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Kumar R, Sun LR, Rodriguez V, Sankar A, Sharma M, Meoded A, Brandão LR, Goldenberg NA. Hemostatic and Thrombotic Considerations in the Diagnosis and Management of Childhood Arterial Ischemic Stroke: A Narrative Review. Semin Pediatr Neurol 2022; 43:101003. [PMID: 36344025 DOI: 10.1016/j.spen.2022.101003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
Although rare in children, arterial ischemic stroke (AIS) is associated with increased mortality and neurological morbidity. The incidence of AIS after the neonatal period is approximately 1-2/100,000/year, with an estimated mortality of 3-7%. A significant proportion of children surviving AIS experience life-long neurological deficits including hemiparesis, epilepsy, and cognitive delays. The low incidence of childhood AIS coupled with atypical clinical-presentation and lack of awareness contribute to delay in diagnosis and consequently, the early initiation of treatment. While randomized-clinical trials have demonstrated the efficacy and safety of reperfusion therapies including thrombolysis and endovascular thrombectomy in appropriately-selected adult patients, similar data for children are unavailable. Consequently, clinical decisions surrounding reperfusion therapy in childhood AIS are either extrapolated from adult data or based on local experience. The etiology of childhood AIS is multifactorial, often occurring in the setting of both acquired and congenital risk-factors including thrombophilia. While multiple studies have investigated the association of thrombophilia with incident childhood AIS, its impact on stroke recurrence and therefore duration and intensity of antithrombotic therapy is less clear. Despite these limitations, a significant progress has been made over the last decade in the management of childhood AIS. This progress can be attributed to international consortiums, and in selected cohorts to federally-funded clinical trials. In this narrative review, the authors have systematically appraised the literature and summarize the hemostatic and thrombotic considerations in the diagnosis and management of childhood AIS focusing on the evidence supporting reperfusion therapies, relevance of thrombophilia testing, and duration and drug choices for secondary-prophylaxis.
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Affiliation(s)
- Riten Kumar
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Lisa R Sun
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD; Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Amanda Sankar
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Mukta Sharma
- Division of Hematology, Children's Mercy Hospital, Kansas City, MO
| | - Avner Meoded
- Edward B. Singleton, Department of Radiology, Texas Children's Hospital, Houston, TX
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON; Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL; Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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102
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Prophylactic Enoxaparin Against Catheter-Associated Thrombosis in Postoperative Cardiac Children: An Interrupted Time Series Analysis. Pediatr Crit Care Med 2022; 23:774-783. [PMID: 35699766 DOI: 10.1097/pcc.0000000000003010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The effectiveness of pharmacologic prophylaxis against catheter-associated thrombosis in children is unclear. We evaluated the compliance and outcomes associated with a prophylactic enoxaparin protocol in postoperative cardiac children. DESIGN The protocol was implemented as a quality improvement initiative and then analyzed using interrupted time series method. Data collected from November 2014 to December 2018 were divided into preprotocol (period 1), protocol implementation (period 2), and protocol revision (period 3). SETTING A 12-bed academic pediatric cardiac ICU. PATIENTS Children less than or equal to 18 years old with congenital heart disease admitted postoperatively with central venous catheter in situ for greater than or equal to 1 day. INTERVENTIONS Before 2016, prophylactic enoxaparin was administered according to physician preference. In January 2016, an enoxaparin protocol was implemented with a goal anti-Xa range of 0.25-0.49 international units/mL. Protocol was revised in February 2017 to increase the starting dose by 25% for infants less than 1 year old. MEASUREMENTS AND MAIN RESULTS We analyzed 780 hospitalizations from 636 children. Median percentage of catheter-days on prophylactic enoxaparin was 33% (interquartile range [IQR], 23-47%), 42% (IQR, 30-51%), and 38% (IQR, 35-52%) in periods 1-3, respectively. Percentage of catheter-days on enoxaparin showed immediate increase of 90% (95% CI, 17-210%) between periods 1 and 2 and sustained increase of 2% (95% CI, 0.3-4%) between periods 2 and 3. Median rates of thrombosis per 1,000 catheter-days were 5.8 (IQR, 0-9.3), 3.8 (IQR, 0-12), and 0 (IQR, 0-5.3) in periods 1-3, respectively. Rate of thrombosis showed immediate decrease of 67% (95% CI, 12-87%) between periods 1 and 2 and sustained decrease of 11% (95% CI, 2-18%) between periods 1 and 3. CONCLUSIONS The temporal association between increase in percentage of catheter-days on enoxaparin and decrease in rate of thrombosis suggests the effectiveness of prophylactic enoxaparin.
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103
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Sheikh IN, Srivaths L, Li E, Steinberg-Shemer O, Mandel-Shorer N, Kenet G, Barg AA. Cerebral sinus venous thrombosis in children with inherited bleeding disorders: A case series. Pediatr Blood Cancer 2022; 69:e29902. [PMID: 35880957 DOI: 10.1002/pbc.29902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/10/2022]
Abstract
In patients with inherited bleeding disorders, thrombus development poses a challenge in balancing the management of thrombosis and bleeding. Pediatric antithrombotic therapy guidelines do not address the treatment of a thrombus in the setting of a bleeding disorder. We present a case series of four children with inherited bleeding disorders presenting with cerebral sinus venous thrombosis and bleeding, in order to summarize the different therapeutic approaches and outcomes of these patients.
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Affiliation(s)
- Irtiza N Sheikh
- Division of Pediatrics and Patient Care, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lakshmi Srivaths
- Division of Hematology, Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Houston, Texas, USA.,Gulf States Hemophilia & Thrombophilia Center, Texas Medical Center, Houston, Texas, USA
| | - Emma Li
- Gulf States Hemophilia & Thrombophilia Center, Texas Medical Center, Houston, Texas, USA.,Division of Medical Genetics, Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston), Houston, Texas, USA
| | - Orna Steinberg-Shemer
- Hematology Unit, Department of Pediatric Hematology Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Mandel-Shorer
- Department of Pediatric Hematology-Oncology, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Gili Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit, and The Amalia Biron Thrombosis Research Institute, Sheba Medical Center, Tel HaShomer, Israel
| | - Assaf A Barg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Israeli National Hemophilia Center and Thrombosis Unit, and The Amalia Biron Thrombosis Research Institute, Sheba Medical Center, Tel HaShomer, Israel
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104
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Case Report of a Massive Life-threatening Neonatal Thrombosis Treated With a Targeted, Goal-oriented Scheme of Urokinase. J Pediatr Hematol Oncol 2022; 44:405-408. [PMID: 35129145 DOI: 10.1097/mph.0000000000002410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/31/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Thrombotic events are severe, often under-diagnosed, complications occurring in newborn infants during their hospital stay. Currently, there is no consensus regarding the optimal treatment scheme for thrombolysis in neonates. OBSERVATIONS We present the case of a newborn suffering from a life-threatening thrombosis. Diagnosis was suggested by a gradual increase of C-reactive protein, with repeatedly normal procalcitonin. Thrombosis was successfully and safely treated with a long scheme of 21 days of urokinase, supported by vascular ultrasound and d-dimer trend. CONCLUSIONS Laboratory and ultrasound results may help in adjusting the duration of the thrombolytic treatment, allowing for longer therapeutic schemes that could optimize treatment success. In addition, our case may suggest a possible combined role of C-reactive protein and procalcitonin as an early diagnostic aid in neonatal thrombosis.
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105
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Abrams CM, Jaffray J, Stillings A, Branchford B, Young G, Goldenberg NA, Abajas YL. Current practices in pediatric hospital-acquired thromboembolism: Survey of the Children's Hospital Acquired Thrombosis (CHAT) Consortium. Res Pract Thromb Haemost 2022; 6:e12793. [PMID: 38024326 PMCID: PMC10656282 DOI: 10.1002/rth2.12793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/03/2022] [Indexed: 11/05/2022] Open
Abstract
Background A rise in hospital-acquired venous thromboembolism (HA-VTE) in children has led to increased awareness regarding VTE prophylaxis and risk assessment. Despite no consensus exists regarding these practices in pediatrics. Objective To describe common practices in VTE prophylaxis, VTE risk assessment models, and anticoagulation dosing strategies in pediatric hospitals that are members of the Children's Hospital Acquired Thrombosis (CHAT) Consortium. Methods An electronic survey of 44 questions evaluating practices surrounding pediatric HA-VTE risk assessment and prevention was distributed between August 9, 2021, and August 30, 2021, to the primary investigators from the 32 institutions within the CHAT Consortium. Results The survey response rate was 100% (n = 32). In total, 85% (n = 27) of the institutions assess HA-VTE, but only 63% (n = 20) have formal hospital guidelines. Within the institutions with formal guidelines, 100% (n = 20) include acute systemic inflammation or infection and presence of a central venous catheter (CVC) as risk factors for VTE. Pharmacologic prophylaxis is prescribed at 87% (28) of institutions, with enoxaparin being the most frequent (96%, n = 27). Variability in responses persisted regarding risk factors, risk assessment, thromboprophylaxis, dosing of prophylactic anticoagulation or anticoagulant drug monitoring. A majority of providers were comfortable providing thromboprophylaxis across all age groups. In addition, the global coronavirus disease 2019 increased the providers' use of prophylactic anticoagulation 78% (n = 25). Conclusion Practices among institutions are variable in regard to use of HA-VTE prophylaxis, risk assessment, or guideline implementation, highlighting the need for further research and a validated risk assessment model through groups like the CHAT Consortium.
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Affiliation(s)
- Christina M. Abrams
- Division of Hematology/Oncology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Julie Jaffray
- Division of Hematology, Oncology, and Bone Marrow Transplant, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Amy Stillings
- Division of Hematology, Oncology, and Bone Marrow Transplant, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Brian R. Branchford
- Versiti Medical Sciences Institute, Milwaukee, Wisconsin, USA
- Children's Wisconsin Hospital, Wauwatosa, Wisconsin, USA
| | - Guy Young
- Division of Hematology, Oncology, and Bone Marrow Transplant, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Neil A. Goldenberg
- Johns Hopkins University School of Medicine, Departments of Pediatrics and Medicine, Baltimore, Maryland, USA
| | - Yasmina L. Abajas
- Hemophilia and Thrombosis Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - for the CHAT Consortium Investigators
- Division of Hematology/Oncology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Hematology, Oncology, and Bone Marrow Transplant, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Versiti Medical Sciences Institute, Milwaukee, Wisconsin, USA
- Children's Wisconsin Hospital, Wauwatosa, Wisconsin, USA
- Johns Hopkins University School of Medicine, Departments of Pediatrics and Medicine, Baltimore, Maryland, USA
- Hemophilia and Thrombosis Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - the VTE Risk Factors and Thromboprophylaxis Working Group of the Pediatric and Neonatal Thrombosis and Hemostasis Subcommittee of the ISTH SSC
- Division of Hematology/Oncology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Hematology, Oncology, and Bone Marrow Transplant, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Versiti Medical Sciences Institute, Milwaukee, Wisconsin, USA
- Children's Wisconsin Hospital, Wauwatosa, Wisconsin, USA
- Johns Hopkins University School of Medicine, Departments of Pediatrics and Medicine, Baltimore, Maryland, USA
- Hemophilia and Thrombosis Center, University of North Carolina, Chapel Hill, North Carolina, USA
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106
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Lemoine CP, Brandt KA, Mohammad S, Bhat R, Superina R. Early thrombotic and hemorrhagic complications associated with a risk-adjusted postoperative anticoagulation protocol after pediatric liver transplantation. Pediatr Blood Cancer 2022; 69:e29898. [PMID: 35906750 DOI: 10.1002/pbc.29898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/28/2022] [Accepted: 06/30/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Systemic anticoagulation after pediatric liver transplantation (pLT) is believed to reduce the incidence of vascular thrombosis, but it may also cause an increase in hemorrhagic complications. PROCEDURE A 5-year retrospective review of pLT done at our institution was performed (2014-2018). The occurrence of early hemorrhagic and thrombotic complications was compared when using low-dose or high-dose anticoagulation after transplant (p < .05 considered significant). RESULTS Sixty-nine patients received 73 transplants during the study period. Median age at transplant was 2.3 years (40 days to 18.5 years). Low-dose anticoagulation was utilized in 71% cases. Additionally, six patients were converted from low-dose to high-dose anticoagulation because of a thrombotic event or concerns for suboptimal vascular inflow. Postoperative anticoagulation was discontinued in 18 occurrences due to bleeding (low dose 19%, high dose 47% vs. low dose to high dose 17%, p = .085). Surgical take back for bleeding occurred in 17 occasions (low dose 13.5%, high dose 53% vs. low dose to high dose 33%, p = .005). The overall incidence of hepatic artery thrombosis (HAT) and portal vein thrombosis were each 5.5%, respectively. While patient survival was not statistically different between groups, graft survival was significantly lower in the high-dose group (low dose 93%, high dose 73% vs. low dose to high dose 100%, p = .046). However, graft losses from HAT were similar between groups (low dose 2%, high dose 7% vs. low dose to high dose 0%, p = .56). CONCLUSION The use of a standardized risk-adjusted anticoagulation protocol after pLT is associated with a low occurrence of thrombotic and hemorrhagic complications. High-dose anticoagulation leads to more bleeding, but those risks outweigh the risks of possible graft loss.
