)
- Sarah Ramiz
- Division of Pediatric Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201, USA
| | - Madhvi Rajpurkar
- Division of Pediatric Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201, USA.
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60
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Magnetic resonance imaging of cardiovascular thrombi in children. Pediatr Radiol 2018; 48:722-731. [PMID: 29224047 DOI: 10.1007/s00247-017-4011-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/27/2017] [Accepted: 10/10/2017] [Indexed: 12/17/2022]
Abstract
Cardiovascular thrombosis is rare in children and usually occurs in the presence of predisposing conditions, such as indwelling vascular catheters, tumors, aneurysms, ventricular dysfunction, or after surgery. Clots can occur in the cardiac chambers, arteries or veins, or inside conduits. Detection of thrombi is feasible with a variety of magnetic resonance imaging (MRI) techniques, including unenhanced methods but also contrast-enhanced MR angiography. In this essay we illustrate the MRI appearance of cardiovascular thrombosis in children and suggest an imaging protocol based on our clinical experience.
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Albisetti M, Biss B, Bomgaars L, Brandão LR, Brueckmann M, Chalmers E, Gropper S, Harper R, Huang F, Luciani M, Manastirski I, Mitchell LG, Tartakovsky I, Wang B, Halton JML. Design and rationale for the DIVERSITY study: An open-label, randomized study of dabigatran etexilate for pediatric venous thromboembolism. Res Pract Thromb Haemost 2018; 2:347-356. [PMID: 30046738 PMCID: PMC6055566 DOI: 10.1002/rth2.12086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 01/26/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The current standard of care (SOC) for pediatric venous thromboembolism (VTE) comprises unfractionated heparin (UFH), or low-molecular-weight heparin (LMWH) followed by LMWH or vitamin K antagonists, all of which have limitations. Dabigatran etexilate (DE) has demonstrated efficacy and safety for adult VTE and has the potential to overcome some of the limitations of the current SOC. Pediatric trials are needed to establish dosing in children and to confirm that results obtained in adults are applicable in the pediatric setting. OBJECTIVES To describe the design and rationale of a planned phase IIb/III trial that will evaluate a proposed dosing algorithm for DE and assess the safety and efficacy of DE versus SOC for pediatric VTE treatment. PATIENTS/METHODS An open-label, randomized, parallel-group noninferiority study will be conducted in approximately 180 patients aged 0 to <18 years with VTE, who have received initial UFH or LMWH treatment and who are expected to require ≥3 months of anticoagulation therapy. Patients will receive DE or SOC for 3 months. DE will be administered twice daily as capsules, pellets, or an oral liquid formulation according to patient age. Initial doses will be calculated using a proposed dosing algorithm. RESULTS There will be two coprimary endpoints: a composite efficacy endpoint comprising the proportion of patients with complete thrombus resolution, freedom from recurrent VTE and VTE-related mortality, and a safety endpoint: freedom from major bleeding events. CONCLUSION Findings will provide valuable information regarding the efficacy and safety of DE for the treatment of pediatric VTE. ClinicalTrials.gov registration number: NCT01895777.
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Affiliation(s)
- Manuela Albisetti
- Hematology DepartmentUniversity Children's HospitalZürichSwitzerland
| | - Branislav Biss
- Department of Clinical DevelopmentBoehringer Ingelheim RCV GmbH & Co. KGViennaAustria
| | - Lisa Bomgaars
- Department for PediatricsBaylor College of MedicineHoustonTXUSA
| | - Leonardo R. Brandão
- Department of PediatricsDivision of Hematology/OncologyUniversity of TorontoThe Hospital for Sick ChildrenTorontoONCanada
| | - Martina Brueckmann
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH& Co. KGIngelheimGermany
- Faculty of Medicine MannheimUniversity of HeidelbergMannheimGermany
| | | | - Savion Gropper
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH& Co. KGIngelheimGermany
| | - Ruth Harper
- Boehringer Ingelheim LtdBracknellBerkshireUK
| | - Fenglei Huang
- Translational Medicine and Clinical PharmacologyBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
| | - Matteo Luciani
- OncoHematology DepartmentBambino Gesù Children's HospitalRomeItaly
| | - Ivan Manastirski
- Department of Clinical DevelopmentBoehringer Ingelheim RCV GmbH & Co. KGViennaAustria
| | | | - Igor Tartakovsky
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH& Co. KGIngelheimGermany
| | - Bushi Wang
- Biostatistics and Data SciencesBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
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Pediatric issues in thrombosis and hemostasis: The how and why of venous thromboembolism risk stratification in hospitalized children. Thromb Res 2018; 172:190-193. [PMID: 29472108 DOI: 10.1016/j.thromres.2018.02.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 02/06/2018] [Accepted: 02/13/2018] [Indexed: 01/23/2023]
Abstract
Multiple observational studies have identified risk factors for venous thromboembolism (VTE) in hospitalized children, but very few interventional studies have assessed the safety and efficacy of thromboprophylaxis in this population. In recent years, however, evidence in pediatric VTE risk stratification has grown considerably. This has led to the conception of a pediatric subpopulation-specific risk-based paradigm for mechanical and pharmacological thromboprophylaxis in hospitalized children. More research is required to validate and further refine pediatric subpopulation-specific risk models and to subsequently investigate risk-stratified thromboprophylaxis strategies for hospitalized children.
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63
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Newall F, Branchford B, Male C. Anticoagulant prophylaxis and therapy in children: current challenges and emerging issues. J Thromb Haemost 2018; 16:196-208. [PMID: 29316202 DOI: 10.1111/jth.13913] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This review is aimed at describing the unique challenges of anticoagulant prophylaxis and treatment in children, and highlighting areas for research for improving clinical outcomes of children with thromboembolic disease. The evidence presented demonstrates the challenges of advancing the evidence base informing optimal management of thromboembolic disease in children. Recent observational studies have identified risk factors for venous thromboembolism in children, but there are few interventional studies assessing the benefit-risk balance of using thromboprophylaxis in risk-stratified clinical subgroups. A risk level-based framework is proposed for administering mechanical and pharmacological thromboprophylaxis. More research is required to refine the assignment of risk levels. The anticoagulants currently used predominantly in children are unfractionated heparin, low molecular weight heparin, and vitamin K antagonists. There is a paucity of robust evidence on the age-specific pharmacology of these agents, and their efficacy and safety for prevention and treatment of thrombosis in children. The available literature is heterogeneous, reflecting age-specific differences, and the various clinical settings for anticoagulation in children. Monitoring assays and target ranges are not well established. Nevertheless, weight-based dosing appears to achieve acceptable outcomes in most indications. Given the limitations of the classical anticoagulants for children, there is great interest in the direct oral anticoagulants (DOACs), whose properties appear to be particularly suitable for children. All DOACs currently approved for adults have Pediatric Investigation Plans ongoing or planned. These are generating age-specific formulations and systematic dosing information. The ongoing pediatric studies still have to establish whether DOACs have a positive benefit-risk balance in the various pediatric indications and age groups.
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Affiliation(s)
- F Newall
- Clinical Haematology & Nursing Research, Royal Children's Hospital, Haematology Research Group, Murdoch Childrens Research Institute and Departments of Paediatrics and Nursing, The University of Melbourne, Melbourne, Australia
| | - B Branchford
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplant and the Hemophilia and Thrombosis Center, School of Medicine and Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - C Male
- Haemostasis and Thrombosis Unit, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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64
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Biss TT, Rajpurkar M, Williams S, van Ommen CH, Chan AKC, Goldenberg NA. Recommendations for future research in relation to pediatric pulmonary embolism: communication from the SSC of the ISTH. J Thromb Haemost 2018; 16:405-408. [PMID: 29197153 DOI: 10.1111/jth.13902] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Indexed: 12/01/2022]
Affiliation(s)
- T T Biss
- Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - M Rajpurkar
- Carman and Ann Adams Department of Pediatrics, Division of Hematology Oncology, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, USA
| | - S Williams
- Division of Pediatric Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - C H van Ommen
- Department of Pediatric Hematology, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, the Netherlands
| | - A K C Chan
- McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - N A Goldenberg
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Medicine Pediatric Thrombosis Program, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
- Johns Hopkins Children's Center, Baltimore, MD, USA
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65
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Branchford BR, Jaffray J, Mahajerin A. Editorial: Pediatric Venous Thromboembolism. Front Pediatr 2018; 6:269. [PMID: 30320050 PMCID: PMC6170657 DOI: 10.3389/fped.2018.00269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/10/2018] [Indexed: 11/18/2022] Open
Affiliation(s)
- Brian R Branchford
- Department of Pediatrics, Section of Hematology, Oncology at University of Colorado School of Medicine and Children's Hospital Colorado, University of Colorado Hemophilia and Thrombosis Center, Denver, CO, United States
| | - Julie Jaffray
- Division of Hematology, Oncology, BMT, Department of Pediatrics, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
| | - Arash Mahajerin
- Division of Hematology, Children's Hospital Orange County Children's Specialists, Orange, CA, United States
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66
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Rajpurkar M, Biss TT, Amankwah EK, Martinez D, Williams S, van Ommen CH, Goldenberg NA. Pulmonary embolism and in situ pulmonary artery thrombosis in paediatrics. Thromb Haemost 2017; 117:1199-1207. [DOI: 10.1160/th16-07-0529] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 03/01/2017] [Indexed: 11/05/2022]
Abstract
SummaryData on paediatric pulmonary embolism (PE) are scarce. We sought to systematically review the current literature on childhood PE and conducted a search on paediatric PE via PubMed (1946–2013) and Embase (1980–2013). There was significant heterogeneity in reported data. Two patterns were noted: classic thromboembolic PE (TE-PE) and in situ pulmonary artery thrombosis (ISPAT). Mean age of presentation for TE-PE was 14.86 years, and 51% of cases were males. The commonest method for diagnosis of TE-PE was contrast CT with angiography (74% of patients). The diagnosis of TE-PE was often delayed. Although 85% of children with TE-PE had an elevated D-dimer at presentation, it was non-discriminatory for the diagnosis. In paediatric TE-PE, the prevalence of central venous catheters was 23%, immobilisation 38%, systemic infection 31% and obesity 13%, elevated Factor VIII or von Willebrand factor levels 27%, Protein C deficiency 17%, Factor V Leiden 14% and Protein S deficiency 7%. In patients with TE-PE, pharmacologic thrombolysis was used in 29%; unfractionated heparin was the most common initial anticoagulant treatment in 64% and low-molecular-weight heparins the most common follow-up treatment in 83%. Duration of anticoagulant therapy was variable and death was reported in 26% of TE-PE patients. In contrast to TE-PE, patients with ISPAT were not investigated systematically for presence of thrombophilia, had more surgical interventions as the initial management and were often treated with anti-platelet medications. This review summarises important data and identifies gaps in the knowledge of paediatric PE, which may help to design future studies.
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Brower LH, Kremer N, Meier K, Wolski C, McCaughey MM, McKenna E, Anadio J, Eismann E, Shaughnessy EE. Quality Initiative to Introduce Pediatric Venous Thromboembolism Risk Assessment for Orthopedic and Surgery Patients. Hosp Pediatr 2017; 7:595-601. [PMID: 28899861 DOI: 10.1542/hpeds.2016-0203] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Pediatric hospital-acquired venous thromboembolism (VTE) is costly, has high morbidity, and is often preventable. The objective of this quality-improvement effort was to increase the percentage of general surgery and orthopedic patients ≥10 years of age screened for VTE risk from 0% to 80%. METHODS At a freestanding children's hospital, 2 teams worked to implement VTE risk screening for postoperative inpatients. The general surgery team used residents and nurse practitioners to perform screening whereas the orthopedic team initially used bedside nursing staff. Both groups employed multiple small tests of change. Shared key interventions included refinement of a screening tool, provider education, mitigation of failures, and embedding the risk assessment task into staff workflow. The primary outcome measure, the percentage of eligible patients with a completed VTE risk assessment, was plotted on run charts. Secondary outcome measures for screened patients included the level of risk, the use of appropriate prophylaxis, and VTE events. RESULTS Median weekly percentage of general surgery patients screened for VTE risk increased from 0% to 86% within 12 months, and median weekly percentage of orthopedic patients screened for VTE risk increased from 0% to 46% within 8 months. Among screened patients, the majority were at low or moderate risk for VTE and received prophylaxis in accordance with or beyond guideline recommendations. No screened patients developed VTE. CONCLUSIONS Quality-improvement methods were used to implement a VTE risk screening process for postoperative patients. Using providers as screeners, as opposed to bedside nurses, led to a greater percentage of patients screened.