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Affiliation(s)
- Caroline P Lemoine
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Katherine A Brandt
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Saeed Mohammad
- Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Rukhmi Bhat
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Riccardo Superina
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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107
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Childhood nephrotic syndrome and the clinical profile of thromboembolism: a systematic review and meta-analysis. Pediatr Res 2022; 93:1463-1469. [PMID: 36127405 DOI: 10.1038/s41390-022-02302-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 07/26/2022] [Accepted: 08/25/2022] [Indexed: 11/08/2022]
Abstract
Nephrotic syndrome (NS) is a common kidney disease of childhood, affecting 2-7 children per 100,000. A potentially life-threatening complication affecting children with NS is thromboembolism (TE). However, there remains a paucity of information regarding the burden of TE and its associated risk factors in this population. A systematic review was performed on observational studies examining TE events in children with NS, published in Medline, Embase, CINAHL, and CENTRAL, until May 2021. Meta-analyses were separately conducted on the prevalence of TE within articles exclusively studying children with congenital NS and among articles including all forms of NS. Out of 13,626 articles, 22 were included (14,290 children). The pooled prevalence of symptomatic TE among articles including patients with all forms of NS was 3.60% (95% CI 1.95-5.63), which increased to 8.70% (95% CI 5.11-12.96) in articles with exclusively congenital NS patients. Children with steroid-resistant NS were at a higher risk of TE compared to steroid-sensitive children (OR 4.40, 95% CI 1.34-15.59, p = 0.013). Focal segmental glomerulosclerosis was the most common histology present in patients with TE (51.2%). Children diagnosed with NS have a significant risk of TE, particularly in patients with congenital NS and steroid resistance. IMPACT: The prevalence of symptomatic thromboembolic (TE) events in children with nephrotic syndrome (NS) was 3.60% (95% CI 1.95-5.63), which increased more than two-fold in children with congenital NS to 8.70% (95% CI 5.11-12.96). Potential risk factors for TE events in this population include congenital forms of NS and steroid resistance. This review provides a better estimate of the prevalence of TE in children with NS, while identifying potentially higher-risk populations who may benefit from TE screening and thromboprophylaxis.
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108
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Direct oral anticoagulants versus standard anticoagulation in children treated for acute venous thromboembolism. Pediatr Res 2022; 93:1491-1498. [PMID: 36071237 DOI: 10.1038/s41390-022-02294-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/07/2022] [Accepted: 08/18/2022] [Indexed: 11/09/2022]
Abstract
Direct oral anticoagulants (DOACs) are widely used to treat venous thromboembolism (VTE) in adults. Little attention is given to pediatric VTE (PVTE). The objective of this study is to study the efficacy and safety of DOACs in published PVTE randomized control trials (RCTs). PubMed, Embase, China National Knowledge Infrastructure, the Cochrane Library, SinoMed, and ClinicalTrials.gov were searched until 2021, to identify RCTs that enrolled patients with VTE <18 years of age who received DOACs versus standard anticoagulation. Outcomes were evaluated using the Mantel-Haenszel method of random-effects model. Our study evaluated seven RCTs that included 1139 cases of PVTE, which had a low risk of publication and assessment bias. Compared with standard anticoagulation, patients receiving DOACs presented a lower rate of recurrent VTE (relative risk [RR], 0.42 [confidence interval {CI}, 0.20 to 0.89]), similar mortality rate (RR, 0.50 [CI, 0.07 to 3.57]), major bleeding (RR, 0.46 [CI, 0.14 to 1.57]), and higher clinically relevant nonmajor bleeding (RR, 2.71 [CI, 1.05 to 7.02]) with low heterogeneity. Limiting to subgroups, dabigatran and rivaroxaban yielded similar findings, except for a higher incidence of nonmajor bleeding during rivaroxaban use. DOACs could be an alternative to standard anticoagulation in PVTE. Dabigatran and rivaroxaban have similar effects. IMPACT: In venous thromboembolism (VTE), direct oral anticoagulants (DOACs) are widely used as a substitution for standard anticoagulation in most situations for adults; however, little attention is paid to the pediatric population. For pediatric VTE, previous meta-analyses have emphasized the epidemiology, risk factors, and the use of traditional anticoagulants, and seldom reported the use of novel oral anticoagulants. This is the first meta-analysis of randomized controlled trials that focuses on the efficacy outcomes and safety endpoints of DOACs compared with standard anticoagulation in pediatric VTE.
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109
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Prodhan P, Steiner M, Greiten LE. Systemic-to-Pulmonary Artery Shunt Thromboprophylaxis: Searching for the Holy Grail. Pediatr Crit Care Med 2022; 23:757-759. [PMID: 36053038 DOI: 10.1097/pcc.0000000000003034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Parthak Prodhan
- Pediatric Cardiology/Pediatric Critical Care, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Marie Steiner
- Pediatric Cardiothoracic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Lawrence E Greiten
- Pediatric Critical Care/Pediatric Hematology-Oncology, University of Minnesota, Minneapolis, MN
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110
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Tran NTT, Cuong TC, Thang LM, Giang NL, Tuan NM, Huy NDN, Linh DH, Muong MV, Duc NM. A rare case of fusiform basilar trunk aneurysm. Radiol Case Rep 2022; 17:3256-3259. [PMID: 35818454 PMCID: PMC9270206 DOI: 10.1016/j.radcr.2022.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 06/12/2022] [Indexed: 11/29/2022] Open
Abstract
Aneurysms in the posterior circulation and distal sites are more common among the pediatric population than among adults, with a male predominance. Symptoms of an aneurysm in the posterior circulation can include a stiff neck or severe headache due to a ruptured aneurysm, whereas an unruptured aneurysm can cause mass effects or neurological deficits. However, in children, the complete occlusion of the aneurysm while preserving the flow of the main artery can be difficult to achieve when attempting a stent-assisted coil embolization technique. A 25-month-old girl presented with left hemiparesis and was diagnosed with a basilar artery aneurysm 10 months prior, but she did not receive any specific treatment. No history of trauma and no significant familial history were recorded. Angiography showed a fusiform aneurysm on the basilar artery trunk, which was successfully occluded using stent-assisted coiling following dual antiplatelet therapy with clopidogrel and aspirin. She was discharged with the complete restoration of motor deficits.
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Affiliation(s)
| | - Tran Chi Cuong
- Digital Subtraction Angiography Unit, Can Tho S.I.S General Hospital, Can Tho, Vietnam
| | - Le Minh Thang
- Digital Subtraction Angiography Unit, Can Tho S.I.S General Hospital, Can Tho, Vietnam
| | - Nguyen-Luu Giang
- Digital Subtraction Angiography Unit, Can Tho S.I.S General Hospital, Can Tho, Vietnam
| | - Ngo Minh Tuan
- Digital Subtraction Angiography Unit, Can Tho S.I.S General Hospital, Can Tho, Vietnam
| | - Nguyen-Dao Nhat Huy
- Digital Subtraction Angiography Unit, Can Tho S.I.S General Hospital, Can Tho, Vietnam
| | - Duong Hoang Linh
- Digital Subtraction Angiography Unit, Can Tho S.I.S General Hospital, Can Tho, Vietnam
| | - Mai-Van Muong
- Digital Subtraction Angiography Unit, Can Tho S.I.S General Hospital, Can Tho, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
- Corresponding author.
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111
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Galura G, Said SJ, Shah PA, Hissong AM, Chokshi NK, Fauman KR, Rose R, Bondi DS. Comparison of Extracorporeal Life Support Anticoagulation Using Activated Clotting Time Only to a Multimodal Approach in Pediatric Patients. J Pediatr Pharmacol Ther 2022; 27:517-523. [PMID: 36042956 PMCID: PMC9400190 DOI: 10.5863/1551-6776-27.6.517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/03/2021] [Indexed: 01/04/2024]
Abstract
OBJECTIVE To evaluate an institutional practice change from an extracorporeal life support (ECLS) anticoagulation monitoring strategy of activated clotting time (ACT) alone to a multimodal strategy including ACT, activated partial thrombin time, heparin anti-factor-Xa, and thromboelastography. METHODS This was a retrospective review of patients younger than 18 years on ECLS and heparin between January 2014 and June 2020 at a single institution. RESULTS Twenty-seven patients used an ACT-directed strategy and 25 used a multimodal strategy. The ACT-directed group was on ECLS for a shorter median duration than the multimodal group (136 versus 164 hours; p = 0.046). There was a non-significant increase in major hemorrhage (85.1% versus 60%; p = 0.061) and a significantly higher incidence of central nervous system (CNS) hemorrhage in the ACT-directed group (29.6% versus 0%; p = 0.004). Rates of thrombosis were similar, with a median of 3 circuit changes per group (p = 0.921). The ACT-directed group had larger median heparin doses (55 versus 34 units/kg/hr; p < 0.001), required more dose adjustments per day (3.8 versus 1.7; p < 0.001), and had higher rates of heparin doses >50 units/kg/hr (62.9% versus 16%; p = 0.001). More anticoagulation parameters were supratherapeutic (p = 0.015) and fewer were therapeutic (p < 0.001) in the ACT-directed group. CONCLUSIONS Patients with a multimodal strategy for monitoring anticoagulation during ECLS had lower rates of CNS hemorrhage and decreased need for large heparin doses of >50 units/kg/hr without an increase in clotting complications, compared with ACT-directed anticoagulation. Multimodal anticoagulation monitoring appears superior to ACT-only strategies and may reduce heparin exposure and risk of hemorrhagic complications for pediatric patients on ECLS.
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Affiliation(s)
- Genevra Galura
- Department of Pharmacy (GG, SJS, PAS, AMH, DSB), University of Chicago Medicine, Chicago, IL
| | - Sana J. Said
- Department of Pharmacy (GG, SJS, PAS, AMH, DSB), University of Chicago Medicine, Chicago, IL
| | - Pooja A. Shah
- Department of Pharmacy (GG, SJS, PAS, AMH, DSB), University of Chicago Medicine, Chicago, IL
| | - Alexandria M. Hissong
- Department of Pharmacy (GG, SJS, PAS, AMH, DSB), University of Chicago Medicine, Chicago, IL
| | - Nikunj K. Chokshi
- Section of Pediatric Surgery (NKC), Department of Surgery, University of Chicago, Chicago, IL
| | - Karen R. Fauman
- Section of Pediatric Critical Care (KRF), Department of Pediatrics, University of Chicago, Chicago, IL
| | - Rebecca Rose
- Department of Cardiac Surgery (RR), University of Chicago Medicine, Chicago, IL
| | - Deborah S. Bondi
- Department of Pharmacy (GG, SJS, PAS, AMH, DSB), University of Chicago Medicine, Chicago, IL
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112
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O'Brien SH, Zia A. Hemostatic and thrombotic disorders in the pediatric patient. Blood 2022; 140:533-541. [PMID: 34724564 DOI: 10.1182/blood.2020006477] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/14/2021] [Indexed: 11/20/2022] Open
Abstract
This review focuses on significant advances in the field of pediatric hemostasis and thrombosis, with a focus on published studies within the past decade. The evaluation and management of patients with excessive bleeding remain cornerstones of consultative hematology. We will describe the development of validated bleeding assessment tools relevant to pediatric practice, laboratory advances in the evaluation of von Willebrand disease, and a shift in clinical practice regarding the interpretation of normal coagulation studies in patients with significant bleeding phenotypes. There have also been critical advances in the management of hemostatic disorders. This review highlights new treatment paradigms in hemophilia and the rise of multidisciplinary medical homes for women living with bleeding disorders. Given the continued increase in the incidence of thrombosis, particularly in the hospital setting, a full call to arms against pediatric venous thromboembolism is now essential. We will describe recently completed clinical trials of direct oral anticoagulants in children and adolescents and ongoing work to elucidate the appropriate duration of therapy for children with provoked thrombosis. Recent work regarding the prevention of pediatric venous thromboembolism is highlighted, including studies of thromboprophylaxis and the development of risk prediction models for hospital-acquired thrombosis. Finally, we review advances in our understanding of thrombotic sequelae and the need for continued refinement of our evaluation tools. Despite the significant advances in pediatric hemostasis and thrombosis over the past decade, many unanswered questions remain for the next generation of investigators.