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Affiliation(s)
| | | | - Katie Meier
- Divisions of Hospital Medicine
- Departments of Pediatrics
| | | | | | - Emily McKenna
- Patient Services, and
- Pediatric General and Thoracic Surgery
| | | | - Emily Eismann
- Mayerson Center for Safe and Healthy Children, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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Brower LH, Shaughnessy EE, Chima RS. Development of a Surveillance System for Pediatric Hospital-Acquired Venous Thromboembolism. Hosp Pediatr 2017; 7:610-614. [PMID: 28899859 DOI: 10.1542/hpeds.2016-0220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Pediatric hospital-acquired (HA) venous thromboembolism (VTE) is a vexing problem with improvement efforts hampered by lack of robust surveillance methods to establish accurate rates of HA-VTE. METHODS At a freestanding children's hospital, a multidisciplinary team worked to develop a comprehensive surveillance strategy for HA-VTE. Starting with diagnosis codes, we implemented complementary detection methods, including clinical and radiology data, to develop a robust surveillance system. HA-VTE events were tracked by using descriptive statistics and a statistical process control chart. Detection methods were evaluated via retrospective application of each method to every identified HA-VTE. Initial detection method was tracked. RESULTS A total of 68 HA-VTE events were identified and the median number of events per 1000 patient days increased from 0.18 to 0.34. No single detection method would have identified all events. Each detection method initially identified HA-VTE events. CONCLUSIONS Implementation of multiple detection methods has optimized timely detection of HA-VTE. This allows the establishment of a reliable baseline rate, enabling quality improvement efforts to address HA-VTE.
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Affiliation(s)
- Laura H Brower
- Divisions of Hospital Medicine and
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Erin E Shaughnessy
- Divisions of Hospital Medicine and
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ranjit S Chima
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Cox M, Epelman M, Chandra T, Meyers AB, Johnson CM, Podberesky DJ. Non–Catheter-related Venous Thromboembolism in Children: Imaging Review from Head to Toe. Radiographics 2017; 37:1753-1774. [DOI: 10.1148/rg.2017170036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Mougnyan Cox
- From the Department of Medical Imaging, Nemours Children’s Health System/Alfred I. duPont Hospital for Children, Wilmington, Del (M.C.); Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (M.C.); and Department of Medical Imaging/Radiology, Nemours Children’s Health System/Nemours Children’s Hospital, University of Central Florida, 13535 Nemours Pkwy, Orlando, FL 32827 (M.E., T.C., A.B.M., C.M.J., D.J.P.)
| | - Monica Epelman
- From the Department of Medical Imaging, Nemours Children’s Health System/Alfred I. duPont Hospital for Children, Wilmington, Del (M.C.); Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (M.C.); and Department of Medical Imaging/Radiology, Nemours Children’s Health System/Nemours Children’s Hospital, University of Central Florida, 13535 Nemours Pkwy, Orlando, FL 32827 (M.E., T.C., A.B.M., C.M.J., D.J.P.)
| | - Tushar Chandra
- From the Department of Medical Imaging, Nemours Children’s Health System/Alfred I. duPont Hospital for Children, Wilmington, Del (M.C.); Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (M.C.); and Department of Medical Imaging/Radiology, Nemours Children’s Health System/Nemours Children’s Hospital, University of Central Florida, 13535 Nemours Pkwy, Orlando, FL 32827 (M.E., T.C., A.B.M., C.M.J., D.J.P.)
| | - Arthur B. Meyers
- From the Department of Medical Imaging, Nemours Children’s Health System/Alfred I. duPont Hospital for Children, Wilmington, Del (M.C.); Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (M.C.); and Department of Medical Imaging/Radiology, Nemours Children’s Health System/Nemours Children’s Hospital, University of Central Florida, 13535 Nemours Pkwy, Orlando, FL 32827 (M.E., T.C., A.B.M., C.M.J., D.J.P.)
| | - Craig M. Johnson
- From the Department of Medical Imaging, Nemours Children’s Health System/Alfred I. duPont Hospital for Children, Wilmington, Del (M.C.); Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (M.C.); and Department of Medical Imaging/Radiology, Nemours Children’s Health System/Nemours Children’s Hospital, University of Central Florida, 13535 Nemours Pkwy, Orlando, FL 32827 (M.E., T.C., A.B.M., C.M.J., D.J.P.)
| | - Daniel J. Podberesky
- From the Department of Medical Imaging, Nemours Children’s Health System/Alfred I. duPont Hospital for Children, Wilmington, Del (M.C.); Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (M.C.); and Department of Medical Imaging/Radiology, Nemours Children’s Health System/Nemours Children’s Hospital, University of Central Florida, 13535 Nemours Pkwy, Orlando, FL 32827 (M.E., T.C., A.B.M., C.M.J., D.J.P.)
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Mornand P, Chalard F, Romain AS, Rohr M, Paluel-Marmont C, Niakaté A, Quinet B, Grimprel E, Odièvre-Montanié MH. [Bilateral pulmonary embolism mimicking acute chest syndrome in an adolescent with sickle cell disease]. Arch Pediatr 2017; 24:625-629. [PMID: 28599856 DOI: 10.1016/j.arcped.2017.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 04/12/2017] [Indexed: 11/18/2022]
Abstract
Pulmonary embolism is a life-threatening and potentially lethal disease. Its incidence in children with sickle cell disease is probably underestimated and pediatric case reports in the literature are rare. Moreover, symptoms can mimic an acute chest syndrome. We report on the case of a 17-year-old boy with SS sickle cell disease, admitted for chest pain with dyspnea and tachycardia. Pulmonary angiography revealed a partial bilateral obstructive pulmonary embolism. We did not find any deep venous thrombosis or thrombophilia. The progression was rapidly favorable with anticoagulant therapy. We recommend a pulmonary angiography for any chest pain that does not evolve favorably in a child with sickle cell disease. Large series of pediatric patients would be useful to establish diagnostic and therapeutic guidelines.
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Affiliation(s)
- P Mornand
- Service de pédiatrie, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France.
| | - F Chalard
- Service de radiologie, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - A-S Romain
- Service de pédiatrie, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - M Rohr
- Service de pédiatrie, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - C Paluel-Marmont
- Service de pédiatrie, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - A Niakaté
- Service de pédiatrie, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - B Quinet
- Service de pédiatrie, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - E Grimprel
- Service de pédiatrie, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - M-H Odièvre-Montanié
- Service de pédiatrie, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; UMR_S1134, institut national de la transfusion sanguine, 6, rue Alexandre-Cabanel, 75015 Paris, France
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71
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Fernandes CJCDS, Alves Júnior JL, Gavilanes F, Prada LF, Morinaga LK, Souza R. New anticoagulants for the treatment of venous thromboembolism. J Bras Pneumol 2017; 42:146-54. [PMID: 27167437 PMCID: PMC4853069 DOI: 10.1590/s1806-37562016042020068] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 03/22/2016] [Indexed: 12/21/2022] Open
Abstract
Worldwide, venous thromboembolism (VTE) is among the leading causes of death from cardiovascular disease, surpassed only by acute myocardial infarction and stroke. The spectrum of VTE presentations ranges, by degree of severity, from deep vein thrombosis to acute pulmonary thromboembolism. Treatment is based on full anticoagulation of the patients. For many decades, it has been known that anticoagulation directly affects the mortality associated with VTE. Until the beginning of this century, anticoagulant therapy was based on the use of unfractionated or low-molecular-weight heparin and vitamin K antagonists, warfarin in particular. Over the past decades, new classes of anticoagulants have been developed, such as factor Xa inhibitors and direct thrombin inhibitors, which significantly changed the therapeutic arsenal against VTE, due to their efficacy and safety when compared with the conventional treatment. The focus of this review was on evaluating the role of these new anticoagulants in this clinical context.
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Affiliation(s)
| | | | | | - Luis Felipe Prada
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | - Rogerio Souza
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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72
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Abstract
Pulmonary embolism (PE) in the pediatric population is relatively rare when compared to adults; however, the incidence is increasing and accurate and timely diagnosis is critical. A high clinical index of suspicion is warranted as PE often goes unrecognized among children leading to misdiagnosis and potentially increased morbidity and mortality. Evidence-based guidelines for the diagnosis, management, and follow-up of children with PE are lacking and current practices are extrapolated from adult data. Treatment options include thrombolysis and anticoagulation with heparins and oral vitamin K antagonists, with newer direct oral anticoagulants currently in clinical trials. Long-term sequelae of PE, although studied in adults, are vastly unknown among children and adolescents. Additional research is needed in order to provide pediatric focused care for patients with acute PE.
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Affiliation(s)
- Ahmar Urooj Zaidi
- Division of Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, United States
| | - Kelley K Hutchins
- Division of Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, United States
| | - Madhvi Rajpurkar
- Division of Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, United States
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73
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Detection of Pulmonary Embolism in High-Risk Children. J Pediatr 2016; 178:214-218.e3. [PMID: 27567411 DOI: 10.1016/j.jpeds.2016.07.046] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/06/2016] [Accepted: 07/28/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate 2 commonly used adult-based pulmonary embolism (PE) algorithms in pediatric patients and to derive a pediatric-specific clinical decision rule to evaluate children at risk for PE, given the paucity of data to guide diagnostic imaging in children for whom PE is suspected. STUDY DESIGN We performed a single-center retrospective study among 561 children <22 years of age undergoing either D-dimer testing or radiologic evaluation (computed tomography or ventilation-perfusion scan) in the emergency department setting for concern of PE. A diagnosis of PE required radiologic confirmation and anticoagulant treatment. We evaluated the test characteristics of the Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC) low-risk rule and used recursive partition analysis to derive a clinical decision rule. RESULTS Among the 561 patients included in the study, 36 (6.4%) were diagnosed with PE. The Wells criteria demonstrated a sensitivity and specificity of 86% and 60%, respectively. The sensitivity and specificity of the PERC were 100% and 24%, respectively. A clinical decision rule including the presence of oral contraceptive use, tachycardia, and oxygen saturation <95% demonstrated a sensitivity and specificity of 90% and 56%, respectively, a positive and negative likelihood ratio of 2.0 and 0.2, and a positive and negative predictive value of 0.12 and 0.99, respectively. CONCLUSIONS The risk of PE is low among children not receiving estrogen therapy and without tachycardia and hypoxia in those with an initial suspicion of PE. Application of the PERC rule and Wells criteria should be used cautiously in the pediatric population.
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74
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Lilje C, Chauhan A, Turner JP, Carson TH, Velez MC, Arcement C, Caspi J. Pediatric Pulmonary Embolism: Diagnostic and Management Challenges. World J Pediatr Congenit Heart Surg 2016; 9:110-113. [PMID: 27619327 DOI: 10.1177/2150135116663698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A rare case of massive pulmonary embolism is presented in an oligosymptomatic teenager with predisposing factors. Computed tomography pulmonary angiography supported by three-dimensional reconstruction was diagnostic. The embolus qualified as massive by conventional anatomical guidelines, but as low risk by more recent functional criteria. Functional assessment has complemented morphologic assessment for risk stratification in adult patients. Such evidence is scarce in pediatrics. The patient underwent surgical embolectomy, followed by prophylactic anticoagulation, without further events. Diagnostic and management challenges are discussed.
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Affiliation(s)
- Christian Lilje
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Aman Chauhan
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Jason P Turner
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Thomas H Carson
- 2 Department of Pathology, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Maria C Velez
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Christopher Arcement
- 3 Department of Radiology, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Joseph Caspi
- 4 Department of Surgery, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
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75
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76
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Risk factors and clinical features of acute pulmonary embolism in children from the community. Thromb Res 2016; 138:86-90. [DOI: 10.1016/j.thromres.2015.12.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 11/24/2015] [Accepted: 12/09/2015] [Indexed: 11/23/2022]
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77
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Halvorson EE, Ervin SE, Russell TB, Skelton JA, Davis S, Spangler J. Association of Obesity and Pediatric Venous Thromboembolism. Hosp Pediatr 2016; 6:22-26. [PMID: 26675300 PMCID: PMC9161240 DOI: 10.1542/hpeds.2015-0039] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND The incidence of venous thromboembolism (VTE) is increasing among pediatric patients in the United States. Previous studies on obesity as a risk factor have produced mixed results. METHODS We completed a retrospective chart review of patients aged 2 to 18 years with VTE identified by using International Classification of Diseases, Ninth Revision, codes and confirmed by imaging. Patients were admitted between January 2000 and September 2012. Control subjects were matched on age, gender, and the presence of a central venous catheter. Data were collected on weight, height, and risk factors, including bacteremia, ICU admission, immobilization, use of oral contraceptives, and malignancy. Underweight patients and those without documented height and weight data were excluded. Independent predictors of VTE risk were identified by using univariate and multivariate analyses. RESULTS We identified 88 patients plus 2 matched control subjects per case. The majority of cases were nonembolic events (77%) of the lower extremity (25%) or head and neck (22%) confirmed by ultrasound (43%) or computed tomography scan (41%). A statistically significant association was found between VTE and increased BMI z score (P = .002). In multivariate analysis, BMI z score (odds ratio [OR]: 3.1; P = .007), bacteremia (OR: 4.9; P = .02), ICU stay (OR: 2.5; P = .02), and use of oral contraceptives (OR: 17.4; P < .001) were significant predictors. CONCLUSIONS In this single-institution study, the diagnosis of VTE was significantly associated with overweight and obesity. Further study is needed to fully define this association.