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Affiliation(s)
- Sarah H O'Brien
- Division of Pediatric Hematology/Oncology and
- Department of Pediatrics, The Ohio State University, Columbus, OH
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH; and
| | - Ayesha Zia
- Division of Pediatric Hematology/Oncology and
- University of Texas Southwestern Medical Center, Dallas, TX
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113
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Neonatal Cerebral Sinovenous Thrombosis and the Main Perinatal Risk Factors—A Retrospective Unicentric Study. CHILDREN 2022; 9:children9081182. [PMID: 36010072 PMCID: PMC9406898 DOI: 10.3390/children9081182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 11/17/2022]
Abstract
(1) Background: Neonatal cerebral sinovenous thrombosis (CSVT) is a rare disorder, associated with long-term neurological sequelae. The aim of this study was to retrospectively evaluate the most commonly encountered perinatal risk factors for this disease in a cohort of newborns from Romania. (2) Methods: The medical records of neonatal CSVT patients treated between January 2017 and December 2021 were descriptively assessed. (3) Results: The study included nine neonates, five males (55.56%) and four females (44.44%), who were born at term. The most commonly presented clinical manifestations were feeding difficulties, lethargy, respiratory distress, loss of consciousness, and seizures. Maternal-inherited thrombophilia, male sex, complicated delivery, perinatal asphyxia, and mechanical ventilation were frequently identified as potential risk factors for developing CSVT. The lesions were more frequently localized in the superior sagittal sinus (n = 7; 77.78%), followed by the transverse (n = 4; 44.44%), sigmoid (n = 2; 22.22%), and cavernous (n = 1; 11.11%) sinuses. Low-molecular-weight heparin was administered to all patients, and two of them died from thrombotic complications. (4) Conclusions: Recognition of potential risk factors and a prompt diagnosis of neonatal CSVT could lead to better patient management and to a reduction of severe complications.
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114
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Gerhart JG, Carreño FO, Loop MS, Lee CR, Edginton AN, Sinha J, Kumar KR, Kirkpatrick CM, Hornik CP, Gonzalez D. Use of Real-World Data and Physiologically-Based Pharmacokinetic Modeling to Characterize Enoxaparin Disposition in Children With Obesity. Clin Pharmacol Ther 2022; 112:391-403. [PMID: 35451072 PMCID: PMC9504927 DOI: 10.1002/cpt.2618] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/13/2022] [Indexed: 01/02/2023]
Abstract
Dosing guidance for children with obesity is often unknown despite the fact that nearly 20% of US children are classified as obese. Enoxaparin, a commonly prescribed low-molecular-weight heparin, is dosed based on body weight irrespective of obesity status to achieve maximum concentration within a narrow therapeutic or prophylactic target range. However, whether children with and without obesity experience equivalent enoxaparin exposure remains unclear. To address this clinical question, 2,825 anti-activated factor X (anti-Xa) surrogate concentrations were collected from the electronic health records of 596 children, including those with obesity. Using linear mixed-effects regression models, we observed that 4-hour anti-Xa concentrations were statistically significantly different in children with and without obesity, even for children with the same absolute dose (P = 0.004). To further mechanistically explore obesity-associated differences in anti-Xa concentration, a pediatric physiologically-based pharmacokinetic (PBPK) model was developed in adults, and then scaled to children with and without obesity. This PBPK model incorporated binding of enoxaparin to antithrombin to form anti-Xa and elimination via heparinase-mediated metabolism and glomerular filtration. Following scaling, the PBPK model predicted real-world pediatric concentrations well, with an average fold error (standard deviation of the fold error) of 0.82 (0.23) and 0.87 (0.26) in children with and without obesity, respectively. PBPK model simulations revealed that children with obesity have at most 20% higher 4-hour anti-Xa concentrations under recommended, total body weight-based dosing compared to children without obesity owing to reduced weight-normalized clearance. Enoxaparin exposure was better matched across age groups and obesity status using fat-free mass weight-based dosing.
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Affiliation(s)
- Jacqueline G. Gerhart
- Division of Pharmacotherapy and Experimental TherapeuticsUniversity of North Carolina Eshelman School of PharmacyThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Fernando O. Carreño
- Division of Pharmacotherapy and Experimental TherapeuticsUniversity of North Carolina Eshelman School of PharmacyThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Matthew Shane Loop
- Division of Pharmacotherapy and Experimental TherapeuticsUniversity of North Carolina Eshelman School of PharmacyThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental TherapeuticsUniversity of North Carolina Eshelman School of PharmacyThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Jaydeep Sinha
- Division of Pharmacotherapy and Experimental TherapeuticsUniversity of North Carolina Eshelman School of PharmacyThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Department of PediatricsUniversity of North Carolina School of MedicineThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Karan R. Kumar
- Duke Clinical Research InstituteDurhamNorth CarolinaUSA
- Department of PediatricsDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Carl M. Kirkpatrick
- Centre for Medicine Use and SafetyMonash UniversityMelbourneVictoriaAustralia
| | - Christoph P. Hornik
- Duke Clinical Research InstituteDurhamNorth CarolinaUSA
- Department of PediatricsDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental TherapeuticsUniversity of North Carolina Eshelman School of PharmacyThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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115
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Hartman LR, Nurmeev I, Svirin P, Wolter KD, Yan JL, Jani D, Goldenberg NA, Sherman N. A phase 2 pharmacodynamic dose-finding, safety, and efficacy study of dalteparin for pediatric venous thromboembolism treatment in children with and without cancer. Pediatr Blood Cancer 2022; 69:e29764. [PMID: 35678616 DOI: 10.1002/pbc.29764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 03/09/2022] [Accepted: 04/03/2022] [Indexed: 11/11/2022]
Abstract
Data from registrational trials of pediatric venous thromboembolism (VTE) treatment are sparse, especially among cancer patients. We conducted a prospective, multicenter, open-label trial (NCT00952380) on dose-finding, safety, and efficacy (measured by 90-day risks of clinically relevant bleeding [CRB] and symptomatic recurrent VTE [srVTE]) of twice-daily subcutaneous dalteparin for acute VTE treatment in patients ≤18 years old. Among 38 patients (cancer, n = 26; noncancer, n = 12), median dalteparin dose requirements per kilogram varied with age but not cancer status. Risks of CRB and srVTE were <4% in cancer and noncancer subgroups. Dalteparin is an important FDA-approved treatment for pediatric VTE, particularly with cancer.
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Affiliation(s)
| | | | - Pavel Svirin
- Municipal Center of Hemophilia Therapy for Children and Adolescents, Municipal Health Children's Hospital Morozovskaya, Moscow, Russia
| | | | | | | | - Neil A Goldenberg
- Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Johns Hopkins All Children's Cancer and Blood Disorders Institute, Heart Institute, and Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
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116
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Athale UH, Flamand Y, Blonquist T, Stevenson KE, Spira M, Asselin BL, Clavell LA, Cole PD, Kelly KM, Laverdiere C, Leclerc JM, Michon B, Schorin MA, Welch JJG, Harris MH, Neuberg DS, Sallan SE, Silverman LB. Predictors of thrombosis in children receiving therapy for acute lymphoblastic leukemia: Results from Dana-Farber Cancer Institute ALL Consortium trial 05-001. Pediatr Blood Cancer 2022; 69:e29581. [PMID: 35316569 DOI: 10.1002/pbc.29581] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/20/2021] [Accepted: 01/06/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND/OBJECTIVES Although thromboembolism (TE) is a serious complication in patients with acute lymphoblastic leukemia (ALL), thromboprophylaxis is not commonly used due to the inherent bleeding risk in this population. Identifying prothrombotic risk factors will help target thromboprophylaxis to those at highest thrombotic risk. We aimed to define predictors and the impact of TE on ALL outcome in children (1-18 years) treated on the Dana-Farber Cancer Institute ALL 05-001 trial. METHODS Clinical and laboratory data including TE events were prospectively collected. PCR-based allelic discrimination assay identified single-nucleotide polymorphisms (SNP) for prothrombin G20210A (rs1799963) and Factor V G1691A (rs6025). Univariate and multivariable competing risk regression models evaluated the effect of diagnostic clinical (age, sex, body mass index, ALL-immunophenotype, risk group) and laboratory variables (presenting leukocyte count, blood group, SNPs) on the cumulative incidence of TE. Cox regression modeling explored the impact of TE on survival. RESULTS Of 794 patients [median age 4.97 (range, 1.04-17.96) years; males 441], 100 developed TE; 25-month cumulative incidence 13.0% (95% CI, 10.7%-15.5%). Univariate analyses identified older age (≥10 years), presenting leucocyte count, T-ALL, high-risk ALL, and non-O blood group as risk factors. Age and non-O blood group were independent predictors of TE on multivariable regression; the blood group impact being most evident in patients 1-5 years of age (P = 0.011). TE did not impact survival. Induction TE was independently associated with induction failure (OR 6.45; 95% CI, 1.64-25.47; P = 0.008). CONCLUSION We recommend further evaluation of these risk factors and consideration of thromboprophylaxis for patients ≥10 years (especially those ≥15 years) when receiving asparaginase.
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Affiliation(s)
- Uma H Athale
- Division of Hematology/Oncology, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Yael Flamand
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Traci Blonquist
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kristen E Stevenson
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Menachem Spira
- Department of Pediatrics, New York-Presbyterian Hospital, New York, New York
| | - Barbara L Asselin
- Department of Pediatrics, University of Rochester Medical Center and School of Medicine, Rochester, New York
| | | | - Peter D Cole
- Division of Pediatric Hematology/Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Kara M Kelly
- Roswell Park Comprehensive Cancer Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Caroline Laverdiere
- Hematology-Oncology Division, Charles Bruneau Cancer Center, Sainte-Justine University Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Jean-Marie Leclerc
- Hematology-Oncology Division, Charles Bruneau Cancer Center, Sainte-Justine University Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Bruno Michon
- Centre Hospitalier Universitaire de Quebec, Sainte-Foy, Quebec, Canada
| | | | - Jennifer J G Welch
- Pediatric Hematology Oncology, Hasbro Children's Hospital/Brown University, Providence, Rhode Island
| | - Marian H Harris
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts
| | - Donna S Neuberg
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Stephen E Sallan
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, Massachusetts
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117
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Willmann S, Ince I, Ahsman M, Coboeken K, Zhang Y, Thelen K, Kubitza D, Zannikos P, Zhou W, Pina LM, Post T, Lippert J. Model‐informed bridging of rivaroxaban doses for thromboprophylaxis in pediatric patients aged 9 years and older with congenital heart disease. CPT Pharmacometrics Syst Pharmacol 2022; 11:1111-1121. [PMID: 35665486 PMCID: PMC9381895 DOI: 10.1002/psp4.12830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/09/2022] [Accepted: 05/23/2022] [Indexed: 12/04/2022] Open
Abstract
Rivaroxaban is approved in various regions for the treatment of acute venous thromboembolism (VTE) in children aged between 0 and 18 years and was recently investigated for thromboprophylaxis in children aged between 2 and 8 years (with body weights <30 kg) with congenital heart disease who had undergone the Fontan procedure. In the absence of clinical data, rivaroxaban doses for thromboprophylaxis in post‐Fontan children aged 9 years and older or ≥30 kg were derived by a bridging approach that used physiologically‐based pharmacokinetic (PBPK) and population pharmacokinetic (popPK) models based on pharmacokinetic (PK) data from 588 pediatric patients and from adult patients who received 10 mg once daily for thromboprophylaxis after major orthopedic surgeries as a reference. Both models showed a tendency toward underestimating rivaroxaban exposure in post‐Fontan patients aged between 2 and 5 years but accurately described rivaroxaban PK in post‐Fontan patients aged between 5 and 8 years. Under the assumption that hepatic function is not impaired in post‐Fontan patients, PBPK and popPK simulations indicated that half of the rivaroxaban doses for the same body weight given to pediatric patients treated for acute VTE would yield in pediatric post‐Fontan patients exposures similar to the exposure observed in adult patients receiving 10 mg rivaroxaban once daily for thromboprophylaxis. Simulation‐derived doses (7.5 mg rivaroxaban once daily for body weights 30–<50 kg and 10 mg once daily for body weights ≥50 kg) were therefore included in the recent US label of rivaroxaban for thromboprophylaxis in children aged 2 years and older with congenital heart disease who have undergone the Fontan procedure.
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Affiliation(s)
- Stefan Willmann
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Ibrahim Ince
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Maurice Ahsman
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics Leiden The Netherlands
| | - Katrin Coboeken
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Yang Zhang
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Kirstin Thelen
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Dagmar Kubitza
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Peter Zannikos
- Janssen Research & Development, LLC Raritan New Jersey USA
| | - Wangda Zhou
- Janssen Research & Development, LLC Raritan New Jersey USA
| | | | - Teun Post
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics Leiden The Netherlands
| | - Jörg Lippert
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
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118
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Mitchell LG, Röshammar D, Huang F, Albisetti M, Brandão LR, Bomgaars L, Chalmers E, Halton J, Luciani M, Joseph D, Tartakovsky I, Gropper S, Brueckmann M. Anticoagulant Effects of Dabigatran on Coagulation Laboratory Parameters in Pediatric Patients: Combined Data from Five Pediatric Clinical Trials. Thromb Haemost 2022; 122:1573-1583. [PMID: 35909257 PMCID: PMC9420551 DOI: 10.1055/s-0042-1744542] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background
Dabigatran etexilate, a direct oral thrombin inhibitor, is approved to treat venous thromboembolism (VTE) in both adults and children.
Objectives
This population analysis characterized relationships between dabigatran total plasma concentrations and coagulation laboratory parameters (activated partial thromboplastin time [aPTT]; diluted thrombin time [dTT]; ecarin clotting time [ECT]).
Methods
Data from three phase 2a and one single-arm and one randomized, comparative phase 2b/3 pediatric studies (measurements: aPTT 2,925 [
N
= 358]; dTT 2,348 [
N
= 324]; ECT 2,929 [
N
= 357]) were compared with adult data (5,740 aPTT, 3,472 dTT, 3,817 ECT measurements;
N
= 1,978). Population models were fitted using nonlinear mixed-effects modeling. Covariates (e.g., sex, age) were assessed on baseline and drug-effect parameters, using a stepwise covariate model-building procedure.
Results
Overall, relationships between dabigatran, aPTT, dTT, and ECT were similar in children and adults. For children aged <6 months, a higher proportion of baseline samples were outside or close to the upper aPTT and ECT adult ranges. No age-related differences were detected for dTT. With increasing dabigatran concentration, aPTT rose nonlinearly (half the maximum effect at 368 ng/mL dabigatran) while dTT and ECT increased linearly (0.37 and 0.73% change per ng/mL dabigatran, respectively). Mean baseline aPTT (45 vs. 36 seconds) and ECT (40 vs. 36 seconds) were slightly increased for those aged <6 months versus older children.
Conclusion
The similar relationships of laboratory parameters observed across pediatric age groups suggests that developmental changes in the hemostatic system may have little effect on response to dabigatran.
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Affiliation(s)
- Lesley G Mitchell
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Fenglei Huang
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States
| | - Manuela Albisetti
- Hematology Department, University Children's Hospital, Zürich, Switzerland
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Bomgaars
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas, United States
| | - Elizabeth Chalmers
- The Glasgow Children's Haemophilia Unit, Royal Hospital for Children, Glasgow, Scotland, United Kingdom
| | - Jacqueline Halton
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Matteo Luciani
- Pediatric Hematology/Oncology Department, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - David Joseph
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States
| | - Igor Tartakovsky
- Therapeutic Area Cardiovascular Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Savion Gropper
- Therapeutic Area Inflammation Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Martina Brueckmann
- Therapeutic Area Cardiovascular Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim, Germany
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Clinical Characteristics of Venous Thrombosis Associated with Peripherally Inserted Central Venous Catheter in Premature Infants. CHILDREN 2022; 9:children9081126. [PMID: 36010017 PMCID: PMC9406451 DOI: 10.3390/children9081126] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 11/21/2022]
Abstract
Background: This study aimed to analyze clinical characteristics and risk factors for peripherally inserted central catheter (PICC) placement in premature infants. Materials: This study included seven premature infants who were hospitalized in the neonatal intensive care unit (NICU) of Peking University Third Hospital from 1 January 2014–30 June 2021, and suffered PICC-related venous thrombosis. The control group included premature infants (n = 56) matched (1:8) by the following: Did not experience venous thrombosis; born with a similar gestational age (±2 w), birth weight (±200 g); and received PICC catheterization in the same period (±4 w). Clinical neonatal data were collected through the hospital electronic medical record system and analyzed using SPSS version 23. Results: The incidence of PICC-related thrombus was 0.23% (7/3043. Univariate analysis revealed that, compared to the non-thrombotic group, mothers in the thrombosis group had autoimmune diseases (χ2 = 9.844, p = 0.030) and used anticoagulative drugs during pregnancy (χ2 = 8.036, p = 0.025). The corrected gestational age when PICC-related thrombosis occurred in the thrombosis group was 32 + 6 (30 + 1, 34 + 1) weeks. The average time from catheter placement to thrombosis was 5 (1, 12) days. Among infants, 85.7% (6/7) experienced deep vein thrombosis, of which four were in the lower extremity veins; three occurred within 2 days after central venous catheter extubation, and four occurred during central venous catheter indwelling. The clinical manifestations of thrombosis include skin edema, color changes, and skin temperature changes in the affected limbs. The seven neonates had normal coagulation at the time of thrombus diagnosis, but D-dimers significantly increased 1–2 days after thrombosis, returning to normal 5–8 days after thrombus. The thrombus persisted for 4.5 (3, 8) days. All seven neonates were treated with low molecular weight heparin calcium anticoagulation for 10 (3, 17) days and recovered completely. Conclusions: PICC-related thrombosis occurred within 1 week after catheter placement, and thrombosis more likely happened in infants whose mothers had autoimmune disease. When this high-risk factor exists and the patient has been intubated for 1 week and has sudden swelling in the intubated limb, venous ultrasound should be performed immediately to diagnose, and treatment should be provided in a timely manner to reduce adverse events.
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120
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Current Antithrombotic Therapy Strategies in Children with a Focus on Off-Label Direct Oral Anticoagulants—A Narrative Review. CHILDREN 2022; 9:children9071093. [PMID: 35884077 PMCID: PMC9319670 DOI: 10.3390/children9071093] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022]
Abstract
(1) Background: The incidence of thromboembolic events is relatively low in the general population, but it increases in hospitalized children and those who underwent thrombogenic procedures. Although the evidence regarding direct oral anticoagulants (DOACs) in children with venous thromboembolism (VTE) is growing, DOACs were excluded from existing guidelines due to the lack of reliable data at that moment. Therefore, current evidence on VTE management in children needs to be critically reviewed. (2) Methods: We have conducted a literature search in the Scopus, EMBASE, and MEDLINE databases using prespecified keywords to retrieve studies published between 2010 and 2022. (3) Results: Clinical trials highlighted that rivaroxaban and dabigatran had predictable pharmacokinetic and pharmacodynamic profiles in children, similar to those observed in adults. Dabigatran and rivaroxaban had a similar safety profile to standard therapy but improved thrombotic burden and resolution during follow-up. Most studies involving apixaban and edoxaban are ongoing, and results are awaited. (4) Conclusions: Dabigatran and rivaroxaban could be valid therapeutic options for VTE management in children. In the case of apixaban and edoxaban, results from ongoing clinical studies are required before using them in pediatric VTE.
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121
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Shima T, Kusuda T, Kan N, Kinjo T. Thrombus calcification after removing peripherally inserted central catheters in extremely preterm infants. BMJ Case Rep 2022; 15:e249174. [PMID: 35793845 PMCID: PMC9260792 DOI: 10.1136/bcr-2022-249174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pericatheter thrombus calcification is a complication that arises due to central venous catheter insertion and is particularly rare in peripherally inserted central catheters (PICCs). In this case report, we reviewed the clinical course of two neonates experiencing thrombus calcification. The first case involved a male neonate weighing 445 g. His PICC dwelt in the superior vena cava for over 49 days. Although a radiograph after removal did not show any silhouette, subsequent radiographs and CT depicted a catheter-like outline. Percutaneous intravascular retrieval was performed to salvage the object. Pathological examination revealed it to be a calcified cast. The calcified thrombosis was successfully dissolved with 6 months of warfarin therapy. The second case involved a male neonate weighing 534 g. After PICC removal, a catheter-like structure was shown on ultrasonograms. It was determined that invasive procedures were unnecessary for diagnosing the calcified thrombosis based on experience with the first case.
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Affiliation(s)
- Takashi Shima
- Neonatology, Fukuoka Children's Hospital, Fukuoka, Fukuoka, Japan
- PGDip in Neonatal Medicine, Cardiff University, Cardiff, UK
| | - Takeshi Kusuda
- Neonatology, Fukuoka Children's Hospital, Fukuoka, Fukuoka, Japan
| | - Nobuhiko Kan
- Neonatology, Fukuoka Children's Hospital, Fukuoka, Fukuoka, Japan
| | - Tadamune Kinjo
- Neonatology, Fukuoka Children's Hospital, Fukuoka, Fukuoka, Japan
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122
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Gunasekaran V, Natarajan RK, Mahmood B, Ibrahim J. An unusual case of hypoxemic respiratory failure in a preterm neonate. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Schmitz AH, Wood KE, Burghardt EL, Koestner BP, Wendt LH, Badheka AV, Sharathkumar AA. Thromboprophylaxis for children hospitalized with COVID-19 and MIS-C. Res Pract Thromb Haemost 2022; 6:e12780. [PMID: 35949885 PMCID: PMC9357887 DOI: 10.1002/rth2.12780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/22/2022] [Accepted: 06/28/2022] [Indexed: 11/26/2022] Open
Abstract
Background Limited data exist about effective regimens for pharmacological thromboprophylaxis in children with acute coronavirus disease 2019 (COVID‐19) and multisystem inflammatory syndrome in children (MIS‐C). Objectives Study the outcomes of institutional thromboprophylaxis protocol for primary venous thromboembolism (VTE) prevention in children hospitalized with acute COVID‐19/MIS‐C. Methods This single‐center retrospective cohort study included consecutive children (aged less than 21 years) with COVID‐19/MIS‐C who received tailored intensity thromboprophylaxis, primarily with low‐molecular‐weight heparin, from April 2020 through October 2021. Thromboprophylaxis was given to those with moderate to severe disease based on the World Health Organization scale and exposure to two or more VTE risk factors. Therapeutic intensity was considered for severe illness. Clinical recovery along with D‐dimer improvement determined thromboprophylaxis duration. Outcomes were incident VTEs, bleeding, and mortality. Results Among 211 hospitalizations, 45 (21.3%) received thromboprophylaxis (COVID‐19, 16; MIS‐C, 29). Median age was 14.8 years (interquartile range [IQR], 8.9–16.1). Among 35 (77.8%) with severe illness, 27 (60.0%) required respiratory support, and 19 (42.2%) required an intensive care unit stay. Median hospitalization was 6 days (IQR, 5.0–10.5). Median thromboprophylaxis duration was 19 days (IQR, 6.0–31.0) with therapeutic intensity in 24 (53.3%) and prophylactic in 21 (46.7%). Outcomes were as follows: VTE, 1 (2.2%); death, 1 (2.2%, unrelated to bleeding/thrombosis); major/clinically relevant nonmajor bleeding, 0; and minor bleeding, 7 (15.5%). D‐dimer was elevated in a majority at diagnosis (median, 2.3; IQR, 1.2–3.3 mg/ml fibrinogen‐equivalent units) and was noninformative in assessing disease severity. D‐dimer normalized at thromboprophylaxis discontinuation. Conclusions Our experience of using clinically directed thromboprophylaxis with tailored intensity approach for children hospitalized with COVID‐19 and MIS‐C favors its inclusion in current standard of care. The role of D‐dimer in directing thromboprophylaxis management deserves further evaluation.
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Affiliation(s)
- Anna H Schmitz
- Stead Family Department of Pediatrics University of Iowa Iowa City Iowa USA.,Carver College of Medicine University of Iowa Iowa City Iowa USA
| | - Kelly E Wood
- Stead Family Department of Pediatrics University of Iowa Iowa City Iowa USA.,Carver College of Medicine University of Iowa Iowa City Iowa USA
| | - Elliot L Burghardt
- Carver College of Medicine University of Iowa Iowa City Iowa USA.,Department of Biostatistics, College of Public Health University of Iowa Iowa City Iowa USA
| | - Bryan P Koestner
- Stead Family Department of Pediatrics University of Iowa Iowa City Iowa USA.,Carver College of Medicine University of Iowa Iowa City Iowa USA
| | - Linder H Wendt
- Institute for Clinical and Translational Science University of Iowa Iowa City Iowa USA
| | - Aditya V Badheka
- Stead Family Department of Pediatrics University of Iowa Iowa City Iowa USA.,Carver College of Medicine University of Iowa Iowa City Iowa USA
| | - Anjali A Sharathkumar
- Stead Family Department of Pediatrics University of Iowa Iowa City Iowa USA.,Carver College of Medicine University of Iowa Iowa City Iowa USA
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Sochet AA, Morrison JM, Jaffray J, Godiwala N, Wilson HP, Thornburg CD, Bhat RV, Zia A, Lawrence C, Kudchadkar SR, Hamblin F, Russell CJ, Streiff MB, Spyropoulos AC, Amankwah EK, Goldenberg NA. Enoxaparin Thromboprophylaxis in Children Hospitalized for COVID-19: A Phase 2 Trial. Pediatrics 2022; 150:e2022056726. [PMID: 35484817 DOI: 10.1542/peds.2022-056726] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Evidence regarding the safety and efficacy of anticoagulant thromboprophylaxis among pediatric patients hospitalized for coronavirus disease 2019 (COVID-19) is limited. We sought to evaluate safety, dose-finding, and preliminary efficacy of twice-daily enoxaparin as primary thromboprophylaxis among children hospitalized for symptomatic COVID-19, including primary respiratory infection and multisystem inflammatory syndrome in children (MISC). METHODS We performed a phase 2, multicenter, prospective, open-label, single-arm clinical trial of twice-daily enoxaparin (initial dose: 0.5mg/kg per dose; max: 60mg; target anti-Xa activity: 0.20-0.49IU/mL) as primary thromboprophylaxis for children <18 years of age hospitalized for symptomatic COVID-19. Study endpoints included: cumulative incidence of International Society of Thrombosis and Haemostasis-defined clinically relevant bleeding; enoxaparin dose-requirements; and cumulative incidence of venous thromboembolism within 30-days of hospital discharge. Descriptive statistics summarized endpoint estimates that were further evaluated by participant age (±12 years) and clinical presentation. RESULTS Forty children were enrolled and 38 met analyses criteria. None experienced clinically relevant bleeding. Median (interquartile range) dose to achieve target anti-Xa levels was 0.5 mg/kg (0.48-0.54). Dose-requirement did not differ by age (0.5 [0.46-0.52] mg/kg for age ≥12 years versus 0.52 [0.49-0.55] mg/kg for age <12 years, P = .51) but was greater for participants with MISC (0.52 [0.5-0.61] mg/kg) as compared with primary COVID-19 (0.48 [0.39-0.51] mg/kg, P = .010). Two children (5.3%) developed central-venous catheter-related venous thromboembolism. No serious adverse events were related to trial intervention. CONCLUSIONS Among children hospitalized for COVID-19, thromboprophylaxis with twice-daily enoxaparin appears safe and warrants further investigation to assess efficacy.