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Affiliation(s)
| | | | | | - Joseph A Skelton
- Departments of Pediatrics, Brenner FIT (Families in Training), Brenner Children's Hospital, Winston-Salem, North Carolina Epidemiology and Prevention, Division of Public Health Sciences, and
| | - Stephen Davis
- Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - John Spangler
- Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
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78
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Venous Thromboembolic Disease in Children and Adolescents. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:149-165. [DOI: 10.1007/5584_2016_113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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79
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Lee H, Baek J, Park S, Jee D. Suspected Pulmonary Embolism during Hickman Catheterization in a Child: What Else Should Be Considered besides Pulmonary Embolism? Korean J Crit Care Med 2016. [DOI: 10.4266/kjccm.2016.31.1.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Haemi Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jonghyun Baek
- Department of Thoracic Surgery, College of Medicine, Yeungnam University, Daegu, Korea
| | - Sangyoung Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Daelim Jee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Yeungnam University, Daegu, Korea
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Rottenstreich A, Revel-Vilk S, Bloom AI, Kalish Y. Inferior vena cava (IVC) filters in children: A 10-year single center experience. Pediatr Blood Cancer 2015; 62:1974-8. [PMID: 26184562 DOI: 10.1002/pbc.25641] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 06/01/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is an increasingly recognized problem among children and adolescents. Although inferior vena cava (IVC) filter placement for pulmonary embolism prevention is well reported in adults, data regarding safety and efficacy in the pediatric age group are lacking. PROCEDURE At a large university hospital with a level I trauma center, medical records of children and adolescents who underwent IVC filter insertion were reviewed. Appropriateness of referral for retrieval was assessed in each case. RESULTS Fifty-nine children and adolescents (mean age 16 years) successfully underwent IVC filter insertion. All filters placed were retrievable. In 47 patients (79.7%), prophylactic filters were placed in the absence of acute VTE in the setting of trauma. In eight patients (13.5%), filters were placed due to contraindication to anticoagulation therapy with concomitant lower extremity deep vein thrombosis or pulmonary embolism. Filters were successfully retrieved in only 12 patients (20.3%), although an attempt at removal was appropriate and feasible in over 90% of cases. Mean duration of follow-up was 2.1 (range 0.4-7.3) years. A significantly higher retrieval rate was found in patients followed at our thrombosis clinic (P < 0.01). Ten patients (17%) experienced at least one filter-related complication. CONCLUSIONS Although in most cases, IVC filters were placed for prophylactic indications, the evidence to support their role in this setting is limited. Their low retrieval rate and high filter-related complication rate question their extensive utilization in children. Dedicated follow-up is necessary to detect complications and to ensure that an attempt at retrieval is made when feasible.
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Affiliation(s)
- Amihai Rottenstreich
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Shoshana Revel-Vilk
- Department of Pediatric Hematology/Oncology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Allan I Bloom
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yosef Kalish
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Arlikar SJ, Atchison CM, Amankwah EK, Ayala IA, Barrett LA, Branchford BR, Streiff MB, Takemoto CM, Goldenberg NA. Development of a new risk score for hospital-associated venous thromboembolism in critically-ill children not undergoing cardiothoracic surgery. Thromb Res 2015; 136:717-22. [DOI: 10.1016/j.thromres.2015.04.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/24/2015] [Accepted: 04/27/2015] [Indexed: 10/23/2022]
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Álvarez Z P, Verdugo L P, Carvajal K L, Múhlhausen M G, Ríos A P, Rodríguez V D. [Recombinant tissue plasminogen activator for the management of intracardiac thrombi in newborns]. ACTA ACUST UNITED AC 2015; 86:194-9. [PMID: 26235268 DOI: 10.1016/j.rchipe.2015.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/30/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The incidence of cardiac thrombi in newborns has increased with the use of central venous catheters. Thrombolysis with recombinant tissue plasminogen activator (rTPA) has been used as an alternative to heparin in life threatening giant thrombus and embolization. The aim of this study is to describe the response and complications related to the use of rTPA in the management of life- threatening cardiac thrombi in newborns. PATIENTS AND METHOD The medical records of 8 newborn were reviewed in a retrospective study, of whom 7 were preterm with cardiac thrombi, and rTPA was used in all of them. RESULTS The patients included 4 males with a mean weight of 1580 gr. The principal pathology was sepsis (7/8), all of them used venous central catheter. The superior vena cava was the most frequent location, with a mean time of installation before the diagnosis of 12 days. RN 7/8 thrombi were located in the right atrium with a size between 7 to 20 mm. Three patients received low molecular weight heparin prior to using rTPA. They received between 1 to 5 cycles with rTPA. In 4 patients complete resolution of the thrombus was achieved in a mean of 3.5 days. Four patients had intracranial haemorrhage grade I, without sequelae at follow-up. There were no deaths or embolism. CONCLUSION This study is the first series of infants treated with rTPA in Chile, and where its use has quickly achieved complete resolution of the thrombus in 50% of cases, and partially in the others, thus reducing the secondary life-threatening risk of this disease.
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Affiliation(s)
- Patricia Álvarez Z
- Hospital Roberto del Río, Santiago, Chile; Departamento de Pediatría Norte, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Clínica Alemana de Santiago, Santiago, Chile.
| | - Patricia Verdugo L
- Hospital Roberto del Río, Santiago, Chile; Departamento de Pediatría Norte, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Clínica Santa María, Santiago, Chile
| | | | - Germán Múhlhausen M
- Departamento de Pediatría Norte, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Servicio de Neonatología, Hospital San José, Santiago, Chile
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83
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Ng M, Pandya N, Conry B, Gale R. A case of panic to pulmonary embolism. BMJ Case Rep 2015; 2015:bcr-2015-209857. [PMID: 26071441 DOI: 10.1136/bcr-2015-209857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pulmonary embolism (PE) is a rare paediatric diagnosis, but its presence is likely to be underestimated due to the subtle and non-specific nature of its symptoms. Common clinical features of PE include shortness of breath, pleuritic chest pain and acute cardiovascular collapse. Less common symptoms can include persistent unexplained tachycardia, fever or deep vein thrombosis. Rarely do patients present with abdominal pain and self-resolving shortness of breath; symptoms our patient experienced. However, in contrast to popular belief, having normal vital signs does not necessarily lower the probability of PE. D-dimer, a specific fibrin degradation product, has a good negative predictive value for venous thromboembolism diagnosis but its use in children is less clear, with up to 40% of children with PE having a normal D-dimer level. CT pulmonary angiography remains the gold standard in diagnosis.