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Affiliation(s)
| | | | - Julie Jaffray
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nihal Godiwala
- Department of Pediatrics, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Hope P Wilson
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, Alabama
| | - Courtney D Thornburg
- Department of Pediatrics, University of California San Diego, La Jolla, California Division of Hematology and Oncology, Rady Children's Hospital San Diego, San Diego, California
| | - Rukhmi V Bhat
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ayesha Zia
- Department of Pediatrics, The University of Texas Southwestern, Dallas, Texas
| | | | - Sapna R Kudchadkar
- Critical Care Medicine
- Pediatrics
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Christopher J Russell
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Alex C Spyropoulos
- Department of Medicine, Zucker School of Medicine at Hofstra and Northwell and Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ernest K Amankwah
- Departments of Anesthesia
- Pediatrics
- Oncology, Johns Hopkins All Children's Institute for Clinical and Translational Research
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McGrady ME, Todd K, Ignjatovic V, Jones S, Rizzi M, Luchtman-Jones L, Thornburg CD. Results of an international survey on adherence with anticoagulation in children, adolescents, and young adults: Communication from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis. J Thromb Haemost 2022; 20:1720-1728. [PMID: 35427434 DOI: 10.1111/jth.15730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 08/31/2023]
Abstract
BACKGROUND The ISTH Scientific and Standardization Committee (SSC) Subcommittee on Pediatric/Neonatal Thrombosis and Hemostasis convened a working group on medication adherence to begin to understand the current state of clinical practice to inform priority areas for efforts to improve adherence for children, and adolescents and young adults (AYA) prescribed anticoagulants. OBJECTIVES We sought to survey an international group of clinicians involved in anticoagulation management in children and/or AYA about perceptions of medication on health outcomes, clinical practice related to medication adherence, and barriers to assessing and improving medication adherence. METHODS Clinicians involved in anticoagulation management in children and/or AYA were surveyed via REDCap® . Descriptive statistics were used to summarize demographic and clinical characteristics and responses to multiple choice and Likert-type questions. Free-text answers were coded based on the Behaviour Change Technique Taxonomy and the Expert Recommendations for Implement Change project. RESULTS AND CONCLUSIONS There were 200 participants, 90% of whom were pediatric hematology/oncology physicians. Based on the results, which demonstrate that clinicians are concerned about impact of poor medication adherence and have limited resources to identify and improve adherence, the working group has identified next steps to further understand impact of medication adherence on anticoagulation-related health outcomes, address the need for validated measures to assess medication adherence for all anticoagulants prescribed to this population, and develop an intervention and implementation research agenda to improve outcomes.
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Affiliation(s)
- Meghan E McGrady
- Division of Behavioral Medicine and Clinical Psychology, Center for Adherence and Self-Management, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kevin Todd
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pediatric Hematology/Oncology, Children's Hospital of the King's Daughters, Norfolk, Virginia, USA
| | - Vera Ignjatovic
- Haematology, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Sophie Jones
- Haematology, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Nursing, The University of Melbourne, Parkville, Victoria, Australia
| | - Mattia Rizzi
- Hematology/Oncology Unit, Division of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | - Lori Luchtman-Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Courtney D Thornburg
- Division of Pediatric Hematology/Oncology, Rady Children's Hospital San Diego, San Diego, California, USA
- Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California, USA
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126
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Beckman EJ, Hovey S, Bondi DS, Patel G, Parrish RH. Pediatric Perioperative Clinical Pharmacy Practice: Clinical Considerations and Management: An Opinion of the Pediatrics and Perioperative Care Practice and Research Networks of the American College of Clinical Pharmacy. J Pediatr Pharmacol Ther 2022; 27:490-505. [DOI: 10.5863/1551-6776-27.6.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/24/2021] [Indexed: 11/11/2022]
Abstract
Pediatric perioperative clinical pharmacists are uniquely positioned to provide therapeutic and medication management expertise at a particularly vulnerable transition of care from the preoperative space, through surgery, and postoperative setting. There are many direct-patient care activities that are included in the role of the pediatric perioperative pharmacist, as well as many opportunities to develop effective, optimized, and safe medication use processes. This article outlines many of the areas in which a pediatric perioperative clinical pharmacist may intervene.
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Affiliation(s)
- Elizabeth J. Beckman
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY (EJB)
| | - Sara Hovey
- Department of Pharmacy Practice, University of Illinois at Chicago, College of Pharmacy, University of Illinois Hospital, Chicago, IL (SH)
| | - Deborah S. Bondi
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, IL (DSB, GP)
| | - Gourang Patel
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, IL (DSB, GP)
| | - Richard H. Parrish
- Department of Biomedical Sciences, Mercer University School of Medicine, Columbus, GA (RHP)
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Management of Central Venous Catheters in Children and Adults on Home Parenteral Nutrition: A French Survey of Current Practice. Nutrients 2022; 14:nu14122532. [PMID: 35745262 PMCID: PMC9227599 DOI: 10.3390/nu14122532] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/09/2022] [Accepted: 06/15/2022] [Indexed: 02/01/2023] Open
Abstract
Although central venous catheter (CVC)-related thrombosis (CRT) is a severe complication of home parenteral nutrition (HPN), the amount and quality of data in the diagnosis and management of CRT remain low. We aimed to describe current practices regarding CVC management in French adult and pediatric HPN centers, with a focus on CVC obstruction and CRT. Current practices regarding CVC management in patients on HPN were collected by an online-based cross-sectional survey sent to expert physicians of French HPN centers. We compared these practices to published guidelines and searched for differences between pediatric and adult HPN centers’ practices. Finally, we examined the heterogeneity of practices in both pediatric and adult HPN centers. The survey was completed by 34 centers, including 21 pediatric and 13 adult centers. We found a considerable heterogeneity, especially in the responses of pediatric centers. On some points, the centers’ responses differed from the current guidelines. We also found significant differences between practices in adult and pediatric centers. We conclude that the management of CVC and CRT in patients on HPN is a serious and complex situation for which there is significant heterogeneity between HPN centers. These findings highlight the need for more well-designed clinical trials in this field.
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128
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Boucher AA, Heneghan JA, Jang S, Spillane KA, Abarbanell AM, Steiner ME, Meyer AD. A Narrative Review of Postoperative Anticoagulation Therapy for Congenital Cardiac Disease. Front Surg 2022; 9:907782. [PMID: 35774388 PMCID: PMC9237365 DOI: 10.3389/fsurg.2022.907782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/26/2022] [Indexed: 11/18/2022] Open
Abstract
Congenital heart disease encompasses a range of cardiac birth defects. Some defects require early and complex surgical intervention and post-operative thromboprophylaxis primarily for valve, conduit, and shunt patency. Antiplatelet and anticoagulant management strategies vary considerably and may or may not align with recognized consensus practice guidelines. In addition, newer anticoagulant agents are being increasingly used in children, but these medications are not addressed in most consensus statements. This narrative review evaluated the literature from 2011 through 2021 on the topic of postoperative thromboprophylaxis after congenital heart disease operations. The search was focused on the descriptions and results of pediatric studies for replacement and/or repair of heart valves, shunts, conduits, and other congenital heart disease operations. Wide variability in practice exists and, as was true a decade ago, few randomized controlled trials have been conducted. Aspirin, warfarin, and perioperative heparin remain the most commonly used agents with varying dosing, duration, and monitoring strategies, making comparisons difficult. Only recently have data on direct oral anticoagulants been published in children, suggesting evolving paradigms of care. Our findings highlight the need for more research to strengthen the evidence for standardized thromboprophylaxis strategies.
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Affiliation(s)
- Alexander A. Boucher
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
- Correspondence: Alexander A. Boucher Julia A. Heneghan
| | - Julia A. Heneghan
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
- Correspondence: Alexander A. Boucher Julia A. Heneghan
| | - Subin Jang
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Kaitlyn A. Spillane
- Division of Critical Care, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, United States
| | - Aaron M. Abarbanell
- Division of Congenital Cardiac Surgery, Department of Cardiothoracic Surgery, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, United States
| | - Marie E. Steiner
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Andrew D. Meyer
- Division of Critical Care, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, United States
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Intravenous thrombolysis and endovascular thrombectomy for acute ischaemic stroke in patients with Moyamoya disease - a systematic review and meta-summary of case reports. J Thromb Thrombolysis 2022; 54:339-349. [PMID: 35699873 DOI: 10.1007/s11239-022-02670-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND AIMS Patients with Moyamoya disease (MMD) can present with ischaemic or haemorrhagic stroke. There is no good evidence for treatment strategies in MMD-associated acute ischaemic stroke (AIS), particularly for treatments like intravenous thrombolysis (IVT) and endovascular thrombectomy (ET). As the intracranial vessels are friable in MMD, and the risk of bleeding is high, the use of IVT and ET is controversial. To clarify the safety and efficacy of IVT/ET in the treatment of MMD-associated AIS, we performed a systematic review and meta-summary to examine this issue. METHODS A systematic search was performed from four electronic databases: PubMed (MEDLINE), Cochrane Library, EMBASE and Scopus, profiling data from inception till 21 November 2021, as well as, manually on Google Scholar. RESULTS Ten case reports detailing 10 MMD patients presenting with AIS and undergoing IVT or ET, or both, were included in the analysis. The median National Institute of Health Stroke Scale score at presentation was 10 (Interquartile Range [IQR] = 6.0-16.5). IVT alone was instituted in 6 patients, primary ET was attempted in 2, and 2 had received bridging IVT with ET. Of the 4 patients who underwent ET, 2 patients achieved successful reperfusion (modified Thrombolysis In Cerebral Infarction scale [mTICI] ≥ 2b). In terms of functional outcomes, One patient achieved complete recovery (modified Rankin Scale 0), 4 patients attained improvement in neurological status, and 4 had no improvement, whilst functional outcome was unreported in 1 patient. No patient experienced symptomatic intracranial haemorrhage. CONCLUSIONS In this systematic review and meta-summary, the utility of IVT and ET in MMD-associated AIS appears feasible in selected cases. Further larger cohort studies are required to evaluate these treatment approaches. HIGHLIGHTS · AIS in MMD was typically managed with bypass surgery but not via thrombolysis or thrombectomy. · In this meta-summary, all patients treated with thrombolysis and/or thrombectomy survived and some experienced symptomatic and/or functional improvement. · Further larger cohort studies are necessary for investigating the role of thrombolysis and/or thrombectomy as treatment of AIS in MMD.
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Zhu S, Mao Y, Li X, Li Y, Liu Z, He X, Geng Y, Wang L. Inherited and acquired causes renal vein thrombosis in an 11-year-old boy who was relieved after piperacillin-tazobactam and rivaroxaban treatment: a case report. Transl Pediatr 2022; 11:1028-1033. [PMID: 35800284 PMCID: PMC9253952 DOI: 10.21037/tp-22-95] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/27/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Physiological hypercoagulability is a well-known condition in older populations, whereas thrombosis, especially in renal veins, is a rare occurrence in teenagers. This paper presents a pediatric case of renal venous infarction and thrombosis. CASE DESCRIPTION We report the case of an 11-year-old Chinese boy who presented with low back discomfort and was afraid to walk. Computed tomography (CT) revealed thrombosis in his renal veins and inferior vena cava. He was being treated for severe refractory mycoplasma pneumoniae pneumonia (MPP). He was treated with rivaroxaban and urokinase for thrombosis, and azithromycin for MPP. On day 2 after admission, his symptoms improved. Therefore, the dosage of rivaroxaban was decreased from 10 to 5 mg twice per day. On day 3 after admission, enhanced CT revealed new thromboses in the bilateral pulmonary trunks and arteries, inferior cava, right renal veins, bilateral common iliac veins, and internal iliac vein. The ultrasonography showed a strip hypoecho at the pulmonary artery bifurcation. All the above imaging suggested that antithrombotic therapy was insufficient. His plasma antithrombin (AT) III activity remained consistently low during hospitalization. The family history was re-examined and revealed that both his father and grandfather had experienced spontaneous pulmonary thrombosis around the age of 30. He was diagnosed with acquired and inherited thrombosis and inherited AT III deficiency. Following a medication regimen of piperacillin-tazobactam for 1 week and rivaroxaban (10 mg, twice daily), he was discharged and no thrombosis and other side effects or complications occurred in the following 3 months. CONCLUSIONS This is a rare case of a teenager with inherited and acquired hypercoagulability. For refractory MPP pediatric patients with thrombosis, clinicians should consider whether hereditary factors, such as inherited AT III deficiency, are involved in thrombosis.