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Affiliation(s)
- Mansum Ng
- Department of Paediatrics, Tunbridge Wells Hospital, Tunbridge Wells, UK
| | - Nikila Pandya
- Department of Paediatrics, Maidstone and Tunbridge Wells, Kent, UK
| | - Brendon Conry
- Department of Radiology, Tunbridge Wells Hospital, Tunbridge Wells, UK
| | - Richard Gale
- Department of Haematology, Maidstone Hospital, Kent, UK
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84
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Kalaniti K, Lo Rito M, Hickey EJ, Sivarajan VB. Successful pulmonary embolectomy of a saddle pulmonary thromboembolism in a preterm neonate. Pediatrics 2015; 135:e1317-20. [PMID: 25896834 DOI: 10.1542/peds.2014-3242] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Symptomatic pulmonary thromboembolism (PTE) is rare in neonates, and the diagnosis is often made only postmortem. The true incidence is probably underestimated because of its varying presentations, ranging from mild respiratory distress to acute right-heart failure and cardiovascular collapse. We report a sudden cardiorespiratory collapse on day 10 of life in a preterm neonate who was subsequently diagnosed as having a saddle pulmonary embolus. The patient underwent an emergency surgical embolectomy as a salvage procedure. Considering the potentially lethal complications of PTE, neonatologists and pediatricians should maintain a high degree of suspicion in infants with sudden inexplicable deterioration in cardiorespiratory status. Surgical removal of the thrombus is an invasive procedure and potentially carries a high mortality rate. Two term neonatal survivors of surgical intervention have been reported in the medical literature so far. However, we believe that this is the first documented preterm neonatal survivor after surgical intervention for a massive saddle PTE.
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Affiliation(s)
| | | | - Edward J Hickey
- Cardiovascular Surgery, Department of Surgery; The Hospital for Sick Children, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - V Ben Sivarajan
- The Hospital for Sick Children, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada Cardiac Critical Care, Department of Critical Care Medicine; Cardiology, Department of Paediatrics;
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85
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Abstract
Chondrosarcoma is a malignant bone tumour common in adults, third to myeloma and osteosarcoma, but is exceptionally rare in children. Here we discuss a 9-year-old girl presenting with occlusive right pulmonary artery neoplastic embolus, resulting from a primary right proximal humerus chondrosarcoma. To the best of our knowledge, this the first pediatric and only second overall case reported in the United States of a neoplastic pulmonary embolus resulting from a primary chondrosarcoma.
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86
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Abstract
We retrospectively analyzed the data of 24 children (whereof 11 neonates), with non-central venous line-related and nonmalignancy-related venous thromboembolism (VTE) at uncommon sites, referred to our Unit from January 1999 to January 2012. Thirty patients who also suffered deep vein thrombosis, but in upper/low extremities, were not included in the analysis. The location of rare site VTE was: portal (n=7), mesenteric (n=2) and left facial vein (n=1), spleen (n=3), lung (n=3), whereas 10 neonates developed renal venous thrombosis. The majority of patients (91.7%) had at least 1 risk factor for thrombosis. Identified thrombophilic factors were: antiphospholipid antibodies (n=2), FV Leiden heterozygosity (n=6), MTHFR C677T homozygosity (n=4), protein S deficiency (n=2), whereas all neonates had age-related low levels of protein C and protein S. All but 6 patients received low-molecular-weight heparin, followed by warfarin in 55% of cases, for 3 to 6 months. Prolonged anticoagulation was applied in selected cases. During a median follow-up period of 6 years, the clinical outcome was: full recovery in 15 patients, evolution to both chronic portal hypertension and esophageal varices in 2 children, and progression to renal failure in 7 of 10 neonates. Neonates are greatly vulnerable to complications after VTE at uncommon sites, particularly renal. Future multicentre long-term studies on neonatal and pediatric VTE at unusual sites are considered worthwhile.
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87
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Development of a new risk score for hospital-associated venous thromboembolism in noncritically ill children: findings from a large single-institutional case-control study. J Pediatr 2014; 165:793-8. [PMID: 25064163 PMCID: PMC7269107 DOI: 10.1016/j.jpeds.2014.05.053] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 04/17/2014] [Accepted: 05/29/2014] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine risk factors for pediatric hospital-associated venous thromboembolism (HA-VTE) in noncritically ill children to derive a novel HA-VTE risk model for this population. STUDY DESIGN Patients with HA-VTE were identified retrospectively via the electronic health record at All Children's Hospital Johns Hopkins Medicine from April 10, 2013 through January 1, 2006. Seven contemporaneous, noncritically ill control children were randomly selected for each case of HA-VTE. The association between putative risk factors and HA-VTE was estimated with ORs and 95% CIs, which were calculated using the Wald method. A P-value threshold ≤.2 was used in univariate analysis for inclusion into a multivariate (adjusted) model. RESULTS Fifty cases of HA-VTE occurred in noncritically ill children. The presence of a central venous catheter (OR 27.67, 95% CI, 8.40-91.22), infection (OR 10.40, 95% CI, 3.46-31.25), and length of stay ≥4 days (OR 5.26, 95% CI, 1.74-15.88) were found to be statistically significant risk factors for HA-VTE. An 8-point risk score was derived in which scores of 8 points, 7 points, and ≤6 points corresponded to venous thromboembolism risks of 12.5%, 1.1%, and 0.1%, respectively. CONCLUSION The presence of a central venous catheter, infection, and length of stay ≥4 days are significant risk factors for HA-VTE in noncritically ill children, forming the basis for a new risk score that could inform venous thromboembolism prophylaxis decision-making. These findings warrant prospective validation.
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88
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89
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Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JSR, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35:3033-69, 3069a-3069k. [PMID: 25173341 DOI: 10.1093/eurheartj/ehu283] [Citation(s) in RCA: 1836] [Impact Index Per Article: 183.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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90
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Abstract
We report a case of successful recanalisation of the left pulmonary artery after occlusion due to embolic thrombi in a 9-month-old infant after surgical repair of a common atrioventricular canal with tetralogy of Fallot. A transhepatic approach was used because of caval vein thrombosis. After the failure of high-pressure balloon angioplasty, the left pulmonary artery was successfully recanalised with cutting balloons, followed by stent implantation with an excellent result.
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91
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Pulmonary artery thrombus in a premature neonate treated with recombinant tissue plasminogen activator. J Perinatol 2014; 34:569-71. [PMID: 24968902 DOI: 10.1038/jp.2014.34] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 01/27/2014] [Accepted: 01/30/2014] [Indexed: 11/08/2022]
Abstract
Pulmonary artery thrombus is a rarely reported complication in premature neonates. The management of life-threatening thrombotic events in neonates is controversial, especially regarding the use of thrombolytics versus anticoagulation alone for treatment. We report a case of a premature neonate with symptomatic pulmonary artery thrombus treated with recombinant tissue plasminogen activator who survived without bleeding complications.
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92
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Kim SJ, Sabharwal S. Risk factors for venous thromboembolism in hospitalized children and adolescents: a systemic review and pooled analysis. J Pediatr Orthop B 2014; 23:389-93. [PMID: 24755850 DOI: 10.1097/bpb.0000000000000053] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
We performed a systematic review of published studies that evaluated the potential risk factors and outcomes of venous thromboembolism (VTE) in hospitalized children. A total of 761 VTE patients from six published studies were identified. The mean prevalence of VTE in children admitted to the hospital was 9.7/10 000 admissions. The presence of a central venous catheter was found to be the single most important predisposing cause of VTE, with a pooled percentage of 29%. Infection was the second most common cause of the disease (20%). Pulmonary embolism occurred in 15% (113/745) of the patients. The overall recurrence rate of VTE was 16% (74/464) and the mortality rate was 8% (59/704). Although uncommon, orthopedic surgeons need to be aware of the unique risk factors for VTE among pediatric inpatients. Hospitalized children and adolescents with known risk factors for VTE should be considered candidates for VTE screening or prophylaxis.
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Affiliation(s)
- Seung-Ju Kim
- aDepartment of Orthopedic Surgery, KEPCO Medical Foundation, KEPCO Medical Center, Seoul, Korea bDepartment of Orthopaedics, New Jersey Medical School, Newark, New Jersey, USA
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93
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Abstract
OBJECTIVES Although critically ill children are at increased risk for developing deep venous thrombosis, there are few pediatric studies establishing the prevalence of thrombosis or the efficacy of thromboprophylaxis. We tested the hypothesis that thromboprophylaxis is infrequently used in critically ill children even for those in whom it is indicated. DESIGN Prospective multinational cross-sectional study over four study dates in 2012. SETTING Fifty-nine PICUs in Australia, Canada, New Zealand, Portugal, Singapore, Spain, and the United States. PATIENTS All patients less than 18 years old in the PICU during the study dates and times were included in the study, unless the patients were 1) boarding in the unit waiting for a bed outside the PICU or 2) receiving therapeutic anticoagulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 2,484 children in the study, 2,159 (86.9%) had greater than or equal to 1 risk factor for thrombosis. Only 308 children (12.4%) were receiving pharmacologic thromboprophylaxis (e.g., aspirin, low-molecular-weight heparin, or unfractionated heparin). Of 430 children indicated to receive pharmacologic thromboprophylaxis based on consensus recommendations, only 149 (34.7%) were receiving it. Mechanical thromboprophylaxis was used in 156 of 655 children (23.8%) 8 years old or older, the youngest age for that device. Using nonlinear mixed effects model, presence of cyanotic congenital heart disease (odds ratio, 7.35; p < 0.001) and spinal cord injury (odds ratio, 8.85; p = 0.008) strongly predicted the use of pharmacologic and mechanical thromboprophylaxis, respectively. CONCLUSIONS Thromboprophylaxis is infrequently used in critically ill children. This is true even for children at high risk of thrombosis where consensus guidelines recommend pharmacologic thromboprophylaxis.
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94
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Abstract
PURPOSE OF REVIEW To review the current literature on venous thromboembolism (VTE) in critically ill children. RECENT FINDINGS There is an increasing concern for VTE and its complications in critically ill children. Critically ill children are at increased risk of thromboembolism because of the treatment that they are receiving and their underlying condition. A complex relationship exists between thrombosis and infection. A thrombus is a nidus for infection, while infection increases the risk of thrombosis. Pediatric-specific guidelines for the prevention and treatment of thromboembolism are lacking. Current guidelines are based on the data from adults. Novel anticoagulants are now available for use in adults. Studies are ongoing to determine their safety in children. Risk assessment tools have recently been developed to determine the risk of thromboembolism in critically ill children. Certain molecules are associated with thromboembolism in adults. SUMMARY Pediatric critical care practitioners should be cognizant of the importance of VTE in critically ill children to allow early identification and treatment. Adequately powered clinical trials are critically needed to generate evidence that will guide the treatment and prevention of thromboembolism in critically ill children. Risk assessment tools that incorporate biomarkers may improve our ability to predict the occurrence of thromboembolism in critically ill children.
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95
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Abstract
BACKGROUND The term venous thromboembolism (VTE) includes deep venous thrombosis of the extremity and pulmonary embolism, a potentially fatal clinical entity. Although the prevalence of VTE may be lower in children compared with adults, recent reports suggest a possible rise in this diagnosis among pediatric patients, especially in association with certain risk factors. We assessed the clinical experience and practice of members of the Pediatric Orthopaedic Society of North America (POSNA) related to VTE among their pediatric patients. METHODS A 36-question online survey was sent to all 636 active POSNA members. The proportion of surgeons who had encountered at least 1 child with VTE and the respondents' practice of using thromboprophylaxis in children (<18 y old) was assessed. The relationship of responders' experience with VTE among pediatric patients with various practice characteristics was evaluated. RESULTS The response rate was 56% (354/636). More than half (55%) [95% confidence interval (CI), 50%-60%] of the respondents could recall at least 1 (median, 2 cases/member) pediatric patient with deep venous thrombosis and 29% (95% CI, 24%-34%) could recall ≥1 child with pulmonary embolism. Approximately one quarter (23%) (95% CI, 18%-27%) of all respondents reported never using mechanical prophylaxis and almost one half (45%) (95% CI, 40%-50%) of respondents reported never using pharmacologic prophylaxis against VTE in children. Only 16% (95% CI, 12%-20%) of the respondents had a thromboprophylaxis protocol for pediatric patients. Respondent characteristics such as being in clinical practice <5 years (P=0.01) and having a surgical volume of <100 cases/y (P=0.03) were associated with a lower likelihood of encountering a pediatric patient with VTE. CONCLUSIONS More than half of responding active POSNA members reported having come across at least 1 case of VTE among pediatric patients during their practice. The routine use of VTE prophylaxis for children is uncommon among pediatric orthopaedists. Further studies aimed at determining the prevalence of VTE and developing specific guidelines for prophylaxis among pediatric patients seeking orthopaedic care are warranted. LEVEL OF EVIDENCE IV.