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Affiliation(s)
- Shumin Zhu
- Department of Laboratory Medicine, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yafei Mao
- Department of Laboratory Medicine, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xinyuan Li
- Department of Laboratory Medicine, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yanming Li
- Department of Laboratory Medicine, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zining Liu
- Department of Laboratory Medicine, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xinqi He
- Department of Vascular Surgery, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yulan Geng
- Department of Laboratory Medicine, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lihui Wang
- Second Department of Neurology, The Children's Hospital of Hebei Province, Affiliated to Hebei Medical University, Shijiazhuang, China
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Abstract
Coronavirus disease 2019 (COVID-19) is an ongoing pandemic caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus. More than 5 million children have been infected in the United States. Risk factors for more severe disease progression include obesity, pulmonary disease, gastrointestinal disorders, and neurologic comorbidities. Children with COVID-19 are admitted to the pediatric intensive care unit because of severe acute COVID-19 illness or COVID-19-associated multisystem inflammatory syndrome in children. The delta surge of 2021 was responsible for an increased disease burden in children and points to the key role of vaccinating children against this sometimes-deadly disease.
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Affiliation(s)
- Meena Kalyanaraman
- Pediatric Critical Care Medicine, Children's Hospital of New Jersey at Newark Beth Israel Medical Center, C-5, 201 Lyons Avenue, Newark, NJ 07112, USA.
| | - Michael R. Anderson
- Children’s National Hospital, George Washington University School of Medicine and Health Sciences
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Wen Y, Zhao M, Fu S, Gu Z, Chen W, Zhao Q, Shu W, Tao X, Zhang F. Pharmaceutical services based on therapeutic care pathway for kidney transplantation from donors of infants and young children: a single-center experience. Transl Pediatr 2022; 11:834-847. [PMID: 35800269 PMCID: PMC9253932 DOI: 10.21037/tp-21-515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/11/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The pharmaceutical services based on therapeutic care pathway for kidney transplantation from infants and young children (age <3 years, weight <15 kg) to pediatric recipients can detect and resolve medication-related problems. In this paper, we report our experience on pharmaceutical services based on therapeutic care pathway to evaluate the therapeutic effects and assess the feasibility of perioperative treatment protocols. METHODS We performed a retrospective study of 12 recipients who received their graft from infants and young children, between September 2011 and December 2013 at our institution. As providers of pharmaceutical services, the clinical pharmacists collected and reviewed the clinical data from all patients, including the clinical characteristics, outcome indices, and follow-up dates. A three-step-protocol of pharmaceutical services including clinician's application, pharmacist consultation, and ongoing direct pharmaceutical care and follow-up was used through the entire length of patient's admission, hospitalization, and discharge. This protocol was developed and refined based on the guidelines for transplant perioperative treatment and experiences of the clinical pharmacists to standardize the workflow, and improve the medical treatment and quality of life of patients. RESULTS There was no acute rejection, graft loss, or death in 10 recipients after transplantation, and another 2 received nephrectomy due to dysfunction. Postoperative follow-up of the patients who received the pharmaceutical services from the clinical pharmacist showed an effectiveness in managing medication-related complications, patient-related factors, and an improvement of the outcomes. CONCLUSIONS The three-step protocol of pharmaceutical services for pharmaceutical care and individual dosing regimen sponsored by pharmacists facilitated access to personalized therapies for children undergoing kidney transplantation in our hospital.
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Affiliation(s)
- Yan Wen
- Department of Pharmacy, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Mengpei Zhao
- Department of Pharmacy, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Shangxi Fu
- Department of Organ Transplantation, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhichun Gu
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wansheng Chen
- Department of Pharmacy, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Qing Zhao
- Department of Pharmacy, Zhabei Central Hospital of Jing'an District, Shanghai, China
| | - Wei Shu
- Department of Pharmacy, Zhabei Central Hospital of Jing'an District, Shanghai, China
| | - Xia Tao
- Department of Pharmacy, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Feng Zhang
- Department of Pharmacy, Changzheng Hospital, Naval Medical University, Shanghai, China
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Pedersen LH, Villadsen GB, Hellfritzsch M, Hvas AM. Prophylaxis of Venous Thromboembolism in Children: A Systematic Review. Semin Thromb Hemost 2022; 48:413-421. [PMID: 35772401 DOI: 10.1055/s-0042-1748151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Venous thromboembolism (VTE) in children is a rare but serious event. Current guidance on pharmacological thromboprophylaxis in children is mostly based on adult studies and expert opinions. The aim of this systematic review was to examine under which conditions children (age ≤ 18 years) would benefit from pharmacological thromboprophylaxis with low molecular weight heparin or unfractionated heparin. Eligible studies included children, who did not receive pharmacological thromboprophylaxis as comparator, and VTE events were radiologically verified. MEDLINE and Embase were searched up to October 3, 2021. Ten studies were included presenting data for 976 children receiving pharmacological thromboprophylaxis. We divided the studies into three categories based on the population studied: children in the intensive care unit (n = 2), children with fractures and/or undergoing surgery (n = 5), and children with systemic disease (n = 3). A lower incidence of VTE was found when pharmacological thromboprophylaxis was used compared with no prophylaxis in children in intensive care unit with central venous catheter and mechanical ventilation (7/27 vs. 13/24), children in the intensive care unit admitted after trauma with a very high risk of VTE based on several risk factors (0/21 vs. 13/96), and children with acute lymphoblastic leukemia treated with L-asparaginase concomitant with steroid and presence of central venous catheter (0/82 vs. 8/121). Pharmacological thromboprophylaxis was not associated with an increased bleeding risk. In conclusion, pharmacological thromboprophylaxis in children is sparsely investigated. Only children with several risk factors for VTE are likely to benefit from pharmacological thromboprophylaxis.
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Affiliation(s)
| | | | | | - Anne-Mette Hvas
- Faculty of Health, Aarhus University, Aarhus, Denmark.,Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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Leong R, Patel J, Samji N, Paes BA, Chan AKC, Petropoulos JA, Bhatt MD. Use of thrombolytic agents to treat neonatal thrombosis in clinical practice. Blood Coagul Fibrinolysis 2022; 33:193-200. [PMID: 35285449 DOI: 10.1097/mbc.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Among children, neonates have the highest incidence of thrombosis. Thrombolytic agents are used for the management of life and/or organ-threatening thrombosis. Literature on the efficacy and safety of thrombolytic agents in neonates is limited. We reviewed the evidence on dosing, administration, monitoring and treatment duration of tissue plasminogen activator (tPA), streptokinase and urokinase (URK) in neonates (≤ 28days). A systematic literature search was conducted of current databases from inception until 31 March 2021. The initial search yielded 6881 articles and 18 were retained for review. tPA, streptokinase and URK was utilized in 12, seven and four studies on 115, 51 and 16 patients, respectively. The dose range for tPA, streptokinase and URK was 0.01 -0.6 mg/kg/h, 50-2000 and 1000-0 000 units/kg/h, respectively, and treatment duration ranged from 30 min to 30 days. This is the first study to objectively summarize the efficacy and safety of thrombolytic agents in neonates. Overall, thrombolysis was associated with 87.9% complete or partial thrombus resolution and 7.4% recurrence risk. The bleeding risk associated with thrombolytic agents was 23.1% on pooled analysis, which is higher than other anticoagulants. Larger prospective studies are required to determine effective dosing regimens of these therapeutic drugs and further clarify their efficacy and safety. Blood Coagul Fibrinolysis 33:000-000 Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
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Affiliation(s)
| | | | | | - Bosco A Paes
- Division of Neonatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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135
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Zhao WG, Zhang WL, Zhang YZ. Characteristics of Deep Venous Thrombosis in Isolated Lower Extremity Fractures and Unsolved Problems in Guidelines: A Review of Recent Literature. Orthop Surg 2022; 14:1558-1568. [PMID: 35633091 PMCID: PMC9363729 DOI: 10.1111/os.13306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 02/21/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022] Open
Abstract
Deep venous thrombosis (DVT) has been characterized by a disorder of venous return caused by abnormal blood clotting in deep veins. It often occurs in the lower limbs and is a common complication in orthopaedics. Therefore, relevant professional organizations domestic and overseas had formulated and constantly updated relevant guidelines to prevent the occurrence of DVT. According to the management strategy of the guidelines, the incidence of DVT can be significantly reduced. However, due to the variety of fractures types, the guidelines cannot expound precautions and characteristics of DVT for all fracture types at present, and there are other related unresolved problems. For example, there is still a lack of consistent optimal strategies for the management of DVT following isolated lower extremity fractures with a higher incidence. The best anticoagulant strategies for patients with upper limb fractures, pediatric fractures, and those combined with other injuries are rarely described in orthopaedic guidelines, but such fractures are common in clinical orthopaedics. The long‐term complications after DVT, such as post‐thrombotic syndrome, are not well‐understood. In the absence of clear guidance, orthopaedic surgeons often resort to empiric anticoagulation or conservative treatment, so the prevention effects of DVT are inconsistent. The purpose of this review is to summarize the characteristics of DVT events after isolated lower extremity fractures and to discuss the unsolved issues in the guidelines by reviewing the previous literature and tracing the history of DVT discovery, to provide more scientific and comprehensive recommendations for the prediction and prevention of DVT.
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Affiliation(s)
- Wei-Guang Zhao
- Department of Orthopedic Surgery, Handan Central Hospital, HanDan, China
| | - Wei-Li Zhang
- Department of Orthopedic Surgery, Handan Central Hospital, HanDan, China
| | - Ying-Ze Zhang
- Department of Trauma Emergency Center, The Third Hospital of Hebei Medical University, Orthopaedics Research Institution of Hebei Province, Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment (The Third Hospital of Hebei Medical University), Shijiazhuang, China.,Chinese Academy of Engineering, Beijing, China
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Durrani NUR, Elfaki E, Sigola NT, Tscherning C, Gupta S, Glass GE, Yajamanyum PK. Severe hematoma following the use of low molecular weight heparin in preterm neonate. CASE REPORTS IN PERINATAL MEDICINE 2022. [DOI: 10.1515/crpm-2021-0086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
With the increased survival of preterm neonates, thromboembolic (TE) events are increasingly being recognized due to the use of indwelling catheters. It is still debatable to treat TE with low molecular weight heparin (LMWH) or follow expectant management. Despite the safety and efficacy profile about using LMWH in adults, its use in extreme preterm neonates with TE events is limited. The therapeutic level and pharmacokinetics of LMWH in the preterm population are relatively variable.
Case presentation
We present a case with a severe hematoma on the left thigh following the use of LMWH, which was surgically drained and had a successful skin graft.
Conclusions
This case highlights the importance of early and close monitoring of injection sites in patients treated with LMWH.
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Affiliation(s)
- Naveed Ur Rehman Durrani
- Division of Neonatology, Department of Pediatrics , Sidra Medicine , Doha , Qatar
- Department of Pediatrics , Weill Cornell Medicine – Qatar , Doha , Qatar
| | - Elhindi Elfaki
- Division of Neonatology, Department of Pediatrics , Sidra Medicine , Doha , Qatar
| | - Nqobile Tessa Sigola
- Division of Neonatology, Department of Pediatrics , Sidra Medicine , Doha , Qatar
| | - Charlotte Tscherning
- Division of Neonatology, Department of Pediatrics , Sidra Medicine , Doha , Qatar
| | - Samir Gupta
- Division of Neonatology, Department of Pediatrics , Sidra Medicine , Doha , Qatar
- Durham University , Durham , UK
| | - Graeme E. Glass
- Department of Pediatric Surgery , Sidra Medicine , Doha , Qatar
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So V, Watts M, Moharir M, Vargas C, Adrian-Gutierrez J, Sakran M, Elmekkawi A, Duong H, Kukreti V. 2-year-old girl with anemia and irritability. Paediatr Child Health 2022; 27:65-67. [DOI: 10.1093/pch/pxab046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/25/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Vincent So
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Queen’s School of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Maria Watts
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Pediatrics, Lakeridge Hospital Oshawa, Lakeridge Health, Oshawa, Ontario, Canada
| | - Mahendranath Moharir
- Pediatric Stroke Program, Division of Neurology, Department of Pediatrics, The Hospital of Sick Children, Toronto, Ontario, Canada
| | - Carolina Vargas
- Pediatric Stroke Program, Division of Neurology, Department of Pediatrics, The Hospital of Sick Children, Toronto, Ontario, Canada
| | - Javier Adrian-Gutierrez
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Pediatrics, Lakeridge Hospital Oshawa, Lakeridge Health, Oshawa, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Pediatrics, Lakeridge Hospital Oshawa, Lakeridge Health, Oshawa, Ontario, Canada
| | - Amir Elmekkawi
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Pediatrics, Lakeridge Hospital Oshawa, Lakeridge Health, Oshawa, Ontario, Canada
| | - Heather Duong
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Pediatrics, Lakeridge Hospital Oshawa, Lakeridge Health, Oshawa, Ontario, Canada
| | - Vinay Kukreti
- Department of Pediatrics, School of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Pediatrics, Lakeridge Hospital Oshawa, Lakeridge Health, Oshawa, Ontario, Canada
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Ciarcià M, Corsini I, Miselli F, Luzzati M, Coviello C, Leonardi V, Pratesi S, Dani C. Is recombinant tissue plasminogen activator treatment a safe choice in very and extremely preterm infants with intracardiac thrombosis? Arch Dis Child 2022; 107:archdischild-2022-323789. [PMID: 35537825 DOI: 10.1136/archdischild-2022-323789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/22/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Martina Ciarcià
- Department of Neurosciences, Psychology, Drug Research and Child Health, Careggi University Hospital, Firenze, Italy
| | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence, Firenze, Italy
| | - Francesca Miselli
- Department of Neurosciences, Psychology, Drug Research and Child Health, Careggi University Hospital, Firenze, Italy
| | - Michele Luzzati
- Department of Neurosciences, Psychology, Drug Research and Child Health, Careggi University Hospital, Firenze, Italy
| | - Caterina Coviello
- Division of Neonatology, Careggi University Hospital of Florence, Firenze, Italy
| | - Valentina Leonardi
- Division of Neonatology, Careggi University Hospital of Florence, Firenze, Italy
| | - Simone Pratesi
- Division of Neonatology, Careggi University Hospital of Florence, Firenze, Italy
| | - Carlo Dani
- Department of Neurosciences, Psychology, Drug Research and Child Health, Careggi University Hospital, Firenze, Italy
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139
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El-Sabrout H, Ganta S, Guyon P, Ratnayaka K, Vaughn G, Perry J, Kimball A, Ryan J, Thornburg CD, Tucker S, Mo J, Hegde S, Nigro J, El-Said H. Neonatal Myocardial Infarction: A Proposed Algorithm for Coronary Arterial Thrombus Management. Circ Cardiovasc Interv 2022; 15:e011664. [PMID: 35485231 DOI: 10.1161/circinterventions.121.011664] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Neonatal myocardial infarction is rare and is associated with a high mortality of 40% to 50%. We report our experience with neonatal myocardial infarction, including presentation, management, outcomes, and our current patient management algorithm. METHODS We reviewed all infants admitted with a diagnosis of coronary artery thrombosis, coronary ischemia, or myocardial infarction between January 2015 and May 2021. RESULTS We identified 21 patients (median age, 1 [interquartile range (IQR), 0.25-9.00] day; weight, 3.2 [IQR, 2.9-3.7] kg). Presentation included respiratory distress (16), shock (3), and murmur (2). Regional wall motion abnormalities by echocardiogram were a key criterion for diagnosis and were present in all 21 with varying degrees of depressed left ventricular function (severe [8], moderate [6], mild [2], and low normal [5]). Ejection fraction ranged from 20% to 54% (median, 43% [IQR, 34%-51%]). Mitral regurgitation was present in 19 (90%), left atrial dilation in 15 (71%), and pulmonary hypertension in 18 (86%). ECG was abnormal in 19 (90%). Median troponin I was 0.18 (IQR, 0.12-0.56) ng/mL. Median BNP (B-type natriuretic peptide) was 2100 (IQR, 924-2325) pg/mL. Seventeen had documented coronary thrombosis by cardiac catheterization. Seventeen (81%) were treated with intracoronary tPA (tissue-type plasminogen activator) followed by systemic heparin, AT (antithrombin), and intravenous nitroglycerin, and 4 (19%) were treated with systemic heparin, AT, and intravenous nitroglycerin alone. Nineteen of 21 recovered. One died (also had infradiaphragmatic total anomalous pulmonary venous return). One patient required a ventricular assist device and later underwent heart transplant; this patient was diagnosed late at 5 weeks of age and did not respond to tPA. Nineteen of 21 (90%) regained normal left ventricular function (ejection fraction, 60%-74%; mean, 65% [IQR, 61%-67%]) at latest follow-up (median, 6.8 [IQR, 3.58-14.72] months). Two of 21 (10%) had residual trivial mitral regurgitation. After analysis of these results, we present our current algorithm, which developed and matured over time, to manage neonatal myocardial infarction. CONCLUSIONS We experienced a lower mortality rate for infants with neonatal infarction than that reported in the literature. We propose a post hoc algorithm that may lead to improvement in patient outcomes following coronary artery thrombus.
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Affiliation(s)
- Hannah El-Sabrout
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
| | - Srujan Ganta
- Division of Pediatric Cardiac Surgery (S.G., J.N.), Rady Children's Hospital/University of California, San Diego
| | - Peter Guyon
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
| | - Kanishka Ratnayaka
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
| | - Gabrielle Vaughn
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
| | - James Perry
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
| | - Amy Kimball
- Division of Neonatology (A.K.), Rady Children's Hospital/University of California, San Diego
| | - Justin Ryan
- 3D Innovation Lab (J.R.), Rady Children's Hospital/University of California, San Diego
| | - Courtney D Thornburg
- Division of Hematology (C.D.T.), Rady Children's Hospital/University of California, San Diego
| | - Suzanne Tucker
- Division of Pathology (S.T., J.M.), Rady Children's Hospital/University of California, San Diego
| | - Jun Mo
- Division of Pathology (S.T., J.M.), Rady Children's Hospital/University of California, San Diego
| | - Sanjeet Hegde
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
| | - John Nigro
- Division of Pediatric Cardiac Surgery (S.G., J.N.), Rady Children's Hospital/University of California, San Diego
| | - Howaida El-Said
- Division of Pediatric Cardiology (H. El-Sabrout, P.G., K.R., G.V., J.P., S.H., H. El-Said), Rady Children's Hospital/University of California, San Diego
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140
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Halimeh S, Male C, Nowak-Goettl U. New Anticoagulants in Neonates, Children, and Adolescents. Hamostaseologie 2022; 42:123-130. [PMID: 35488165 DOI: 10.1055/a-1740-7080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Thrombotic events are an increasing challenge in pediatrics. Standard-of-care anticoagulants for pediatric thrombosis have several disadvantages which could be overcome by using direct oral anticoagulants (DOACs). Until recently, there was not enough evidence from clinical trials to recommend for or against the use of any of the four DOACs in children with thrombosis. In this literature review, we looked at the latest clinical trials in this field. On clinicaltrials.gov, we found 13 current studies with published results. For two of the four DOACs, namely dabigatran and rivaroxaban, we found successful phase III studies which led to the approval for the use in children. The results of these pivotal phase III studies allow to finally recommend rivaroxaban and dabigatran for the prophylaxis and treatment of thrombotic events in children.
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Affiliation(s)
- Susan Halimeh
- Gerinnungszentrum Rhein Ruhr, Duisburg, North Rhine-Westphalia, Germany
| | - Christoph Male
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Wien, Austria
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141
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Gerstl L, Borggräfe I, Heinen F, Olivieri M. Arteriell ischämischer Schlaganfall im Kindes- und Jugendalter. Monatsschr Kinderheilkd 2022; 170:458-471. [PMID: 35465384 PMCID: PMC9020421 DOI: 10.1007/s00112-022-01465-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/27/2022]
Abstract
Der arteriell ischämische Schlaganfall im Kindes- und Jugendalter gehört zu den zeitkritischsten pädiatrischen Notfällen, wird aber häufig erst mit prognostisch relevanter Zeitverzögerung diagnostiziert. Gründe sind geringe „Awareness“, die zuweilen unspezifische klinische Präsentation mit einer Breite an kritischen Differenzialdiagnosen und in der Fläche noch wenig verzahnte Akutversorgungsstrukturen. Die beim Erwachsenen etablierten Revaskularisationsstrategien zeigen auch beim Kind mögliche, z. T. spektakuläre Erfolge. Diese sind daher nach Möglichkeit auch betroffenen Kindern zur Verfügung zu stellen, auch wenn hier derzeit keine annähernd vergleichbare Evidenz vorliegt. Postakut ist die ätiologische Aufarbeitung aufgrund zu bedenkender Risikofaktoren komplex, muss aber das individuelle Risikoprofil mit Sekundärprophylaxe, Rezidivrisiko und Outcome präzise identifizieren. Die Langzeitbetreuung im multiprofessionellen, interdisziplinären Team muss die bio-psycho-sozialen Aspekte des Kindes in seiner jeweiligen Entwicklungsphase berücksichtigen.
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Affiliation(s)
- L. Gerstl
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Pädiatrische Neurologie, Entwicklungsneurologie und Sozialpädiatrie, LMU Zentrum für Entwicklung und komplex chronisch kranke Kinder – iSPZ Hauner, LMU Klinikum München, Campus Innenstadt, Lindwurmstr. 4, 80337 München, Deutschland
| | - I. Borggräfe
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Pädiatrische Neurologie, Entwicklungsneurologie und Sozialpädiatrie, LMU Zentrum für Entwicklung und komplex chronisch kranke Kinder – iSPZ Hauner, LMU Klinikum München, Campus Innenstadt, Lindwurmstr. 4, 80337 München, Deutschland
| | - F. Heinen
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Pädiatrische Neurologie, Entwicklungsneurologie und Sozialpädiatrie, LMU Zentrum für Entwicklung und komplex chronisch kranke Kinder – iSPZ Hauner, LMU Klinikum München, Campus Innenstadt, Lindwurmstr. 4, 80337 München, Deutschland
| | - M. Olivieri
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Pädiatrische Hämostaseologie, LMU Klinikum München, Campus Innenstadt, München, Deutschland
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Abteilung für Kinderintensivmedizin und Notfallmedizin, LMU Klinikum München, Campus Innenstadt, München, Deutschland
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Li H, Lu Y, Zeng X, Feng Y, Fu C, Duan H, Shu Q, Zhu J. Risk factors for central venous catheter-associated deep venous thrombosis in pediatric critical care settings identified by fusion model. Thromb J 2022; 20:18. [PMID: 35414086 PMCID: PMC9004113 DOI: 10.1186/s12959-022-00378-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 03/29/2022] [Indexed: 12/03/2022] Open
Abstract
Background An increase in the incidence of central venous catheter (CVC)-related thrombosis (CRT) has been reported in pediatric intensive care patients over the past decade. Risk factors for the development of CRT are not well understood, especially in children. The study objective was to identify potential clinical risk factors associated with CRT with novel fusion machine learning models. Methods Patients aged 0–18 who were admitted to intensive care units from December 2015 to December 2018 and underwent at least one CVC placement were included. Two fusion model approaches (stacking and blending) were used to build a better performance model based on three widely used machine learning models (logistic regression, random forest and gradient boosting decision tree). High-impact risk factors were identified based on their contribution in both fusion artificial intelligence models. Results A total of 478 factors of 3871 patients and 3927 lines were used to build fusion models, one of which achieved quite satisfactory performance (AUC = 0.82, recall = 0.85, accuracy = 0.65) in 5-fold cross validation. A total of 11 risk factors were identified based on their independent contributions to the two fusion models. Some risk factors, such as D-dimer, thrombin time, blood acid-base balance-related factors, dehydrating agents, lymphocytes and basophils were identified or confirmed to play an important role in CRT in children. Conclusions The fusion model, which achieves better performance in CRT prediction, can better understand the risk factors for CRT and provide potential biomarkers and measures for thromboprophylaxis in pediatric intensive care settings. Supplementary information The online version contains supplementary material available at 10.1186/s12959-022-00378-y.
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Affiliation(s)
- Haomin Li
- The Children's Hospital of Zhejiang University School of Medicine and National Clinical Research Center for Child Health, Hangzhou, China. .,Clinical Data Center, The Children's Hospital, Zhejiang University School of Medicine, 3333 Binsheng Road, 310052, Hangzhou, China.
| | - Yang Lu
- The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Xian Zeng
- The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Yuqing Feng
- The Children's Hospital of Zhejiang University School of Medicine and National Clinical Research Center for Child Health, Hangzhou, China.,Clinical Data Center, The Children's Hospital, Zhejiang University School of Medicine, 3333 Binsheng Road, 310052, Hangzhou, China
| | - Cangcang Fu
- The Children's Hospital of Zhejiang University School of Medicine and National Clinical Research Center for Child Health, Hangzhou, China.,Department of Nursing, The Children's Hospital, Zhejiang University School of Medicine, 3333 Binsheng Road, 310052, Hangzhou, China
| | - Huilong Duan
- The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Qiang Shu
- The Children's Hospital of Zhejiang University School of Medicine and National Clinical Research Center for Child Health, Hangzhou, China
| | - Jihua Zhu
- The Children's Hospital of Zhejiang University School of Medicine and National Clinical Research Center for Child Health, Hangzhou, China. .,Department of Nursing, The Children's Hospital, Zhejiang University School of Medicine, 3333 Binsheng Road, 310052, Hangzhou, China.