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96
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Abstract
OBJECTIVE To describe patients who present to the pediatric emergency department (PED) and are subsequently diagnosed with pulmonary embolism (PE). METHODS Electronic medical records from 2003 to 2011 of a tertiary care pediatric health care system was retrospectively reviewed to identify patients <21 years who had a final International Classification of Diseases, Ninth Revision diagnosis of PE. Patient demographics, and hospital course were recorded. Adult validated clinical decision rules Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC) were retrospectively applied. PERC identified 8 clinical criteria for adult patients using logistic regression modeling to exclude PE without additional diagnostic evaluation. If all criteria are met, further evaluation is not indicated. RESULTS Of 1 185 794 PED visits, 105 patients had an ultimate diagnosis of PE. Twenty-five met study criteria, and all were admitted. Forty percent of these patients had PE diagnosed in the PED. The most common risk factors were BMI ≥25 (50%, 10 of 20), oral contraceptive use (38% 5 of 13 female patients), and history of previous thrombus without PE (28%, 7 of 25). When the PERC rule was applied retrospectively, 84% of patients could not be ruled out, indicating additional evaluation for PE was needed. CONCLUSIONS Pulmonary embolism is rare in children but does occur. This study emphasizes risk factors among children that should raise the suspicion of PE. Additional studies are needed to further evaluate risk factors and signs and symptoms of PE to develop pediatric specific clinical decision rules to provide reliable and reproducible means of determining pretest probability of PE.
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97
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Karimi M, Vining M, Pellenberg R, Jajosky R. Papillary fibroelastoma of tricuspid valve in a pediatric patient. Ann Thorac Surg 2013; 96:1078-80. [PMID: 23992707 DOI: 10.1016/j.athoracsur.2012.12.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 12/03/2012] [Accepted: 12/10/2012] [Indexed: 11/25/2022]
Abstract
We are reporting a rare case of papillary fibroelastoma of the tricuspid valve in an 8-year-old child who presented with pulmonary embolism. Echocardiography was instrumental in determining the source of the pulmonary embolism, but not in delineating between tumor and thrombus. Successful surgical resection of the mass was accomplished and good outcome was attained despite the delay in diagnosis and failure of medical management. A high index of suspicion for tumor involving the tricuspid valve is emphasized despite its rarity in children.
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Affiliation(s)
- Mohsen Karimi
- Department of Cardiothoracic Surgery, Section of Pediatric Cardiothoracic Surgery, Yale School of Medicine, New Haven, Connecticut 06510, USA.
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98
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Cardiac findings and long-term thromboembolic outcomes following pulmonary embolism in children: a combined retrospective-prospective inception cohort study. Cardiol Young 2013; 23:344-52. [PMID: 23088931 DOI: 10.1017/s1047951112001126] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In paediatric pulmonary embolism, cardiac findings and thromboembolic outcomes are poorly defined. We conducted a mixed retrospective-prospective cohort study of paediatric pulmonary embolism at the Children's Hospital Colorado between March, 2006 and January, 2011. A total of 58 consecutive children - age less than or equal to 21 years - with acute pulmonary embolism were enrolled. Data collection included clinical and laboratory characteristics, treatments, serial echocardiographic and electrocardiographic findings, and outcomes of pulmonary embolism non-resolution and recurrence. The median age was 16.5 years ranging from 0 to 21 years. The most prevalent clinical risk factors were oral contraceptive pill use (52% of female patients), presence of a non-infectious inflammatory condition (21%), and trauma (21%). Thrombophilias included heterozygous factor V Leiden in 21%; antiphospholipid antibody syndrome was established in 31% overall. Proximal pulmonary artery involvement was present in 34%. At presentation, nearly half of the patients had hypoxaemia and 37% had tachycardia. The classic electrocardiographic finding of S1Q3T3 was present in 12% acutely; tricuspid regurgitation greater than 3 metres per second, septal flattening, and right ventricular dilation were each present on acute echocardiogram in 25%. Nearly all patients received therapeutic anticoagulation, with initial systemic tissue plasminogen activator administered in 16% for occlusive iliofemoral deep venous thrombosis and/or massive pulmonary embolism. Pulmonary embolism resolution was observed in 82% by 6 months. Recurrent pulmonary embolism occurred in 9%. There were no pulmonary embolism-related deaths. Right ventricular dysfunction was rare in follow-up. These data indicate that acute heart strain is common, but chronic cardiac dysfunction is rare, following aggressive management of acute pulmonary embolism in children.
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99
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Abstract
Pulmonary thromboembolism (PTE) is rare in neonates and infants; however evidence suggests it is underdiagnosed. The primary objective is to conduct a scientific review to determine if the presentation, diagnosis, treatment and outcomes of neonates and infants with PTE are consistent across studies. Secondly, to develop an algorithm to establish the diagnosis and management of the condition based on current information. Two authors searched the literature independently using existing databases and verified that identical articles were assembled. Infants aged less than 1 year with PTE were included and further categorized into neonates 28 days or less and infants 29 days to 1 year or less. Forty-five articles with 157 cases (121 neonates; 36 infants) were identified with PTE. All of the reports were descriptive and neither randomized controlled trials nor prospective or case-control studies were identified. The reports are sub-classified into cases of pulmonary air embolism (PAE) with a higher mortality rate and patients with PTE. Diagnostic and treatment strategies varied widely and were individually case-based, dependent on clinical findings, which influenced patient outcomes. Scientific data to guide an evidence-based, diagnostic and treatment approach to PTE is limited because of the absence of rigorous clinical trials. Large scale, multicenter collaborative studies are required to firmly establish the management of PTE in this population.
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100
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Sing AC, Webb JL, Low DW, Chen AE. Pulmonary emboli associated with isolated lower-extremity venous malformation: a case report. Pediatr Emerg Care 2013; 29:371-3. [PMID: 23462395 DOI: 10.1097/pec.0b013e31828547a9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pulmonary thromboembolism is a relatively rare entity in the pediatric population; however, it should always be part of the differential diagnosis in patients with the appropriate clinical presentation. We report the case of a 13-year-old girl with a history of a lower-extremity venous malformation status post sclerotherapy 2 years prior but otherwise healthy who presented with painless hemoptysis. She was found to have multiple bilateral pulmonary emboli on computed tomographic angiography of the chest. Magnetic resonance venography of the lower extremities showed stable venous changes from prior studies and no obvious source of emboli. She was started on anticoagulation and was discharged home.
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Affiliation(s)
- Alan C Sing
- Department of Pediatrics, The Children's Hospital of Philadelphia, PA 19104, USA.
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