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143
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Wilson HP, Capio R, Aban I, Lebensburger J, Goldenberg NA. Secondary thrombosis prevention practice patterns in pediatrics: Results of an international survey. Res Pract Thromb Haemost 2022; 6:e12693. [PMID: 35425876 PMCID: PMC8988862 DOI: 10.1002/rth2.12693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 02/23/2022] [Accepted: 02/27/2022] [Indexed: 11/20/2022] Open
Abstract
Background Pediatric venous thromboembolism (VTE) rates continue to increase. Although most children present with transient provoking factors, some have persistent prothrombotic risks beyond the initial treatment period warranting secondary anticoagulation. Current pediatric VTE guidelines provide limited recommendations in this regard. Objectives Our primary objective was to identify key influences on pediatric thrombosis physicians’ decisions to initiate secondary anticoagulation. Methods We targeted pediatric hematologists/oncologists internationally using Duration of Therapy for Thrombosis in Children, Children’s Hospital Acquired Thrombosis consortium, and Venous Thromboembolism Network US pediatric subgroup membership rosters, who self‐identified as primary outpatient thrombosis providers. Of 124 total surveys distributed, 61 complete surveys were evaluable. We defined secondary anticoagulation as anticoagulant use beyond the initial treatment period, on a daily basis (extended) or limited to periods of superimposed clinical risk factors (episodic). Results Pediatric thrombosis physicians surveyed indicated that they prescribe secondary anticoagulation in <25% of children despite persistent risks. Among those who indicated use of secondary anticoagulation, the preferred modality was extended anticoagulation in children with a history of recurrent unprovoked VTE (98%), chronic central venous catheter (74%), and potent thrombophilia (73%). Episodic anticoagulation was preferred in children with a history of mild thrombophilia (54%). Respondents were more likely to prescribe secondary anticoagulation for adolescents as opposed to children <12 years old. Conclusions Among pediatric thrombosis physicians surveyed, they perceived the prevalence of persistent prothrombotic risks to be high in children who have completed a course of anticoagulation for provoked VTE; however, estimated use of secondary anticoagulation was low. Studies involving real‐world data are needed to further evaluate use of secondary anticoagulation in this setting.
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Affiliation(s)
- Hope P. Wilson
- Department of Pediatric Hematology/Oncology University of Alabama at Birmingham Birmingham Alabama USA
| | - Rosebella Capio
- Department of Biostatistics University of Alabama at Birmingham Birmingham Alabama USA
| | - Inmaculada Aban
- Department of Biostatistics University of Alabama at Birmingham Birmingham Alabama USA
| | - Jeffrey Lebensburger
- Department of Pediatric Hematology/Oncology University of Alabama at Birmingham Birmingham Alabama USA
| | - Neil A. Goldenberg
- Departments of Pediatrics and Medicine Divisions of Hematology Johns Hopkins University School of Medicine Baltimore Maryland USA
- Johns Hopkins All Children’s Institute for Clinical and Translational Research Cancer & Blood Disorders Institute, and Heart Institute Johns Hopkins All Children’s Hospital St. Petersburg Florida USA
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144
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Figueroa-Sánchez M, Nuño-Guzmán CM, Álvarez-López MC, Ordónez-Cárdenas M, Montaño-Rodríguez LJ. Case Report: Splanchnic Vein Thrombosis as a Complication of Necrotizing Acute Pancreatitis in a Pediatric Patient. Front Surg 2022; 9:747671. [PMID: 35433812 PMCID: PMC9010654 DOI: 10.3389/fsurg.2022.747671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
Splanchnic vein thrombosis is an unusual manifestation of venous thromboembolism and includes portal vein thrombosis, mesenteric veins thrombosis, splenic vein thrombosis, and the Budd-Chiari syndrome. The most common risk factors include hematologic and autoimmune disorders, hormonal therapy, liver cirrhosis, solid abdominal cancer, recent abdominal surgery, and abdominal infections or inflammatory conditions, such as pancreatitis. Splanchnic vein thrombosis in acute pancreatitis is most commonly associated with the severe form of the disease and pancreatic necrosis. This report describes a case of splanchnic vein thrombosis as a complication of necrotizing acute pancreatitis in a pediatric patient. Splanchnic vein thrombosis was incidentally detected on contrast-enhanced computed tomography to assess the pancreas. There was no evidence of prior risk factors for the thrombotic condition. The patient was treated with anticoagulation and showed complete resolution after recovery from necrotizing acute pancreatitis, at a 16-month follow-up. The complication of necrotizing acute pancreatitis with splanchnic vein thrombosis in pediatric age is a rare presentation.
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Affiliation(s)
- Mauricio Figueroa-Sánchez
- Department of Radiology and Imaging, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
- Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Carlos M. Nuño-Guzmán
- Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
- Department of General Surgery, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
- *Correspondence: Carlos M. Nuño-Guzmán
| | - M. Carmen Álvarez-López
- Department of Pediatric Gastroenterology, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
| | - Mariana Ordónez-Cárdenas
- Department of Pediatric Gastroenterology, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
| | - Leidy J. Montaño-Rodríguez
- Department of Radiology and Imaging, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
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145
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Investigating the experience of parents who have given their infants enoxaparin at home. Thromb Res 2022; 214:16-20. [DOI: 10.1016/j.thromres.2022.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 11/23/2022]
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146
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Perrone S, Lembo C, Gironi F, Petrolini C, Catalucci T, Corbo G, Buonocore G, Gitto E, Esposito SMR. Erythropoietin as a Neuroprotective Drug for Newborn Infants: Ten Years after the First Use. Antioxidants (Basel) 2022; 11:antiox11040652. [PMID: 35453337 PMCID: PMC9031072 DOI: 10.3390/antiox11040652] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/19/2022] [Accepted: 03/24/2022] [Indexed: 01/27/2023] Open
Abstract
Protective strategies against perinatal brain injury represent a major challenge for modern neonatology. Erythropoietin (Epo) enhances endogenous mechanisms of repair and angiogenesis. In order to analyse the newest evidence on the role of Epo in prematurity, hypoxic ischemic encephalopathy (HIE) and perinatal stroke, a critical review using 2020 PRISMA statement guidelines was conducted. This review uncovered 26 clinical trials examining the use of Epo for prematurity and brain injury-related outcomes. The effects of Epo on prematurity were analysed in 16 clinical trials. Erythropoietin was provided until 32–35 weeks of corrected postnatal age with a dosage between 500–3000 UI/kg/dose. Eight trials reported the Epo effects on HIE term newborn infants: Erythropoietin was administered in the first weeks of life, at different multiple doses between 250–2500 UI/kg/dose, as either an adjuvant therapy with hypothermia or a substitute for hypothermia. Two trials investigated Epo effects in perinatal stroke. Erythropoietin was administered at a dose of 1000 IU/kg for three days. No beneficial effect in improving morbidity was observed after Epo administration in perinatal stroke. A positive effect on neurodevelopmental outcome seems to occur when Epo is used as an adjuvant therapy with hypothermia in the HIE newborns. Administration of Epo in preterm infants still presents inconsistencies with regard to neurodevelopmental outcome. Clinical trials show significant differences mainly in target population and intervention scheme. The identification of specific markers and their temporal expression at different time of recovery after hypoxia-ischemia in neonates might be implemented to optimize the therapeutic scheme after hypoxic-ischemic injury in the developing brain. Additional studies on tailored regimes, accounting for the risk stratification of brain damage in newborns, are required.
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Affiliation(s)
- Serafina Perrone
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (C.P.); (S.M.R.E.)
- Correspondence:
| | - Chiara Lembo
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy; (C.L.); (F.G.); (T.C.); (G.C.); (G.B.)
| | - Federica Gironi
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy; (C.L.); (F.G.); (T.C.); (G.C.); (G.B.)
| | - Chiara Petrolini
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (C.P.); (S.M.R.E.)
| | - Tiziana Catalucci
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy; (C.L.); (F.G.); (T.C.); (G.C.); (G.B.)
| | - Giulia Corbo
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy; (C.L.); (F.G.); (T.C.); (G.C.); (G.B.)
| | - Giuseppe Buonocore
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy; (C.L.); (F.G.); (T.C.); (G.C.); (G.B.)
| | - Eloisa Gitto
- Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, 98125 Messina, Italy;
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148
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Shi ZY, Hou SL, Li XW. Silver dressing in the management of an infant's urachal anomaly infected with methicillin-resistant Staphylococcus aureus: A case report. World J Clin Cases 2022; 10:2629-2636. [PMID: 35434059 PMCID: PMC8968584 DOI: 10.12998/wjcc.v10.i8.2629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/29/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Symptomatic urachal anomalies are rare disorders. The management of urachal remnants has historically been surgical excision because of the connection between urachal remnants and risk of malignancy development later in life. However, recent literature suggests that urachal anomalies that do not extend to the bladder can be treated with conservative management. In this case, we report a newborn with an infected urachal remnant who was treated with a combination of antibiotics and a silver-based dressing and finally recovered well.
CASE SUMMARY Female baby A, weighing 2.88 kg at 38+5 wk of gestational age, was referred to the hospital because of a red, swollen umbilicus approximately 2 cm × 2 cm in size with yellow purulent exudate. Through physical and ultrasound examination, the baby was finally diagnosed with a urachal anomaly. We first used oxacillin to prevent infection for 3 d. On the 4th day, microbiology testing of the umbilical exudate revealed the presence of methicillin-resistant Staphylococcus aureus (MRSA). We changed the treatment with oxacillin to vancomycin for systemic infection and treated the umbilical inflammation with a silver sulfate dressing. After 5 d, the symptoms of the umbilicus disappeared, and we discontinued silver dressing application. On the 12th day, umbilical exudate testing was negative for MRSA. On the 14th day, the baby's blood testing showed a white blood cell count of 14.7 × 109/L, neutrophil percentage of 27.8%, and C-reactive protein level of 1.0 mg/L, suggesting that the infection had been controlled. We stopped treatment, and the baby was discharged with no complications. In this case, the infected urachal anomaly was cured with silver dressing and antibiotic application instead of surgical methods, which was a different course from that of some other urachal remnant cases.
CONCLUSION Anomalies that do not connect with the bladder can be treated with nonoperative management, including application of conservative antibiotics and local intervention with silver-based dressings. Silver sulfate dressings are absolutely safe for neonates with judicious use, and they play an established role in preventing infection without resistance, which is a common problem with other antibiotics and antiseptics.
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Affiliation(s)
- Ze-Yao Shi
- Department of Neonatology Nursing, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, Sichuan Province, China
| | - Shu-Lin Hou
- Department of Neonatology Nursing, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, Sichuan Province, China
| | - Xiao-Wen Li
- Department of Neonatology Nursing, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, Sichuan Province, China
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149
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Maggioni A, Sattar S, Thakkar H, Milan A. Infraumbilical surgical retrieval of transected umbilical artery catheter in an 840 g newborn. BMJ Case Rep 2022; 15:e247296. [PMID: 35288426 PMCID: PMC8921858 DOI: 10.1136/bcr-2021-247296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2022] [Indexed: 11/03/2022] Open
Abstract
An 840 g female baby born at 25 weeks gestation suffered a rare complication of umbilical arterial catheter (UAC) insertion, involving an accidental transection resulting in 11 cm of retained catheter inside the baby. Investigations revealed migration of the proximal tip of the catheter within 10 hours into the left subclavian artery.This complication is rare and has not frequently been described in the literature. Given the size and gestation of the patient, the risks and benefits of both conservative and non-conservative management were discussed in detail prior to any treatment decision being made. Effective multidisciplinary teamwork contributed to the successful removal of the UAC, done via a minimally invasive infraumbilical approach, associated with no further complications.
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Affiliation(s)
- Alessandra Maggioni
- Neonatal Unit, Evelina London Children's Hospital, London, UK
- Faculty of Life Sciences and Medicine, Department of Perinatal Imaging and Health, King's College London, London, UK
| | - Sarah Sattar
- Neonatal Unit, Evelina London Children's Hospital, London, UK
| | | | - Anna Milan
- Neonatal Unit, Evelina London Children's Hospital, London, UK
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150
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O'Brien SH, Stanek JR, Witmer CM, Raffini L. The Continued Rise of Venous Thromboembolism Across US Children's Hospitals. Pediatrics 2022; 149:184770. [PMID: 35156127 DOI: 10.1542/peds.2021-054649] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES In 2009, a large multicenter study demonstrated that the rate of pediatric venous thromboembolism (VTE) across US children's hospitals had significantly increased from 2001 to 2007. The objective of this study was to evaluate the rate of pediatric VTE from 2008 to 2019 using similar methodology. METHODS A retrospective cohort study using the Pediatric Health Information System (PHIS) database. Subjects from birth to <18 years admitted from 2008 through 2019 who had an ICD-9-CM or ICD-10-CM code for VTE were included. Demographics, underling medical comorbidities and mortality were collected. VTE location and anticoagulation data during admission were extracted. RESULTS During the 12-year study period, there were 52 401 hospital admissions among 39 713 pediatric patients with a diagnosis of VTE. The VTE admission rate increased from 46 VTE cases per 10 000 admissions in 2008 to 106 VTE cases per 10 000 admissions in 2019, a 130% increase (P < .0001) in VTE events. The median age at admission was 6.1 years, and almost one-third (31.3%) of patients with VTE were in the adolescent age group (13-17 years). Most patients (78%) had an underlying chronic medical condition. CONCLUSIONS The rate of VTE in hospitalized pediatric patients continues to increase from a 70% increase reported from 2001 to 2007 to the 130% increase from 2008 to 2019. These findings support the need for more effective VTE prevention strategies. Clinical trials focused on risk stratification and VTE prevention are needed.
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Affiliation(s)
- Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio.,Center for Health Equity and Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph R Stanek
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio.,Biostatistics Resource at Nationwide Children's Hospital, Columbus, Ohio
| | - Char M Witmer
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Leslie Raffini
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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